This study evaluates the efficacy of a protocol using an intra-arterial infusion of tissue plasminogen activator (TPA) for free flap salvage following venous thrombosis. A retrospective review of a single surgeon’s experience with 122 free tissue transfers was performed and 10 flaps with venous anastomotic complications were identified. Upon identification of flap venous compromise, all patients were returned to the OR for surgical exploration, the venous anastomosis resected, and the thrombus manually removed. The veins were left open to drain and 2 units of TPA were injected into the afferent artery. The resected vein was next re-anastomosed to the original recipient vein, or if insufficient, to a new recipient vein. All cases of microsurgical venous thrombosis were salvaged using the TPA protocol. There were no cases of partial flap loss, no allergic reactions to TPA, and no postoperative hematomas. One patient with preoperative anemia required transfusion. The authors conclude that intra-arterial TPA is an effective adjunct in the treatment of microsurgical venous thrombosis and may increase salvage rates following anastomotic complications.
Despite refined microsurgical skills, a 5-10% rate of thrombosis exists after free-tissue transfer. Salvage of a thrombosed venous anastomosis are notoriously challenging because detection of venous insufficiency is often delayed and by the time of recognition, advanced microcirculatory changes have already occurred within the flap. For this reason, revision of the venous anastomosis alone is often inadequate and thrombolytic assistance may be required for flap salvage. Although this study contained a relatively small number of patients, the authors show excellent results using TPA that is comparable to the results in previous reports with using urokinase. This study does not demonstrate superiority of TPA compared with urokinase as supplemental therapy in the treatment of free flap venous thrombosis; however, it does support its use as an effective adjunct in the management of this difficult problem.
Free, Tissue, Transfer, Anastamosis, Venous, Tissue, Plasminogen, Activator. Thrombosis
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