ABSTRACT
Approximately 5 percent of microvascular free-tissue transfers fail; often this is
due to microvascular or peri-anastomotic thrombosis. Various reports have advocated
the use of thrombolytics for salvage of these flaps, although clinical evidence supporting
this approach is sparse. The authors attempted to review their own and other published
results and present an algorithm for the use of thrombolytics in the management of
failing free flaps.
A retrospective review of 590 free flaps, revealed 71 (12 percent) requiring re-exploration
for impending flap failure, determined by standard clinical indicators. Forty-four
(62 percent) were found to have pedicle thrombosis and 20 (28 percent) received thrombolysis
with streptokinase or urokinase. All 44 flaps were grouped by final outcome and thrombolytic
use for comparison.
In 24 (55 percent) of the flaps with evidence of thrombosis, the use of thrombolytics
was felt to be inappropriate or unnecessary; 13 (54 percent) of these were salvaged.
Twenty flaps, however, did receive thrombolysis and 6 (30 percent) of these were salvaged.
There was no statistically significant difference among groups with respect to preoperative
risk factors, age, gender, flap type, and site of anastomotic thrombosis. There was
a twofold higher use of vein grafts in the failed vs. salvaged flaps (36 percent vs.
15.7 percent), and no flaps with vessel grafts were salvaged with thrombolytics. Despite
the fact that all flaps were re-explored within 3 hr of a problem being detected,
the mean time from the initial operation to re-exploration was significantly higher
in flaps that did not respond to thrombolytics (63. 8 vs. 32.8 hr, respectively, p=0.0457). Also, the mean time to re-exploration was significantly higher in the salvaged
flaps receiving thrombolysis vs. those that did not (32.8 vs. 22.3 hr, respectively,
p=0.0264).
While early detection and re-exploration are crucial for salvaging failing free flaps,
those flaps unresponsive to other standard interventions may benefit from the selective
use of thrombolytics.
KEYWORDS
Failing free-tissue transfers - thrombolytics - retrospective review
