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Hathorn T, Nickel C, Sharma A, Shabani S, Padhya T, Mifsud M. How do i salvage that flap?; An evidence-based primer on salvage techniques for head & neck microvascular free flaps. Oral Oncol 2023; 136:106246. [PMID: 36402054 DOI: 10.1016/j.oraloncology.2022.106246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an "other" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.
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Affiliation(s)
- Travis Hathorn
- USF Health Morsani College of Medicine, 560, Channelside Dr, Tampa, FL 33602, United States
| | - Christopher Nickel
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Abhay Sharma
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Sepehr Shabani
- The University of Texas Medical Branch, Department of Otolaryngology - Head & Neck Surgery, 301 University Blvd., Galveston, TX 77555, United States
| | - Tapan Padhya
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Matthew Mifsud
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States.
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Kim DY, Kim Y, Moon SH. Overcoming severe calcified lower extremity artery in lower limb salvage operation by using the Fogarty catheter and vein graft. Microsurgery 2021; 41:734-742. [PMID: 34636068 DOI: 10.1002/micr.30816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/15/2021] [Accepted: 09/17/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND With severe vascular calcifications, vascular clamp application and utilizing the vessel for free flap recipient vessel becomes impossible. These obstacles can be overcome with the Fogarty catheter and vein graft. PATIENTS AND METHODS When unclampable artery was encountered intraoperatively, a vein graft was used to make a clampable recipient site for six diabetic foot patients (ages from 42 to 80). The end of the Fogarty catheter was inserted into the proximal end of the vein graft and the transected calcified vessel in sequence, and the balloon of the catheter was used as an intraluminal tourniquet. The remaining end of the vein graft was connected to the distal vessel with a vascular clamp. RESULTS Five short vein graft revascularization for segmental arterial occlusion, one long vein graft for recipient artery elongation was done (lengths from 2 to 13.8 cm). Three delayed, and two immediate anterolateral thigh flaps (sizes from 15 to 150 cm2 ) were performed, and one patient received vein graft revascularization surgery only. Postoperative vascular sonography of all six patients showed well-maintained patency. Minor flap marginal disruption occurred at two patients but healed with conservative care. Postoperative follow-up was done for 1-18 months (average 7.17). Limb salvage was achieved for five patients and all five free flaps survived. However, for one patient, arterial restenosis at popliteal artery a month later lead to major amputation. CONCLUSION Using a Fogarty catheter and a vein graft may obtain perfect hemostasis during micro-anastomosis and achieve successful microvascular reconstruction in patients with severely calcified vessels.
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Affiliation(s)
- Dong Yeon Kim
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yesol Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Rao S, Kashyap NK, Panda C, Kumar N. Compromised microvascular free flaps; salvage using Fogarty vascular catheter thrombectomy. BMJ Case Rep 2020; 13:13/12/e239251. [PMID: 33303511 DOI: 10.1136/bcr-2020-239251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Compromised free flap perfusion secondary to thrombus formation is a routinely encountered complication in microvascular free tissue transfer. Various modalities were tried out prophylactically to prevent thrombus formation, and likewise, various methods are tried for salvaging the flap with effective thrombectomy. We present the use of Fogarty vascular catheter for thrombectomy and effective salvage of the flap.
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Affiliation(s)
- Santhosh Rao
- Dentistry - Oral & Maxillofacial Surgey, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | | | - Chinmaya Panda
- Anesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Naveen Kumar
- Radiodiagnosis, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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Brouwers K, Kruit AS, Hummelink S, Ulrich DJ. Management of free flap salvage using thrombolytic drugs: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1806-1814. [DOI: 10.1016/j.bjps.2020.05.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 01/22/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
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Avoiding complications in microsurgery and strategies for flap take-back. Arch Plast Surg 2019; 46:488-490. [PMID: 31462031 PMCID: PMC6759449 DOI: 10.5999/aps.2019.00059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/01/2019] [Indexed: 11/08/2022] Open
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Namgoong S, Yang JP, Jeong SH, Han SK, Kim WK, Dhong ES. Pharmacological thrombolysis: the last choice for salvaging free flaps. J Plast Surg Hand Surg 2018; 52:367-374. [PMID: 30286670 DOI: 10.1080/2000656x.2018.1523177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Microvascular free flap transfer has become a prevailing surgery with a failure rate of <5%. However, pedicle thrombosis occurs more frequently than indicated by the failure rate. This difference is due to the successful salvage of failing flaps. During exploration, thrombi are often encountered at anastomotic sites, whereas these causes could not explain vascular compromise in other patients. Thus, we hypothesized that thrombogenic processes might occur at remote sites, specifically within microvessels of the transferred flap. This study retrospectively evaluated 323 patients who underwent microvascular free flap transfer between March 2012 and October 2016 at Korea University Guro Hospital. All patients requiring emergency exploration within 7 days after surgery were retrospectively reviewed. Of patients, 15 required explorative surgery for suspected circulatory compromise. Eight were diagnosed with thrombosis at the perianastomotic site and salvaged in accordance with our protocol. There was no detectable thrombosis at the anastomotic site in seven patients, including one patient in whom thrombosis resolved with topical papaverine application and heparinization. The remaining six patients were diagnosed with intra-flap microthrombosis without discernable thrombosis at the anastomotic site. All patients were treated following our urokinase administration protocol and salvaged without complications. Possible external causes should first be evaluated when salvaging free flaps; in the absence of such evidence, urokinase administration may be utilized as a last resort. This study is the first report describing the effectiveness of pharmacological thrombolysis in resolving intra-flap microthrombosis. Furthermore, a safe and efficient urokinase administration protocol is suggested for perianastomotic thrombosis and intra-flap microthrombosis.
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Affiliation(s)
- Sik Namgoong
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
| | - Jong-Phil Yang
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
| | - Seong Ho Jeong
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
| | - Seung Kyu Han
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
| | - Woo Kyung Kim
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
| | - Eun Sang Dhong
- a Department of Plastic Surgery , Korea University Guro Hospital , Seoul , South Korea
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Late Arterial Thrombosis after Microvascular Head and Neck Reconstruction due to Combined Factors of Pedicle Artery Loop and Submandibular Gland Swelling. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1446. [PMID: 28894665 PMCID: PMC5585438 DOI: 10.1097/gox.0000000000001446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/20/2017] [Indexed: 12/03/2022]
Abstract
Late arterial thrombosis of a free flap is rare and usually unsalvageable because it is hard to detect. We herein report 2 cases of arterial thrombosis of a free flap after microvascular head and neck reconstruction due to the combined factors of pedicle artery loop and compression by a swollen submandibular gland, the occurrence of thrombosis in both of which was > 72 hours after the operation. In case 1, the arterial thrombosis was undetectable, and it was too late for a successful take-back operation, so the flap was lost. However, we applied the lessons learned from case 1 and were able to detect the late arterial thrombosis of case 2 at an early stage; we subsequently salvaged the flap successfully. During the take-back operation in both cases, it was found that the submandibular gland became swollen and compressed the pedicle artery, which then became occluded due to a steep loop formation. Postoperative swelling of the submandibular gland can sometimes compress the vascular pedicle, and complete occlusion of the pedicle artery may occur when it is looped. Meticulous care concerning the geometry of the vascular pedicle is required to avoid such complications.
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Current concepts in salvage procedures for failing microvascular flaps: is there a superior technique? Insights from a systematic review of the literature. Int J Oral Maxillofac Surg 2016; 45:1378-1387. [DOI: 10.1016/j.ijom.2016.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/14/2016] [Accepted: 06/29/2016] [Indexed: 12/27/2022]
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Ihler F, Matthias C, Canis M. Free flap salvage with subcutaneous injection of tissue plasminogen activator in head and neck patients. Microsurgery 2013; 33:478-81. [DOI: 10.1002/micr.22132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/02/2013] [Accepted: 04/05/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Friedrich Ihler
- Department of Otorhinolaryngology; Head and Neck Surgery, University of Göttingen; Germany
| | - Christoph Matthias
- Department of Otorhinolaryngology; Head and Neck Surgery, University of Göttingen; Germany
| | - Martin Canis
- Department of Otorhinolaryngology; Head and Neck Surgery, University of Göttingen; Germany
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Coeugniet E, Harris PG, Soulez G, Paek LS, Dellifraine P, Danino MA. [Interventional angioradiology as a solution for microsurgical flap failure]. ANN CHIR PLAST ESTH 2013; 58:188-93. [PMID: 23602272 DOI: 10.1016/j.anplas.2013.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 02/13/2013] [Indexed: 10/26/2022]
Abstract
The microsurgical failure rate is almost constant for several decades. We present two case reports describing a novel method of free flap salvage using angioradiological techniques. Our first case shows the potential utility of in situ thrombolysis, our second case describes the first use of stents within a microsurgical anastomosis. In boths cases, the flap would have been lost immediately, because flap revisions failed. Thus, before abandoning on a flap, one could perform a simple angiography to evaluate further angioradiological salvage possibilities and hereby contribute to improve long term microsurgical failure rate.
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Affiliation(s)
- E Coeugniet
- Service de chirurgie plastique, CHUM, Hôtel-Dieu de Montréal, 3840 rue Saint-Urbain, Montréal, Québec, Canada.
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Pignatti M, Iwuagwu FC, Browne TF. Late partial failure of a free ALT flap. J Plast Reconstr Aesthet Surg 2012; 65:e124-7. [DOI: 10.1016/j.bjps.2011.11.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 11/26/2011] [Indexed: 11/26/2022]
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12
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Chang EI, Mehrara BJ, Festekjian JH, Da Lio AL, Crisera CA. Vascular complications and microvascular free flap salvage: The role of thrombolytic agents. Microsurgery 2011; 31:505-9. [DOI: 10.1002/micr.20905] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 03/03/2011] [Indexed: 11/12/2022]
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13
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Zhong T. Invited commentary. J Plast Reconstr Aesthet Surg 2011; 64:1520-1. [PMID: 21531644 DOI: 10.1016/j.bjps.2011.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 04/05/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Toni Zhong
- University Health Network, Surgery, Surgical Oncology, 200 Elizabeth St, 8N 871 Eaton's Wing, Toronto, ON, Canada.
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Egozi D, Fodor L, Ullmann Y. Salvage of compromised free flaps in trauma cases with combined modalities. Microsurgery 2011; 31:109-15. [DOI: 10.1002/micr.20852] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 10/04/2010] [Indexed: 11/08/2022]
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Rizis D, Bibeau Poirier J, Nikolis A, Brutus JP, Cordoba C. Mechanical failure of a Fogarty catheter in a microsurgical procedure: a case report. J Plast Reconstr Aesthet Surg 2010; 64:966-8. [PMID: 21093395 DOI: 10.1016/j.bjps.2010.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 10/19/2010] [Indexed: 10/18/2022]
Abstract
Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter.
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Affiliation(s)
- D Rizis
- Service of Plastic and Reconstructive Surgery, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Kadota H, Sakuraba M, Kimata Y, Yano T, Hayashi R. Analysis of thrombosis on postoperative day 5 or later after microvascular reconstruction for head and neck cancers. Head Neck 2009; 31:635-41. [DOI: 10.1002/hed.21021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Trussler AP, Watson JP, Crisera CA. Late free-flap salvage with catheter-directed thrombolysis. Microsurgery 2008; 28:217-22. [DOI: 10.1002/micr.20480] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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