J Reconstr Microsurg 2007; 23(2): 069-073
DOI: 10.1055/s-2007-970185
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Role of Recombinant Tissue Plasminogen Activator in Free Flap Salvage

Brian D. Rinker1 , Daniel H. Stewart1 , Lee L.Q Pu1 , Henry C. Vasconez1
  • 1Division of Plastic Surgery, University of Kentucky, Lexington, KY
Further Information

Publication History

Accepted: October 11, 2006

Publication Date:
01 March 2007 (online)


The use of recombinant tissue plasminogen activator (rTPA) in microvascular surgery has been previously reported, but no consensus exists regarding its indications, dose, efficacy, or safety. The records of all patients undergoing free tissue transfer at one institution between 2000 and 2005 were reviewed. Patients requiring reexploration for pedicle thrombosis were identified. Chi-square and the two-sided Fisher's exact tests were used to compare differences between the two groups. Two hundred seventy-five free flaps were performed in 259 patients. In 27 cases (10 percent), reexploration for impending failure was performed, and pedicle thrombosis was observed in 22 cases. In 15 cases, rTPA was administered. Ten of these flaps (67 percent) were successfully salvaged, compared to 2/7 (29 percent) in the no-rTPA group. Heparin was used in 12 patients but was not associated with a higher salvage rate.

These findings suggest that the isolated perfusion of rTPA in the salvage of the failing free flap may be more effective than anastomotic revision alone and should be considered when vascular thrombosis is encountered on reexploration of the failing free flap.


  • 1 Kroll S S, Schusterman M A, Reece G P et al.. Timing of pedicle thrombosis and flap loss after free-tissue transfer.  Plast Reconstr Surg. 1996;  98 1230-1233
  • 2 Khouri R K, Cooley B C, Kunselman A R et al.. A prospective study of microvascular free-flap surgery and outcome.  Plast Reconstr Surg. 1998;  102 711-721
  • 3 Hidalgo D A, Disa J J, Cordeiro P G et al.. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique.  Plast Reconstr Surg. 1998;  102 722-732
  • 4 Romano J E, Biel M A. Thrombolysis in microvascular surgery using tissue-type plasminogen activator.  Arch Otolaryngol Head Neck Surg. 1989;  115 1318-1321
  • 5 Hayden R E, McLear P W, Phillips J G et al.. Thrombolysis with systemically administered t-PA in a new venous thrombosis model.  Laryngoscope. 1989;  99 100-104
  • 6 Rohrich R J, Handren J R, Kersh R et al.. Prevention of microvascular thrombosis with short-term infusion of human tissue-type plasminogen activator.  Plast Reconstr Surg. 1996;  98 118-128
  • 7 Fudem G M, Walton R L. Microvascular thrombolysis to salvage a free flap using human recombinant tissue plasminogen activator.  J Reconstr Microsurg. 1989;  5 231-234
  • 8 Hashim H A, Atiyeh B S, Hamdan A M et al.. Local intravenous thrombolysis with recombinant tissue plasminogen activator for salvage of forearm replantation.  J Reconstr Microsurg. 1996;  12 543-546
  • 9 Atiyeh B S, Fuleihan N S, Musharafieh R S. Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-PA).  J Reconstr Microsurg. 1999;  15 585-590
  • 10 Atiyeh B S, Hashim H A, Hamdan A M et al.. Local recombinant tissue plasminogen activator (rt-PA) thrombolytic therapy in microvascular surgery.  Microsurgery. 1999;  19 265-271
  • 11 Parry D J, Byrne P, Kessel D et al.. Pharmacological salvage of a combined distal bypass and free flap with catheter-directed thrombolysis.  Br J Plast Surg. 2002;  55 140-144
  • 12 Bonde C T, Heslet L, Jansen E et al.. Salvage of free flaps after venous thrombosis: case report.  Microsurgery. 2004;  24 298-301
  • 13 Jafri S M, Walters B L, Borzak S. Medical therapy of acute myocardial infarction: Part I. Role of thrombolytic and antithrombotic therapy.  J Intensive Care Med. 1995;  10 54-63
  • 14 Gurwitz J H, Gore J M, Goldberg R J et al.. Risk for intracranial hemorrhage after tissue plasminogen activator treatment for acute myocardial infarction. Participants in the National Registry of Myocardial Infarction 2.  Ann Intern Med. 1998;  129 597-604
  • 15 Bero C J, Cardella J F, Reddy K et al.. Recombinant tissue plasminogen activator for the treatment of lower extremity peripheral vascular occlusive disease.  J Vasc Interv Radiol. 1995;  6 571-577
  • 16 The National Institutes of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke.  N Engl J Med. 1995;  333 1581-1587
  • 17 Yii N W, Evans G R, Miller M J et al.. Thrombolytic therapy: what is its role in free flap salvage?.  Ann Plast Surg. 2001;  46 601-604
  • 18 Panchapakesan V, Addison P, Beausang E et al.. Role of thrombolysis in free-flap salvage.  J Reconstr Microsurg. 2003;  19 523-530
  • 19 Wheatley M J, Meltzer T R. The role of vascular pedicle thrombectomy in the management of compromised free tissue transfers.  Ann Plast Surg. 1996;  36 360-364
  • 20 Disa J J, Cordeiro P G, Hidalgo D A. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases.  Plast Reconstr Surg. 1999;  104 97-101

Brian D RinkerM.D. 

Division of Plastic Surgery, University of Kentucky, Kentucky Clinic

K454 Lexington, KY 40536-0284