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Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure
Michael N. Mirzabeigi, Theresa Wang, Jesse A. Taylor, Stephen J. Kovach, Joseph M. Serletti, Liza C. Wu

Purpose: Postoperative microvascular compromise remains an infrequent yet devastating complication following free tissue transfer. Optimal perioperative strategies for achieving a successful take-back have yet to be elucidated. As attempted salvage is a relatively uncommon occurrence, limited clinical data has come forth to supplant questions surrounding successful free flap salvage. The purpose of this study is twofold: 1) to stratify preoperative risk factors that predict the success of a take-back 2) to identify perioperative strategies that correlate with successful salvage.

Methods: A retrospective chart review was performed on all free flaps performed from January 2005 – April 2011. All flaps were monitored by means of conventional clinical indicators and hand-held Doppler ultrasonography. The time until salvage was defined as the end of the initial procedure until the initiation of the salvage attempt. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss. Univariate statistical analyses included Fisher’s exact test and the Mann-Whitney U test, in addition to binary logistic regression for multivariate significance. A value of p<0.05 was utilized to determine statistical significance.

Results: A total of 2,260 free flaps were reviewed and 47 take-backs for delayed microvascular compromise were identified. Twenty three of 47 flaps were salvaged (salvage rate of 49 percent). The rates of salvage for arterial and venous compromise were 52 and 46 percent respectively. Figure 1 describes the salvage rate for each respective time period. No flap beyond postoperative day 4 was salvaged. Preoperative factors were then examined among those flaps which were salvaged versus those which ultimately failed. Following univariate analysis, the mean time until take-back, presence of thrombophilia, and preoperative platelet counts were factors predictive of unsuccessful salvage.(Table 1) A multivariate analysis was performed in which platelet counts remained significant (p = 0.05) Figure 2 demonstrates that preoperative platelets above 300 were associated with the lowest rates of salvage. Intraoperative maneuvers were examined, and following univariate analysis surgeon experience (defined as >5 yrs in practice) was the only factor that was significant; however, intra-operative heparin anticoagulation and complete mechanical thrombectomy trended toward significance. The type of thrombolytic agent utilized was not found to have a statistically significant difference. Following flap failure, 17 patients underwent secondary flaps in order to complete their reconstruction (82 percent success rate).

Conclusions: This study represents one of the largest take-back series in the published literature. There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage while intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies.

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