Abstract
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.
Keywords
free tissue flaps - microsurgery - vasoconstrictor agents - flap outcomes
