Successful free flap revision with off-label use of Alteplase: A case report and review of the literature

Introduction:

Microvascular free tissue transfer and especially the free radial forearm flap is an essential part of head and neck surgery. Microvascular thromboses cause flap failures in 5 to 15%. They are a challenge even for experienced hands. We present a case of a successful free flap revision with local administration of Alteplase.

Methods:

A 39-year old patient with a recurrent rpT3 rpN0 squamous cell carcinoma of the left soft palate was treated with transoral tumor resection and free flap reconstruction with a radial forearm flap. Postoperatively a venous thrombosis of the pedicle and the flap tissue occurred on the first day. The venous anastomosis was reopened and a thrombus of the pedicle was removed but this did not lead to a reperfusion of the flap tissue. Only when Alteplase was injected directly into the radial artery reperfusion was achieved. To prevent systemic effects and to control reperfusion the venous anastomosis was open during the time of thrombolysis and reanastomosed after successful reperfusion.

Results:

The radial forearm flap was salvaged and further survived adjuvant radiochemotherapy. The patient is now 27 month free of disease and the free flap is completely incorporated into the mucosa.

Conclusion:

Despite difficult revision permanent free flap perfusion could be achieved with the off-label use of Alteplase with excellent long term results.

 

MissingLinkText

No conflict of interest has been declared by the author(s).

Dr. med. Claudia Scherl

Hals-Nasen-Ohrenklinik Universitätsklinikum Erlangen,

Waldstr. 1, 91054,

Erlangen

Email: [e-mail]

Publication History

Publication Date:
18 April 2018 (online)