Salvage of compromised free flaps in trauma cases with combined modalities

Abstract

Using the microsurgical technique for reconstruction in trauma cases represents a challenge for the reconstructive surgeon. Several methods of salvaging of a compromised free flap have been reported, among them: intravenous heparin washing, thrombolitic therapy, thrombectomy, use of grafts and others. Here, we present our experience from nine cases and a review of the literature regarding the use of various modalities for free flap salvage in trauma cases, and their results. Data was collected from trauma cases in our institutions over a period of 2 years, where reconstruction was performed using microsurgical techniques, and where subsequent complications required some type of salvage procedure. The techniques that were used for the salvage included: intravascular irrigation with heparin, papaverine and lidocaine; administration of continuous intravenous heparin, use of the Fogarty catheter, flap washing with streptokinase, and adventitia stripping. The free flaps used were latissimus dorsi, serratus anterior, and the anteromedial thigh flap. Either vein or artery thromboses were identified during the procedure or immediately after surgery in seven patients. Two patients had prolonged spasms of the recipient artery with low flow. In all cases, the No. 2 Fogarty catheter was used for thrombectomy and also for release of the vessel spasm. There was only one complete failure among these patients, and partial necrosis was encountered in three. From our experience and review of the literature, we offer an algorithm for determining treatment strategies in a range of flap salvage situations.

The Distally Based Adipofascial Sural Artery Flap

“…9 Despite its reliability and minimal donor-site morbidity, there are disadvantages to free tissue transfer. 10,11 Microsurgery is time consuming, requires a special infrastructure that can hardly be provided by smaller hospitals, and is thus quite expensive. With the advent of true, pedicled perforator flaps, new local options became available, fueling a renewed interest in local flaps.…”

Heparin‐induced thrombocytopenia and thrombosis as an under‐diagnosed cause of flap failure in heparin‐naive patients: A case report and systematic review of the literature

“…However, the theoretical benefits of heparin use were confirmed by Khouri et al, who demonstrated a reduction of post‐operative complications with application of subcutaneous heparin, although no reductions in thrombotic complications were observed with vessel irrigation with heparin or post‐operative intravenous heparin treatment. A case series evaluating compromised flaps in trauma patients proposed a treatment algorithm for salvaging compromised free flaps, and recommends heparin irrigation of the flap as an option upon identification of thrombosis as the cause of flap failure. The debate among the timing, delivery, and associated benefits of heparin treatment during microsurgery, in addition to further complications such as HITT, underscore the need for development of evidence‐based guidelines for the use of anticoagulation during microsurgical procedures.…”

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

“…17 For thrombectomy, the successful use of Fogarty catheters has been described recently. 15 In 1987 Lipton and Jupiter, 18 first reported pharmacological thrombolysis by administering streptokinase intra-arterially for salvage of an osteocutaneous fibular free flap that suffered from venous pedicle thrombosis. Today, intra-arterial administration is welldescribed and many studies reported successful free flap salvage.…”