Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction

Nelson, Jonas A.; Fischer, John P.; Grover, Ritwik; Nelson, Priscilla; Au, Alex; Serletti, Joseph M.; Wu, Liza C.

doi:10.1080/2000656x.2016.1269777

Cited by 24 publications

(30 citation statements)

References 22 publications

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“…A variety of defects were reconstructed, most commonly of the head and neck 13,15,16,[19][20][21][22][23][24]26 and breast. 14,16,18,23,25,27 Most studies reported no significant association between vasopressor use and the outcome measures of this study. Isolated studies found increased pedicle thrombosis with postoperative vasopressor use (OR: 3.40, p < 0.05) 22 and increased flap-related complications with intraoperative vasopressor use (OR: 1.67, p < 0.01).…”

Section: Resultsmentioning

confidence: 57%

“…Isolated studies found increased pedicle thrombosis with postoperative vasopressor use (OR: 3.40, p < 0.05) 22 and increased flap-related complications with intraoperative vasopressor use (OR: 1.67, p < 0.01). 25 Interestingly, some studies found that vasopressor use was associated with less free flap failure (OR: 0.56, p ¼ 0.02; OR: 0.16, p ¼ 0.04), 16,19 microvascular thrombosis (OR: 0.59, p < 0.01), 16 and overall flap complications (OR: 0.25, p ¼ 0.05). 19 One study found that vasopressors did not affect arterial thrombosis rates but were instead associated with a lower risk of venous congestion (OR: 0.60, p ¼ 0.018).…”

Section: Resultsmentioning

confidence: 99%

“…The most common vasopressor agents reported were phenylephrine and ephedrine. [13][14][15][16]19,21,24,25,27 While phenylephrine had no significant association with complication rates, the effects of ephedrine appeared inconsistent. Most studies found no significant association of ephedrine use with flap complications.…”

Section: Vasopressor Administrationmentioning

confidence: 95%

“…The numbers for each recorded flap-related complication were added up for studies where the overall flap-related complication rate was not explicitly stated. 16,19,24,25 Deduction in this fashion possibly overestimates the incidence of flap-related complications, albeit to an equal degree between the vasopressor and non-vasopressor groups.…”

Section: Data Extractionmentioning

confidence: 98%

“…22 Whether the agent was delivered in boluses or as infusions was unspecified in four studies. [20][21][22]24 Four of the remaining 10 studies reported using infusions of dopamine, 23 phenylephrine, 13,25 norepinephrine, or metaraminol 26 to maintain blood pressure but none observed a significant increase in flap failure or thrombotic rates over the non-vasopressor group.…”

Section: Vasopressor Administrationmentioning

confidence: 99%

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Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

Goh

Song

et al. 2019

J reconstr Microsurg

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Background The use of vasopressors in free flap surgery has traditionally been avoided due to the presumed risk of pedicle vasospasm leading to flap failure. However, there is a lack of strong clinical evidence to suggest that their administration during microvascular surgery is absolutely contraindicated. The aim of this study is to clarify the impact of perioperative vasopressor use on free flap outcomes. Methods A systematic review was performed of all English-language articles that have compared free flap outcomes between patients who received vasopressors and those who did not. The outcome measures were total flap failure, pedicle thrombosis, and overall flap complications. Meta-analysis was performed using Mantel–Haenszel fixed-effects and DerSimonian and Laird random-effects models. Results From a total of 130 citations, 14 studies representing 8,653 cases were analyzed. Majority of these did not find any negative effects of vasopressor use irrespective of dose, timing of administration, and method of delivery. Meta-analysis demonstrated that vasopressors were associated with less total flap failure overall (odds ratio, [OR]: 0.71, p = 0.05) and less pedicle thrombosis in head and neck reconstruction specifically (OR: 0.58, p = 0.02). Flap complication rates were similar across all defect types (OR: 0.97, p = 0.81) but appeared to be increased in breast reconstruction (OR: 1.46, p = 0.01). Conclusion Perioperative vasopressor administration does not appear to be as detrimental to free flap survival as has been previously feared. Their role in optimizing hemodynamic stability may have a more beneficial effect on overall flap perfusion and in minimizing the complications of iatrogenic fluid overload.

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Section: Resultsmentioning

confidence: 57%

Section: Resultsmentioning

confidence: 99%

Section: Vasopressor Administrationmentioning

confidence: 95%

Section: Data Extractionmentioning

confidence: 98%

Section: Vasopressor Administrationmentioning

confidence: 99%

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Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

Goh

Song

et al. 2019

J reconstr Microsurg

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A literature review and meta‐analysis of outcomes in microsurgical reconstruction using vasopressors

2018

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Our results suggest that vasopressor utilization does not directly result in increased complications. Flaps that received vasopressors had a statistically lower rate of take-back and failure. Due to the paucity of data available for analysis and limited reporting relating flap characteristics to outcomes, prospective, well-designed studies are necessary to verify the safety of vasopressor use in microsurgical reconstruction.

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Intraoperative vasopressors in head and neck free flap reconstruction

et al. 2020

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Introduction Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free‐flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis. Patients and methods Post hoc analysis was performed of a single‐blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16‐month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume‐based support, or goal‐directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review. Results Forty‐one and 38 patients were randomized to traditional and pressor‐based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor‐based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04–3.31, p = .63) or flap‐related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40–1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor‐based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor‐based protocols, respectively. Conclusions Intraoperative goal‐directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.

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Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction

Abstract: This study demonstrates that the use of intraoperative vasopressor agents in the anaesthetic care of free flap breast reconstruction patients is common, but likely does not impact thrombotic events or flap loss. Minor complications may, however, be more common in these patients.

Cited by 24 publications

References 22 publications

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

A literature review and meta‐analysis of outcomes in microsurgical reconstruction using vasopressors

Intraoperative vasopressors in head and neck free flap reconstruction

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