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J Reconstr Microsurg 2019; 35(07): 529-540
DOI: 10.1055/s-0039-1687914
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

Cindy S.L. Goh 
1   Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
,
Marcus J.M. Ng
2   Yong Loo Lin School of Medicine, National University of Singapore, Singapore
,
David H. Song
3   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Adrian S.H. Ooi
1   Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
› Author Affiliations
Further Information

Publication History

16 October 2018

21 February 2019

Publication Date:
01 May 2019 (online)

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Abstract

Background The use of vasopressors in free flap surgery has traditionally been avoided due to the presumed risk of pedicle vasospasm leading to flap failure. However, there is a lack of strong clinical evidence to suggest that their administration during microvascular surgery is absolutely contraindicated. The aim of this study is to clarify the impact of perioperative vasopressor use on free flap outcomes.

Methods A systematic review was performed of all English-language articles that have compared free flap outcomes between patients who received vasopressors and those who did not. The outcome measures were total flap failure, pedicle thrombosis, and overall flap complications. Meta-analysis was performed using Mantel–Haenszel fixed-effects and DerSimonian and Laird random-effects models.

Results From a total of 130 citations, 14 studies representing 8,653 cases were analyzed. Majority of these did not find any negative effects of vasopressor use irrespective of dose, timing of administration, and method of delivery. Meta-analysis demonstrated that vasopressors were associated with less total flap failure overall (odds ratio, [OR]: 0.71, p = 0.05) and less pedicle thrombosis in head and neck reconstruction specifically (OR: 0.58, p = 0.02). Flap complication rates were similar across all defect types (OR: 0.97, p = 0.81) but appeared to be increased in breast reconstruction (OR: 1.46, p = 0.01).

Conclusion Perioperative vasopressor administration does not appear to be as detrimental to free flap survival as has been previously feared. Their role in optimizing hemodynamic stability may have a more beneficial effect on overall flap perfusion and in minimizing the complications of iatrogenic fluid overload.

Keywords

free tissue flaps - microsurgery - vasoconstrictor agents - flap outcomes

Disclosure Statement

The authors have no relevant commercial associations, financial interests, or conflicts of interest to disclose.


 

  • References

  • 1 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 2 Corbitt C, Skoracki RJ, Yu P, Hanasono MM. Free flap failure in head and neck reconstruction. Head Neck 2014; 36 (10) 1440-1445
    PubMedGoogle Scholar
  • 3 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135 (01) 290-299
    CrossrefPubMedGoogle Scholar
  • 4 Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010; 120 (04) 717-723
    CrossrefPubMedGoogle Scholar
  • 5 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Perioperative management for microsurgical free tissue transfer: survey of current practices with a comparison to the literature. J Reconstr Microsurg 2015; 31 (05) 355-363
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Vyas K, Wong L. Intraoperative management of free flaps: current practice. Ann Plast Surg 2014; 72 (06) S220-S223
    CrossrefPubMedGoogle Scholar
  • 7 Gooneratne H, Lalabekyan B, Clarke S, Burdett E. Perioperative anaesthetic practice for head and neck free tissue transfer -- a UK national survey. Acta Anaesthesiol Scand 2013; 57 (10) 1293-1300
    CrossrefPubMedGoogle Scholar
  • 8 Ibrahim AM, Kim PS, Rabie AN, Lee BT, Lin SJ. Vasopressors and reconstructive flap perfusion: a review of the literature comparing the effects of various pharmacologic agents. Ann Plast Surg 2014; 73 (02) 245-248
    CrossrefPubMedGoogle Scholar
  • 9 Cordeiro PG, Santamaria E, Hu QY, Heerdt P. Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine. Ann Plast Surg 1997; 39 (05) 524-531
    CrossrefPubMedGoogle Scholar
  • 10 Massey MF, Gupta DK. The effects of systemic phenylephrine and epinephrine on pedicle artery and microvascular perfusion in a pig model of myoadipocutaneous rotational flaps. Plast Reconstr Surg 2007; 120 (05) 1289-1299
    CrossrefPubMedGoogle Scholar
  • 11 Banic A, Krejci V, Erni D, Wheatley AM, Sigurdsson GH. Effects of sodium nitroprusside and phenylephrine on blood flow in free musculocutaneous flaps during general anesthesia. Anesthesiology 1999; 90 (01) 147-155
    CrossrefPubMedGoogle Scholar
  • 12 Banic A, Krejci V, Erni D, Petersen-Felix S, Sigurdsson GH. Effects of extradural anesthesia on microcirculatory blood flow in free latissimus dorsi musculocutaneous flaps in pigs. Plast Reconstr Surg 1997; 100 (04) 945-955 , discussion 956
    CrossrefPubMedGoogle Scholar
  • 13 Monroe MM, McClelland J, Swide C, Wax MK. Vasopressor use in free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142 (02) 169-173
    CrossrefPubMedGoogle Scholar
  • 14 Chen C, Nguyen MD, Bar-Meir E. , et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg 2010; 65 (01) 28-31
    CrossrefPubMedGoogle Scholar
  • 15 Harris L, Goldstein D, Hofer S, Gilbert R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery 2012; 32 (01) 15-19
    CrossrefPubMedGoogle Scholar
  • 16 Fang L, Liu J, Yu C, Hanasono MM, Zheng G, Yu P. Intraoperative use of vasopressors does not increase the risk of free flap compromise and failure in cancer patients. Ann Surg 2018; 268 (02) 379-384
    CrossrefPubMedGoogle Scholar
  • 17 Stroup DF, Berlin JA, Morton SC. , et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283 (15) 2008-2012
    CrossrefPubMedGoogle Scholar
  • 18 Anker AM, Prantl L, Strauss C. , et al. Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction - a randomized controlled trial. Clin Hemorheol Microcirc 2018; 69 (1-2): 37-44
    CrossrefPubMedGoogle Scholar
  • 19 Chan JY, Chow VL, Liu LH. Safety of intra-operative vasopressor in free jejunal flap reconstruction. Microsurgery 2013; 33 (05) 358-361
    CrossrefPubMedGoogle Scholar
  • 20 Farquhar DR, Masood MM, Pappa AK, Patel SN, Hackman ATG. Predictors of adverse outcomes in free flap reconstruction: a single-institution experience. Otolaryngol Head Neck Surg 2018; 159 (06) 973-980
    CrossrefPubMedGoogle Scholar
  • 21 Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg 2014; 72 (06) S135-S138
    CrossrefPubMedGoogle Scholar
  • 22 Kotsougiani D, Banz CM, Hundepool CA. , et al. Influence of postoperative vasoactive agent administration on free flap outcomes. Eur J Plast Surg 2016; 39: 421-428
    CrossrefPubMedGoogle Scholar
  • 23 Martellani L, Stocco C, Papa G, Renzi N, Ramella V, Arnež ZM. Arterial pressure management in reconstructive microsurgery patients by dopamine infusion in a nonintensive care ward. Plast Reconstr Surg Glob Open 2016; 4 (03) e656
    CrossrefPubMedGoogle Scholar
  • 24 Monroe MM, Cannady SB, Ghanem TA, Swide CE, Wax MK. Safety of vasopressor use in head and neck microvascular reconstruction: a prospective observational study. Otolaryngol Head Neck Surg 2011; 144 (06) 877-882
    CrossrefPubMedGoogle Scholar
  • 25 Nelson JA, Fischer JP, Grover R. , et al. Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction. J Plast Surg Hand Surg 2017; 51 (05) 336-341
    CrossrefPubMedGoogle Scholar
  • 26 Rose L, Prado N, Mulvey D, Laugharne D, Jones K, Stenhouse J. Vasoactive agents do not adversely influence the success of maxillo-facial microvascular free flap surgery: a retrospective analysis. Int J Anesthesiol Res 2016; 4: 327-330
    PubMedGoogle Scholar
  • 27 Szabo Eltorai A, Huang CC, Lu JT, Ogura A, Caterson SA, Orgill DP. Selective intraoperative vasopressor use is not associated with increased risk of DIEP flap complications. Plast Reconstr Surg 2017; 140 (01) 70e-77e
    CrossrefPubMedGoogle Scholar
  • 28 Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959; 22 (04) 719-748
    PubMedGoogle Scholar
  • 29 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7 (03) 177-188
    CrossrefPubMedGoogle Scholar
  • 30 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315 (7109): 629-634
    CrossrefPubMedGoogle Scholar
  • 31 Haughey BH, Wilson E, Kluwe L. , et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001; 125 (01) 10-17
    CrossrefPubMedGoogle Scholar
  • 32 Wei FC, Mardini S. Flaps and Reconstructive Surgery. 1st ed. Philadelphia, PA: Saunders (Imprint), Elsevier; 2009
    Google Scholar
  • 33 Sigurdsson GH. Perioperative fluid management in microvascular surgery. J Reconstr Microsurg 1995; 11 (01) 57-65
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Booi DI. Perioperative fluid overload increases anastomosis thrombosis in the free TRAM flap used for breast reconstruction. Eur J Plast Surg 2011; 34 (02) 81-86
    CrossrefPubMedGoogle Scholar
  • 35 Drugs. Epocrates Medical References for Apple iOS Version 18.6 [Mobile application software]. Epocrates, Inc, San Francisco, CA. Available at: http://www.epocrates.com/mobile/iphone/essentials . Accessed August 17, 2018
    PubMed
  • 36 Meng L, Cannesson M, Alexander BS. , et al. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth 2011; 107 (02) 209-217
    CrossrefPubMedGoogle Scholar
  • 37 Overgaard CB, Dzavík V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008; 118 (10) 1047-1056
    CrossrefPubMedGoogle Scholar
  • 38 Bein B, Christ T, Eberhart LH. Cafedrine/Theodrenaline (20:1) is an established alternative for the management of arterial hypotension in Germany—a review based on a systematic literature search. Front Pharmacol 2017; 8: 68
    PubMedGoogle Scholar
  • 39 Critchley LA, Conway F. Hypotension during subarachnoid anaesthesia: haemodynamic effects of colloid and metaraminol. Br J Anaesth 1996; 76 (05) 734-736
    CrossrefPubMedGoogle Scholar
  • 40 Hengstmann JH, Weyand U, Dengler HJ. The physiological disposition of etilefrine in man. Eur J Clin Pharmacol 1975; 9 (2-3): 179-187
    CrossrefPubMedGoogle Scholar
  • 41 Wajima Z, Shiga T, Imanaga K. Bolus administration of ephedrine and etilefrine induces transient vasodilation just after injection in combined epidural and general anesthesia patients: a randomized clinical study. Biosci Trends 2018; 12 (04) 382-388
    CrossrefPubMedGoogle Scholar
  • 42 Kanagy NL. Alpha(2)-adrenergic receptor signalling in hypertension. Clin Sci (Lond) 2005; 109 (05) 431-437
    CrossrefPubMedGoogle Scholar
  • 43 Swanson EW, Cheng HT, Susarla SM. , et al. Intraoperative use of vasopressors is safe in head and neck free tissue transfer. J Reconstr Microsurg 2016; 32 (02) 87-93
    PubMedGoogle Scholar
  • 44 Banbury J, Siemionow M, Porvasnik S, Petras S, Zins JE. Muscle flaps' triphasic microcirculatory response to sympathectomy and denervation. Plast Reconstr Surg 1999; 104 (03) 730-737
    PubMedGoogle Scholar
  • 45 Godden DR, Little R, Weston A, Greenstein A, Woodwards RT. Catecholamine sensitivity in the rat femoral artery after microvascular anastomosis. Microsurgery 2000; 20 (05) 217-220
    CrossrefPubMedGoogle Scholar
  • 46 Rizzoni D, Perlini S, Mircoli L. , et al. Enhanced vascular reactivity in the sympathectomized rat: studies in vivo and in small isolated resistance arteries. J Hypertens 2000; 18 (08) 1041-1049
    CrossrefPubMedGoogle Scholar
  • 47 Lecoq JP, Joris JL, Nelissen XP, Lamy ML, Heymans OY. Effect of adrenergic stimulation on cutaneous microcirculation immediately after surgical adventitiectomy in a rat skin flap model. Microsurgery 2008; 28 (06) 480-486
    CrossrefPubMedGoogle Scholar
  • 48 Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine, dobutamine, and dopexamine effects on free flap skin blood flow. Plast Reconstr Surg 2012; 130 (03) 564-570
    CrossrefPubMedGoogle Scholar
  • 49 Eley KA, Young JD, Watt-Smith SR. Power spectral analysis of the effects of epinephrine, norepinephrine, dobutamine and dopexamine on microcirculation following free tissue transfer. Microsurgery 2013; 33 (04) 275-281
    CrossrefPubMedGoogle Scholar
  • 50 Scholz A, Pugh S, Fardy M, Shafik M, Hall JE. The effect of dobutamine on blood flow of free tissue transfer flaps during head and neck reconstructive surgery. Anaesthesia 2009; 64 (10) 1089-1093
    CrossrefPubMedGoogle Scholar
  • 51 Suominen S, Svartling N, Silvasti M, Niemi T, Kuokkanen H, Asko-Seljavaara S. The effect of intravenous dopamine and dobutamine on blood circulation during a microvascular TRAM flap operation. Ann Plast Surg 2004; 53 (05) 425-431
    CrossrefPubMedGoogle Scholar
  • 52 Vargas CR, Iorio ML, Lee BT. A systematic review of topical vasodilators for the treatment of intraoperative vasospasm in reconstructive microsurgery. Plast Reconstr Surg 2015; 136 (02) 411-422
    CrossrefPubMedGoogle Scholar
  • 53 Yu JT, Patel AJ, Malata CM. The use of topical vasodilators in microvascular surgery. J Plast Reconstr Aesthet Surg 2011; 64 (02) 226-228
    CrossrefPubMedGoogle Scholar
  • 54 Nelson JA, Chung CU, Fischer JP, Kanchwala SK, Serletti JM, Wu LC. Wound healing complications after autologous breast reconstruction: a model to predict risk. J Plast Reconstr Aesthet Surg 2015; 68 (04) 531-539
    CrossrefPubMedGoogle Scholar
  • 55 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Chichester: John Wiley & Sons Ltd; 2008
    Google Scholar
  • 56 Chao JW, Taylor EW, Rahmati RW, Rohde CH. Continuous high-dose vasopressors in free anterolateral thigh flap transfer for pharyngeal reconstruction: a report of two cases. Microsurgery 2014; 34 (03) 237-239
    CrossrefPubMedGoogle Scholar
  • 57 Swanson EW, Susarla SM, Yalanis GC. , et al. Vasopressor-dependent recipient vessel blood flow in head and neck free tissue transfer: a report of two cases. J Reconstr Microsurg 2015; 31 (06) 477-480
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Hanasono MM, Yu P. Discussion: Selective intraoperative vasopressor use is not associated with increased risk of DIEP flap complications. Plast Reconstr Surg 2017; 140 (01) 80e-81e
    CrossrefPubMedGoogle Scholar
  • 59 Brinkman JN, Derks LH, Klimek M, Mureau MA. Perioperative fluid management and use of vasoactive and antithrombotic agents in free flap surgery: a literature review and clinical recommendations. J Reconstr Microsurg 2013; 29 (06) 357-366
    Article in Thieme ConnectPubMedGoogle Scholar