Successful Salvage of Late Anastomotic Thrombosis after Free Tissue Transfer

Abstract

Background Anastomotic thrombosis following free tissue transfer (FTT) on or after day 5 (“late thrombosis”) is reported to have extremely low rates of salvage. Analysis of our institution's experience with FTT was performed to make recommendations about the optimal management of late thrombosis, and to identify any variables that are correlated with increased salvage rates.

Methods The study included patients who underwent FTT between 1986 and 2014, then suffered anastomotic thrombosis on or after postoperative day 5. Twenty-six variables involving demographic information, flap characteristics, circumstances of the thrombotic event, and details of any salvage attempt were analyzed. Patients whose FTT were successfully salvaged and those whose were not were statistically compared.

Results Of the 3,212 patients who underwent FTT, 23 suffered late thrombosis (0.7%), and the salvage rate was 60.8% (14 of 23). The salvage rate for reconstruction of the head and neck was 53.3%, breast was 66.7%, and extremity was 100%. There was a statistically significantly greater salvage rate in flaps performed after 1998 than in those performed before 1998 (p = 0.023). There was a nonstatistically significant trend toward increased salvage rates in patients who had no anastomotic thrombotic risk factors, reconstruction using fasciocutaneous flaps, and anastomotic revision using new recipient vessels.

Conclusion Our data demonstrate that flap survival after episodes of late thrombosis can be higher than what the literature has previously reported. This underscores the importance of rigorous postoperative monitoring, as well as the importance of exploration at the earliest instance of concern for threatened flap viability.

Keywords

late thrombosis - free flap - free tissue transfer - salvage

• References

• 1 Kroll SS, Schusterman MA, Reece GP , et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (7) 1230-1233
• 2 Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol 2009; 1: 33
• 3 Yoshimoto S, Kawabata K, Mitani H. Analysis of 59 cases with free flap thrombosis after reconstructive surgery for head and neck cancer. Auris Nasus Larynx 2010; 37 (2) 205-211
• 4 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 (5) 635-641
• 5 Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009; 31 (1) 45-51
• 6 Hyodo I, Nakayama B, Kato H , et al. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope 2007; 117 (2) 357-360
• 7 Ribuffo D, Chiummariello S, Cigna E, Scuderi N. Salvage of a free flap after late total thrombosis of the flap and revascularisation. Scand J Plast Reconstr Surg Hand Surg 2004; 38 (1) 50-52
• 8 Anavekar NS, Lim E, Johnston A, Findlay M, Hunter-Smith DJ. Minimally invasive late free flap salvage: indications, efficacy and implications for reconstructive microsurgeons. J Plast Reconstr Aesthet Surg 2011; 64 (11) 1517-1520
• 9 Trussler AP, Watson JP, Crisera CA. Late free-flap salvage with catheter-directed thrombolysis. Microsurgery 2008; 28 (4) 217-222
• 10 Ihler F, Matthias C, Canis M. Free flap salvage with subcutaneous injection of tissue plasminogen activator in head and neck patients. Microsurgery 2013; 33 (6) 478-481
• 11 Guidera AK, Kelly BN, Rigby P, MacKinnon CA, Tan ST. Early oral intake after reconstruction with a free flap for cancer of the oral cavity. Br J Oral Maxillofac Surg 2013; 51 (3) 224-227
• 12 Kakarala K, Emerick KS, Lin DT, Rocco JW, Deschler DG. Free flap reconstruction in 1999 and 2009: changing case characteristics and outcomes. Laryngoscope 2012; 122 (10) 2160-2163
• 13 Ryan MW, Hochman M. Length of stay after free flap reconstruction of the head and neck. Laryngoscope 2000; 110 (2, Pt 1): 210-216
• 14 Yeung JK, Dautremont JF, Harrop AR , et al. Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction. Plast Reconstr Surg 2014; 133 (6) 1477-1484
• 15 Allak A, Nguyen TN, Shonka Jr DC, Reibel JF, Levine PA, Jameson MJ. Immediate postoperative extubation in patients undergoing free tissue transfer. Laryngoscope 2011; 121 (4) 763-768
• 16 Handschel J, Burghardt S, Naujoks C, Kübler NR, Giers G. Parameters predicting complications in flap surgery. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115 (5) 589-594
• 17 Kolbenschlag J, Daigeler A, Lauer S , et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery?. Microsurgery 2014; 34 (4) 253-260
• 18 Lin PY, Cabrera R, Chew KY, Kuo YR. The outcome of free tissue transfers in patients with hematological diseases: 20-year experiences in single microsurgical center. Microsurgery 2014; 34 (7) 505-510
• 19 Ozkan O, Chen HC, Mardini S , et al. Microvascular free tissue transfer in patients with hematological disorders. Plast Reconstr Surg 2006; 118 (4) 936-944
• 20 Wang TY, Serletti JM, Cuker A , et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 2012; 129 (2) 443-453
• 21 Eichhorn W, Blake FA, Pohlenz P, Gehrke G, Schmelzle R, Heiland M. Conditioning of myocutaneous flaps. J Craniomaxillofac Surg 2009; 37 (4) 196-200
• 22 Mallick IH, Yang W, Winslet MC, Seifalian AM. Ischemia-reperfusion injury of the intestine and protective strategies against injury. Dig Dis Sci 2004; 49 (9) 1359-1377
• 23 Kulkarni AR, Mehrara BJ, Pusic AL , et al. Venous thrombosis in handsewn versus coupled venous anastomoses in 857 consecutive breast free flaps. J Reconstr Microsurg 2015; (e-pub ahead of print)