Free flap salvage via direct urokinase injection into thrombosed veins: a case report

Comparative osteoradionecrosis rates in bony reconstructions for head and neck malignancy

Rationale:A 54-year-old Taiwanese male came to our hospital presented with right retromolar mucoepidermoid carcinoma. Composite resection and right modified radical neck dissection were performed. We then use free anteral lateral thigh flap to reconstruct the defect. However, venous congestion was found 32 h after the surgery.Patient concerns:The main concerns of the patient is complete salvage of the free flap, and avoiding the secondary free flap harvesting and reconstruction surgeries.Diagnoses:Right retromolar mucoepidermoid carcinoma.Interventions:We report the case of a patient with an anterolateral thigh flap with venous perianastomosis thrombosis and intraflap microvascular thrombosis successfully salvaged using anterograde intra-arterial injection of low-dose urokinase (60,000 U), without administering intravenous anticoagulation heparin during the postoperative period.Outcomes:The flap was completely salvaged 3 days after treatment. No other flap-associated or bleeding complications were noted. The intra-oral wounds around the flap completely healed without any post-ischemic complications.Lessons subsections:Although the ideal urokinase doses and delivery procedures for free flap salvage have not been developed thus far, our method maximizes the urokinase gradient in the flap, minimizes the total dose required for flap salvage, and ensures no systemic spread. Thus, compared with other thrombolytic agents, urokinase may be more effective and safe for free flap salvage. With more experience, a standardized dosage and procedure can be developed.

The treatment of hand soft tissue defects primarily relies on flap reconstruction. However, traditional venous/arterial free flaps have several disadvantages, including damage to the donor site, blood stasis, cyanosis, blister formation, and even necrosis. These issues can significantly affect patient recovery and outcomes. Therefore, there is a need for alternative approaches that minimize these complications and improve overall patient treatment. To compare the efficacy of medial tarsal free venous flaps and traditional venous/arterial free flaps in the reconstruction of hand soft tissue defects, by evaluating various clinical outcomes and patient recovery metrics. We screened 30 suitable patients with hand soft tissue defects and randomly assigned them to three groups. Patients in each group were transplanted with either medial tarsal free venous flaps or traditional arterial/venous free flaps to achieve coverage and reconstruction of the soft tissue defects. The results were compared and analyzed using the following metrics: operation time, complication rate, pain index, postoperative infection rate, and functional evaluations of both the donor and recipient areas. There was no significant difference in operation time between the medial tarsal free venous flaps and the traditional forearm free venous flaps. The operative time of both types of flaps above was shorter than that of the traditional fibular-side arterial flap of the hallux. The complication rate of the medial tarsal free venous flaps was comparable to that of the fibular-side arterial flaps from the great toes and significantly lower than that of the traditional forearm free venous flaps. In terms of pain, the pain index for the medial tarsal free venous flaps was significantly lower than that of the fibular-side arterial flap from the hallux and comparable to that of the forearm free venous flaps. Regarding postoperative infection rates, the forearm free venous flaps had the highest rate, while there was no significant difference between the medial tarsal free venous flaps and the fibular-side arterial flaps from the great toes. The functional recovery of the medial tarsal free venous flaps was outstanding in both the donor and recipient areas. There was no poor functional performance in the donor areas of the forearm free venous flaps or the recipient areas of the fibular-side arterial flaps of the halluces. The medial tarsal free venous flaps effectively avoid the disadvantages of traditional venous and arterial free flaps, combining their advantages. This kind of flaps offer shorter operative times, and lower pain indices. They also provide excellent functional recovery in both donor and recipient areas. Thus, medial tarsal free venous flaps represent an ideal solution for reconstructing hand soft tissue defects.

Salvage of a free osteocutaneous fibula flap by creating a distal arteriovenous fistula in facial reconstruction

Through and through complex oro-mandibular defect usually involves buccal mucosa, mandibular segment, lip, and outer cheek skin. Reconstruction of such extensive three-dimensional defects pose a great challenge to reconstructive surgeons which requires use of two flaps. There are diverse options for such types of defects like use two pedicled flaps, one free flap, one pedicled flap or use of two free flaps. Amongst them the use of dual free flaps is ideal for the reconstruction. Commonly used dual free flaps are free fibula osteocutaneous flap for mandible, buccal mucosal defect and free radial artery flap or antero-lateral flap for cheek defect. The major disadvantages of using these two free flaps include two different sites for flap harvest, more time for harvesting and increased overall surgery time. We present our experience of reconstruction of large oro-mandibular defect using free osteo-cutaneous fibula flap and lateral sural artery free flap from single limb in six patients between January 2019 and December 2020. Minimum follow up was 6 months.

Surgical Management of Ameloblastoma in the Mandible: Segmental Mandibulectomy and Immediate Reconstruction With Free Fibula or Deep Circumflex Iliac Artery Flap (Evaluation of the Long-Term Esthetic and Functional Results)

Background: Microsurgical reconstructions for free flap transfer have been highly successful applications in the past decades. Antithrombotic prophylactic agents, such as low molecular- weight heparin, aspirin and dextran have been routinely used for the prevention of microvascular thrombosis. Even though these agents are efficacious in microsurgery, some systemic morbidity is still reported. Methods: The present prospective study was conducted in the Department of Surgical Oncology, Regional cancer center, Pt. JNMC, Raipur (C.G.), India from the January 2014 to June 2015. Each patient was informed and consent was taken to participate in the study. Detailed clinical history and examination of the patients was recorded. All Investigations relevant to the study were done before the surgical procedure. Outcome of the surgery were noted. Data was compiled in MS Excel and checked for its completeness and correctness. Then it was analyzed. Results: During the study period, 20 microsurgery operations on 20 patients were performed. There were 17 male and 3 female patients. In all patients neck dissection was done and resective part was reconstructed with free flap. Out of 20 free flap 12 radial artery free flaps and 8 free fibula flap was harvested. Conclusions: The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.

In this report, we present our experience with subcutaneous rt-PA injection for salvage of free radial forearm flaps with vascular compromise. Three patients underwent reconstruction of defects of the soft palate or the lateral tongue with a free radial forearm flap. Patients underwent on average two attempted operative revisions with thrombectomy and intravenous heparin injections. After recurrent venous thrombosis 3-6 days after surgery, rt-PA (Alteplase 2 mg; 1,160,000 IE) was injected subcutaneously at multiple sites into the compromised flap as final attempt. In all three patients, successful thrombolysis with no or only partial soft tissue loss was achieved after subcutaneous injection of rt-PA. We therefore suggest subcutaneous rt-PA injection as an additional tool in managing difficult and recurrent cases of venous thrombosis in free flap head and neck reconstruction.

In free osteofasciocutaneous fibula flaps, secondary donor sites are avoided using one of three local closure methods: full-thickness skin grafts (FTSGs), split-thickness skin grafts (STSGs), or flaps. This systemic review aimed to evaluate the differences in outcomes among the three groups of closure methods used for free fibula flap defects. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the PubMed and Web of Science medical databases from inception to January 2021 for articles focused on closure of the free fibula flap donor site using the lower leg area-local skin graft or flap-that mentioned the free fibula flap defect size, and/or complications of the donor site. Study characteristics, free fibula flap size, and short-term complication rates were extracted for analysis. The pooled complication rates and confidence intervals were calculated based on the random-effects model. Eleven studies were included in the qualitative synthesis, and ten studies were included in the quantitative synthesis (meta-analysis). The FTSG (n=79, 52.3%) was the most widely used method, while both STSG (n=36, 23.8%) and flap (n=36, 23.8%) were the least commonly used methods. The mean free fibula flap length and width were largest for the flap method (11.5 ± 2.5cm and 6.0 ± 1.8cm), and all closure methods were used for free fibula flap widths ≥3cm. Rates of partial and complete necrosis were highest for the FTSG method (20.3%, p=.95, I2 =0%) and lowest for the flap method (12.7%, p=.95, I2 =0%). This systemic review indicated that any closure method could be adapted for a free fibula flap width ranging from 3 to 9cm, and the flap method was associated with the lowest rate of short-term complications.


 
 
 
 Background: Head and neck reconstruction following cancer resection remains a challenge for surgeons. Microsurgical free tissue transfer is the technique of choice to close the defect. Extensive complex defects resulted from radical excision often require two free flaps to provide adequate bony structure and soft tissue coverage.
 Method: Three cases following head and neck cancer resection that require reconstruction with two combined free flaps were reported. The combination of two free flaps between vastus lateral free flap, radial forearm free flap, and free fibular flap was reviewed in this study. The patients were then followed up for 1-2 months.
 Result: Two of the patients had a flow through chimeric free flap between radial forearm free flap and free fibular flap to reconstruct the maxillary, palatal and mandibular defect. One patient had a combination of free fibular flap and vastus lateral free flap to reconstruct the mandibular defect. No complications were observed in all patients. All the flaps were vital without donor site morbidity. However, two patients needed secondary procedures for further reconstructions.
 Conclusion: Combined free flaps are reliable for closing the complex defect after wide resection of head and neck cancer. They can provide adequate tissues, reduce recipient site morbidity, permit simultaneous reconstruction with two-team approach. Therefore, provide a practical method of defect coverage for these patients.
 
 
 

The reverse flow technique describes flap revascularization via anastomoses at the distal pedicle. The technique has been described for various indications but rarely as a means of flap salvage. To our knowledge, there are no previously reported cases where the reverse flow concept was utilized as a means of salvage of an osteocutaneous fibula free flap with severe atherosclerosis of the proximal peroneal artery. We describe the use of reverse flow to salvage the case of a 71-year-old male with significant atherosclerosis of the proximal peroneal artery preventing adequate microvascular anastomosis and inflow, despite multiple attempts. We were able to establish arterial perfusion of the flap using a reverse flow technique, with perfusion through the distal peroneal artery via the contralateral facial artery. This case describes the first reported use of the reverse flow technique for salvage of an osteocutaneous fibula free flap when severe atherosclerosis prevented antegrade arterial inflow. The technique appears to be a viable option for free flap salvage in similar instances.

Thrombolytic agents have been demonstrated to improve free flap salvage in animal models. However, clinical evidence regarding their efficacy has been scant. The authors reviewed their experience with flap salvage using thrombolytic therapy in 1,733 free flaps from February 1990 to July 1998. Patients with intraoperative pedicle thrombosis were excluded from this review. Forty-one of the 55 free flaps that were reexplored emergently were identified as having pedicle thrombosis. Of these 41 flaps, 28 free flaps were salvaged (flap salvage group, 68%) and 13 free flaps failed (flap failure group, 32%). Thrombolytic therapy (urokinase in 7 patients, tissue plasminogen activator in 1 patient) was used in six flaps in the flap salvage group and two flaps in the flap failure group. Statistical analysis demonstrated no difference between the two groups with regard to thrombolytic therapy. There was also no difference between the two groups with regard to use of systemic heparin (100-500 U per hour) at the time of pedicle thrombosis or with regard to whether Fogarty catheters were used. Smoking, preoperative radiotherapy, and the use of interpositional vein grafts during initial flap reconstruction had no impact on the outcome of flap salvage. The flap salvage group was reexplored at a mean of 1.5 days compared with the flap failure group, which was reexplored at a mean of 4.2 days (p = 0.007). Early detection of pedicle thrombosis remains the most important factor in the salvage of free flaps. Although these numbers are small and definitive statements cannot be made, the role of thrombolytic agents in free flap salvage requires further clinical evaluation.

Poster 12: Venous Anastomoses Coupler With Implantable Doppler in Head and Neck Microvascular Reconstruction: A Preliminary Cohort

Despite high success rates with free-tissue transfer, flap loss continues to be a devastating event. Flap salvage is often successful if vascular complications are recognized and treated early. However, delayed presentation of flap compromise is an ominous predictor of flap loss. Late free-flap salvage has been described with poor long-term results. Catheter-directed thrombolysis (CDT) has only been described in context with free-tissue transfer in a case of distal bypass salvage. The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise. Two patients underwent highly selective CDT after delayed presentation (>5 days) of flap compromise. Patient 1 is a 59-year-old woman who underwent delayed breast reconstruction with a free TRAM flap and presented with arterial thrombosis 12 days postoperatively. Patient 2 is a 53-year-old man who underwent fibular osteocutaneous free-flap reconstruction of a floor of mouth defect who developed venous thrombosis 6 days postoperatively. Patient 2 underwent two attempted operative anastamotic revisions with thrombectomies and local thrombolysis prior to CDT. The average time of presentation was 9 days, with the average time to CDT being 9.5 days. Patient 1 had an arterial thrombosis, whereas Patient 2 had a venous thrombosis. Both patients underwent successful thrombolysis after super-selective angiograms. Continuous infusions of thrombolytic agents were used in both patients for approximately 24 h. Average length of stay postCDT was 7 days with no perioperative complications. Long-term follow-up demonstrated complete flap salvage with no soft tissue loss. Despite extremely delayed presentation, aggressive CDT was successful in both breast, and head and neck reconstructions with excellent long-term flap results. CDT appears to be a useful modality in managing difficult cases of free-flap salvage.

Extensive flap salvage attempts are routinely performed in patients with late-onset flap vascular crisis despite low flap survival rates. A knowledge gap exists in management of compromised free flaps in patients who present with perfusion-related complications after hospital discharge. A retrospective review of 7443 free flaps used in 7128 cancer patients at a single institution from January of 2001 to March of 2015 was performed. Of 7443 free flap reconstructions, 856 patients (12 percent) were taken back to the operating room. Also, 261 patients (4 percent) suffered from microvascular compromise, of whom 110 (1 percent) experienced total flap loss. The authors identified 17 patients (10 breast cancer patients and seven head and neck cancer patients) who had vascular flap compromise and underwent reoperation after hospital discharge (median, 10 days; range, 4 to 107 days) after free flap reconstruction. Of these 17 patients, nine breast cancer patients and two head and neck cancer patients underwent flap salvage attempts. Salvage procedures included thrombectomy, thrombolytic and heparin injections, and reanastomoses (11 patients); vein grafting (four patients); vein supercharging with cephalic turndown (two patients); and change of recipient vessels (two patients). Sixteen of the 17 patients (94 percent) experienced total flap loss, and one patient (6 percent) had partial flap loss requiring long-lasting wound treatment. Outpatient free flap salvage has a low success rate regardless of flap type, recipient site, or patient population. The authors' study suggests that immediate second-line reconstruction is more effective for late-onset flap vascular crisis than extensive flap salvage procedures. Therapeutic, V.