Anterograde Intra-Arterial Urokinase Injection for Salvaging Fibular Free Flap

We present a case of a 57-year-old male patient who presented with squamous cell carcinoma on his mouth floor with cervical and mandibular metastases. Wide glossectomy with intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous free flap were planned. When the anastomosis between the peroneal artery of the fibular free flap and the right lingual artery was performed, no venous flow was observed at the vena comitans. Then re-anastomosis followed by topical application of papaverine and lidocaine was attempted. However, the blood supply was not recovered. Warm saline irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels were clinically suspected, so a solution of 100,000 units of urokinase was infused once through a 26-gauge angiocatheter inserted into the recipient artery just at the arterial anastomotic site, until the solution gushed out through the flap vena comitans. Immediately after the application of urokinase, arterial flow and venous return were restored. There were no complications during the follow-up period of 11 months. We believe that vibrating injuries from the reciprocating saw during osteotomies and flap insetting might be the cause of microvascular thromboses. The use of urokinase may provide a viable option for the treatment of suspicious intraoperative arterial thrombosis.

Keywords

Salvage therapy - Free tissue flaps - Tissue plasminogen activator

Publication History

Received: 22 November 2012

Accepted: 09 April 2013

Article published online:
01 May 2022

• References

• 1 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98: 1230-1233
• 2 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102: 711-721
• 3 Ozbek MR, Deune EG, Cooley BC. et al. Experimental reproduction of free flap errors: a new model of thrombosis. Ann Plast Surg 1994; 32: 474-477
• 4 Schubert W, Hunter DW, Guzman-Stein G. et al. Use of streptokinase for the salvage of a free flap: case report and review of the use of thrombolytic therapy. Microsurgery 1987; 8: 117-121
• 5 Lipton HA, Jupiter JB. Streptokinase salvage of a free-tissue transfer: case report and review of the literature. Plast Reconstr Surg 1987; 79: 977-981
• 6 Romano JE, Biel MA. Thrombolysis in microvascular surgery using tissue-type plasminogen activator. Arch Otolaryngol Head Neck Surg 1989; 115: 1318-1321
• 7 Lepore DA, Knight KR, Bhattacharya S. et al. Drug mixture which improves survival of ischemic rabbit epigastric skin flaps. Microsurgery 1994; 15: 685-692
• 8 D'Arpa S, Cordova A, Moschella F. Pharmacological thrombolysis: one more weapon for free-flap salvage. Microsurgery 2005; 25: 477-480
• 9 Panchapakesan V, Addison P, Beausang E. et al. Role of thrombolysis in free-flap salvage. J Reconstr Microsurg 2003; 19: 523-530
• 10 Esclamado RM, Carroll WR. The pathogenesis of vascular thrombosis and its impact in microvascular surgery. Head Neck 1999; 21: 355-362
• 11 Betancourt FM, Mah ET, McCabe SJ. Timing of critical thrombosis after replantation surgery of the digits. J Reconstr Microsurg 1998; 14: 313-316
• 12 Serletti JM, Moran SL, Orlando GS. et al. Urokinase protocol for free-flap salvage following prolonged venous thrombosis. Plast Reconstr Surg 1998; 102: 1947-1953
• 13 Stephan B, Schenk JF, Nemeh A. et al. The use of antithrombotic agents in microvascular surgery. Clin Hemorheol Microcirc 2009; 43: 51-56
• 14 Anavekar NS, Lim E, Johnston A. et al. Minimally invasive late free flap salvage: indications, efficacy and implications for reconstructive microsurgeons. J Plast Reconstr Aesthet Surg 2011; 64: 1517-1520