Monitoring Vascular Compromise Using Ultrasound After Free Tissue Transfer

Abstract

Objectives-To report the clinical utility of high-resolution ultrasound (US) for monitoring vascular compromise after free tissue transfer.Methods-Fifty-two tissue transfers in the extremities were included in this study. Blood flow around the anastomotic pedicle and subcutaneous tissue of the grafted flap was monitored with pulsed color and power Doppler US whenever the conventional monitoring method, comprising the bedside assessment of the temperature, capillary refill, and flap color, showed abnormalities until 1 week after reconstruction.Results-All flaps were indicated for US monitoring, with 44 flaps showing Doppler signals in each position, even though conventional flap monitoring showed an abnormality. Forty of the 44 flaps showed no flap failure, whereas the remaining 4 flaps developed partial necrosis. Abnormal US findings were noted in 8 of the 52 flaps. Ultrasound revealed interruption of venous blood flow around the anastomotic pedicle in 6 of 8 flaps. Emergent exploration revealed venous occlusion at the anastomotic pedicle, similar to the US finding. In 2 of the 8 flaps, US showed no blood flow to either the anastomotic pedicle or subcutaneous tissue. Emergent exploration revealed arterial occlusion at the anastomotic pedicle. Seven of the 8 reexplored flaps were salvaged after revision surgery with complete flap survival. Partial flap survival was noted in 1 case, but complete flap failure was avoided.Conclusions-Ultrasound is a useful adjunct that enables a direct assessment of perfusion in grafted tissues, which may reduce unnecessary exploration when conventional flap monitoring shows an abnormality.

Real-Time Assessment of Free Flap Capillary Circulation Using Videocapillaroscopy

“…1–4 There are many conventional modalities used to monitor blood circulation of a flap, including but not limited to handheld Doppler ultrasonography, flap skin temperature measurement, flap skin color tone monitoring, capillary refilling test, and pinprick examination. 4–7 Although previous reports have shown that use of these clinical monitoring modalities during the first few postoperative days increases flap salvage rates from 40 to 80 percent, 4–7 they also have many limitations.…”

Ultrasound in Microsurgery: Current Applications and New Frontiers

“…Postoperative monitoring of free flaps for potential arterial or venous compromise is a critical component of free tissue transfer procedures. Unless these complications can be successfully salvaged, achieving a high success rate remains challenging [ 34 , 35 ]. A study by Shinomiya et al found that revascularization surgeries performed within 4 h of diagnosing vascular compromise achieve a higher salvage rate compared to those conducted at 9 h, underscoring the importance of early, accurate detection of postoperative flap complications [ 34 ].…”

Applications of Ultrasound in the Postoperative Period: A Review

“…These measures, however, are highly subjective and can lead to the misdiagnosis of compromised flaps. 13 14 Newer modalities such as hand-held Doppler and implantable Doppler have been employed in many institutions for routine monitoring. 12 14 Utilizing audible signals to suggest vessel patency, both are practical tools that allow for rapid identification of threatened flaps, but are not without limitations.…”

“…13 14 Newer modalities such as hand-held Doppler and implantable Doppler have been employed in many institutions for routine monitoring. 12 14 Utilizing audible signals to suggest vessel patency, both are practical tools that allow for rapid identification of threatened flaps, but are not without limitations. Handheld Doppler, for example, lacks the ability to differentiate between venous and arterial signals originating from a microsurgical anastomosis and those stemming from the surrounding superficial vasculature.…”