Late free-flap salvage with catheter-directed thrombolysis.
BACKGROUND
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.


OBJECTIVE
The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Trussler
Andrew P
AP
Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles (UCLA), Los Angeles, CA 90095-6960, USA.
Watson
James P
JP
Crisera
Christopher A
CA
D001940:Breast / Q000601:surgery*; D002406:Catheterization, Peripheral / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009055:Mouth / Q000601:surgery*; D011859:Radiography; D012086:Reoperation; D016879:Salvage Therapy / Q000379:methods; D013300:Streptokinase / Q000627:therapeutic use; D013524:Surgical Flaps / Q000009:adverse effects* / Q000098:blood supply; D015912:Thrombolytic Therapy / Q000379:methods*; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology*; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D006493:Heparin; D013300:Streptokinase; D014568:Urokinase-Type Plasminogen Activator