Duplex echography as an adjuvant tool to clinical examination to detect early postoperative free flap vascular compromise.

Abstract

Clinical examination remains the cornerstone for postoperative monitoring of free flaps but is highly dependent on the surgeon's ability and experience. Duplex echography provides a noninvasive objective evaluation of tissue perfusion. The authors hypothesized that duplex echography may be a more sensitive and specific monitoring method for early detection of postoperative flap compromise compared to clinical examination alone. The goal was to evaluate any differences between combined duplex echography and clinical examination flap monitoring versus isolated clinical evaluation. A total of 730 free flaps in 700 patients were included in the study. We conducted an intra-subject prospective study of a cohort of patients who underwent free flap reconstruction in our unit to compare clinical examination with duplex echography for postoperative monitoring. An inter-subject study was also undertaken comparing the prospective cohort with a historical control group of patients in whom free flap monitoring was made using clinical examination alone. The patency flow and velocities through the artery and vein of the flap were measured at the donor and recipient vessels of every anastomosis by duplex scanning, by the same plastic surgeon every 4 hr, during the first 18 hr after surgery. Duplex echography and clinical evaluation were used in 175 patients. The historical cohort included a total of 525 flaps. Every patient with suspicion of vascular compromise based on duplex echography was taken back for surgical re-exploration. There were no cases of overdiagnosis using duplex echography (Sensitivity 100%, Specificity 100%). Clinical evaluation detected issues with the vascularan astomoses in 23/175 flaps. However, it failed to detect 12/22 cases which presented with vascular complications and gave a false indication of possible complications in 13 flaps (Sensitivity 45%, Specificity 92%). In our practice, duplex echography is considered a useful adjunct monitoring tool for early detection of postoperative flap compromise, which compliments clinical evaluation. It provides anatomic and hemodynamic information of the vascular status and may therefore increase survival of flaps by allowing earlier detection of vascular compromise, compared to clinical examination alone, in postoperative monitoring of free flaps.