Free flap salvage with subcutaneous injection of tissue plasminogen activator in head and neck patients

Abstract

In this report, we present our experience with subcutaneous rt-PA injection for salvage of free radial forearm flaps with vascular compromise. Three patients underwent reconstruction of defects of the soft palate or the lateral tongue with a free radial forearm flap. Patients underwent on average two attempted operative revisions with thrombectomy and intravenous heparin injections. After recurrent venous thrombosis 3-6 days after surgery, rt-PA (Alteplase 2 mg; 1,160,000 IE) was injected subcutaneously at multiple sites into the compromised flap as final attempt. In all three patients, successful thrombolysis with no or only partial soft tissue loss was achieved after subcutaneous injection of rt-PA. We therefore suggest subcutaneous rt-PA injection as an additional tool in managing difficult and recurrent cases of venous thrombosis in free flap head and neck reconstruction.

Successful Salvage of Late Anastomotic Thrombosis after Free Tissue Transfer

“…Some published reports advocate for nonoperative management in cases of anastomotic thrombosis, such as anticoagulation, systemic thrombolysis, and catheter-based thrombolysis. [8][9][10] While this may be appropriate in certain selective circumstances, we feel that in the overwhelming majority of cases operative exploration is the most appropriate course of action.…”

“…The literature has many reports that suggest the use of nonoperative techniques such as anticoagulation and thrombolysis in these circumstances. [8][9][10] All of the available recommendations, however, are based on heterogeneous patient series with small sample sizes. Therefore, the purpose of this study was to analyze our institution's 28-year experience with FTT to make evidence-based recommendations about the optimal management of late thrombosis and, while doing so, to identify any patient-, flap-, or management-specific variables that are correlated with increased salvage rates.…”

Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin

“…On analysis of the literature it is clear that is no consensus on the amount of tPA used (Table 1) [8,[10][11][12]. The average amount used was 2.0 mg, but 2.5 mg and 4.0 mg has also been used.…”

Successful free flap salvage surgery with off-label use of Alteplase: A case report, review of the literature and our free flap salvage algorithm

“…In single cases with recurrent venous thrombosis that received several revisions or when patients withdrew their consent for another surgery Ihler et al injected Alteplase subcutaneously directly into the flap. According to them no further salvage surgery was necessary [ 11 ].…”