Management of free flap salvage using thrombolytic drugs: A systematic review

Brouwers, Kaj; Kruit, Anne Sophie; Hummelink, Stefan; Ulrich, Dietmar

doi:10.1016/j.bjps.2020.05.057

Cited by 14 publications

(14 citation statements)

References 49 publications

(29 reference statements)

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“…These results are consistent with the published flap salvage (60 to 70 percent) 11 and rethrombosis (40 to 70 percent) 15,31 rates in the clinical setting. Previous research has discovered that this second period of ischemia is the most damaging to the flap, leading to partial or even complete flap loss.…”

Section: Discussionsupporting

confidence: 91%

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine

Brouwers

Kruit

Midden

et al. 2022

Plastic &Amp; Reconstructive Surgery

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icrovascular free tissue transfer is an established and reliable technique in reconstructive surgery, with overall high success rates (95 to 98 percent). 1,2 However, postoperative microvascular compromise remains a serious complication. The majority of free flap failure is attributable to venous thrombosis (74 percent). 3 Various techniques can be used to salvage the flap, such as surgical revision of the anastomosis, mechanical thrombectomy, and administration of heparin solution and/or thrombolytic drugs. 4 However, these interventions are successful in only 50 to 70 percent of cases, depending

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Section: Discussionsupporting

confidence: 91%

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine

Brouwers

Kruit

Midden

et al. 2022

Plastic &Amp; Reconstructive Surgery

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“…Yet there is little consensus regarding the ideal strategy. 13 This case also demonstrates the unique application of HBOT. Compromised tissue from epinephrine can be salvaged by HBOT once the process of ischemic necrosis is suspected and is an important tool for the clinician to consider when treating a sensitive location such as a digit.…”

Section: Discussionmentioning

confidence: 75%

Ischemia Developing in a Fibrotic Finger Following the Use of Anesthetic With Epinephrine, Salvaged by Hyperbaric Oxygen Therapy

Engwall

Oakes

Torabi

et al. 2021

Plastic Surgery Case Studies

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Background: The use of epinephrine for hand surgery has been rising over the past decade following the popularization of Wide Awake Local Anesthetic No Tourniquet (WALANT). Traditional teaching from the 20th century forbade the use of epinephrine claiming it could induce digital ischemia, yet trial data now contradicts this assumption. Purpose: Digital ischemia after epinephrine injection cases are important to report because epinephrine is being used increasingly in finger anesthesia. We wish to communicate to a growing number of hand surgeons who may be new to WALANT that epinephrine may have adverse effects in a fibrotic poorly perfused environment which is salvageable by hyperbaric oxygen therapy (HBOT). Case presentation: A 22-year-old male sustained a crush injury resulting in right index phalanx fracture. Acute open reduction with K wire fixation was performed under WALANT using 1% lidocaine with 1:100,000 epinephrine. After removal of wires, he was found to require elective open reduction and internal fixation with bone graft for delayed union, which was performed tension free using general anesthetic plus bupivacaine and 1:200,000 epinephrine. Despite mild congestion, phentolamine was not acutely administered when it might have been justified. The patient presented to the clinic five days later with blistering ischemic necrosis of the pulp, which was salvaged by HBOT. Summary: This case of digital ischemia following a crush injury with fibrotic scarring treated with lidocaine and epinephrine is reported as a warning to other hand surgeons performing WALANT. Epinephrine should be used with caution for digital blocks associated with scarred or fibrotic tissue and phentolamine should be used to reverse acute ischemia. HBOT can still salvage compromised tissue once the subacute process of ischemic necrosis has begun.

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“…In addition, multiple salvage techniques have been undertaken beforehand such as the use of aspirin, heparin, Fogarty catheter, thrombectomy, and thrombolytics, with potential impact on the vessel morphology. 40 Aside from anastomotic errors, graft handling is of importance to avoid kinking or pressure. 41 Intrinsic thrombogenicity of VG is a potential cause for graft failure.…”

Section: Discussionmentioning

confidence: 99%

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

Gazyakan

Xiong

Sun

et al. 2021

J Reconstr Microsurg

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Objective Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. Patients and Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.

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Management of free flap salvage using thrombolytic drugs: A systematic review

Cited by 14 publications

References 49 publications

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine

Ischemia Developing in a Fibrotic Finger Following the Use of Anesthetic With Epinephrine, Salvaged by Hyperbaric Oxygen Therapy

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

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