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J Reconstr Microsurg 2022; 38(09): 757-766
DOI: 10.1055/s-0042-1749341
Original Article

Ex Vivo Thrombolysis to Salvage Free Flaps Using Machine Perfusion: A Pilot Study in a Porcine Model

Kaj Brouwers 
1   Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
,
Anne Sophie Kruit
1   Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
,
Erik J. Koers
2   Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
,
Her J. H. Zegers
2   Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
,
Stefan Hummelink 
1   Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
,
Dietmar J. O. Ulrich
1   Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Abstract

Background Mechanical evacuation of capillary thrombi in free flaps is difficult, and often requires thrombolytic therapy. Utilizing machine perfusion systems, the possibility rises to salvage free flaps ex vivo by administering high doses of thrombolytic agents. The primary aim of this pilot study in a porcine model is to investigate the feasibility of ex vivo thrombolysis using an extracorporeal perfusion machine.

Methods A model of stasis-induced thrombosis was used in 12 free rectus abdominis flaps harvested from six Dutch Landrace pigs. Compromised flaps were ex vivo perfused with University of Wisconsin preservation solution and treated according to the following study groups: (1) 1 mg of tissue plasminogen activator (t-PA) as additive, (2) 3 mg of t-PA as an additive, and (3) no thrombolytic additive. Microcirculation was assessed using near-infrared fluorescence angiography.

Results Pedicled abdominal flaps were created and thrombus formation was successfully induced. Eleven abdominal flaps were perfused using the modified heart-lung machine setup. Near-infrared fluorescence angiography showed delayed or no filling was noted in the control group. In comparison, the flaps which were perfused with 1 mg t-PA or 3 mg t-PA as additive showed increased fluorescence intensity curves.

Conclusion This pilot study in a porcine model presents a reliable and reproductive stasis-induced thrombosis model in free flaps. By adding t-PA to a custom-made extracorporeal perfusion system, the indocyanine green fluorescence intensity curves increased of all flaps that were perfused with different dosages of t-PA as additives, indicating restoration of capillary pressure and microcirculatory inflow.

Keywords

swine - therapeutic thrombolysis - perfusion

Authors' Contributions (All Authors)

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.




Publication History

Received: 12 November 2021

Accepted: 22 March 2022

Article published online:
17 June 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    Google Scholar
  • 2 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
    CrossrefPubMedGoogle Scholar
  • 3 Trussler AP, Watson JP, Crisera CA. Late free-flap salvage with catheter-directed thrombolysis. Microsurgery 2008; 28 (04) 217-222
    CrossrefPubMedGoogle Scholar
  • 4 DeFazio MV, Economides JM, Anghel EL, Tefera EA, Evans KK. Lower extremity free tissue transfer in the setting of thrombophilia: analysis of perioperative anticoagulation protocols and predictors of flap failure. J Reconstr Microsurg 2019; 35 (04) 270-286
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Nguyen TT, Egan KG, Crowe DL, Nazir N, Przylecki WH, Andrews BT. Outcomes of head and neck microvascular reconstruction in hypercoagulable patients. J Reconstr Microsurg 2020; 36 (04) 271-275
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Lidman D, Daniel RK. Evaluation of clinical microvascular anastomoses–reasons for failure. Ann Plast Surg 1981; 6 (03) 215-223
    CrossrefPubMedGoogle Scholar
  • 7 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
    Google Scholar
  • 8 Brouwers K, Kruit AS, Hummelink S, Ulrich DJO. Management of free flap salvage using thrombolytic drugs: a systematic review. J Plast Reconstr Aesthet Surg 2020; 73 (10) 1806-1814
    CrossrefPubMedGoogle Scholar
  • 9 Fudem GM, Walton RL. Microvascular thrombolysis to salvage a free flap using human recombinant tissue plasminogen activator. J Reconstr Microsurg 1989; 5 (03) 231-234
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Atiyeh BS, Fuleihan NS, Musharafieh RS. Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-PA). J Reconstr Microsurg 1999; 15 (08) 585-590
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Casey III WJ, Craft RO, Rebecca AM, Smith AA, Yoon S. Intra-arterial tissue plasminogen activator: an effective adjunct following microsurgical venous thrombosis. Ann Plast Surg 2007; 59 (05) 520-525
    CrossrefPubMedGoogle Scholar
  • 12 Rinker BD, Stewart DH, Pu LL, Vasconez HC. Role of recombinant tissue plasminogen activator in free flap salvage. J Reconstr Microsurg 2007; 23 (02) 69-73
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Chan RK, Mathy JA, Przylecki W, Guo L, Caterson SA. Case report superior gluteal artery perforator flap breast reconstruction salvage following late venous congestion after discharge. Eplasty 2010; 10: e63
    PubMedGoogle Scholar
  • 14 Khansa I, Chao AH, Taghizadeh M, Nagel T, Wang D, Tiwari P. A systematic approach to emergent breast free flap takeback: Clinical outcomes, algorithm, and review of the literature. Microsurgery 2013; 33 (07) 505-513
    CrossrefPubMedGoogle Scholar
  • 15 Senchenkov A, Lemaine V, Tran NV. Management of perioperative microvascular thrombotic complications - the use of multiagent anticoagulation algorithm in 395 consecutive free flaps. J Plast Reconstr Aesthet Surg 2015; 68 (09) 1293-1303
    CrossrefPubMedGoogle Scholar
  • 16 Kruit AS, Brouwers K, van Midden D. et al. Successful 18-h acellular extracorporeal perfusion and replantation of porcine limbs - histology versus nerve stimulation. Transpl Int 2020
    PubMedGoogle Scholar
  • 17 Slater NJ, Zegers HJH, Küsters B, Beune T, van Swieten HA, Ulrich DJO. Ex-vivo oxygenated perfusion of free flaps during ischemia time: a feasibility study in a porcine model and preliminary results. J Surg Res 2016; 205 (02) 292-295
    CrossrefPubMedGoogle Scholar
  • 18 Constantinescu MA, Knall E, Xu X. et al. Preservation of amputated extremities by extracorporeal blood perfusion; a feasibility study in a porcine model. J Surg Res 2011; 171 (01) 291-299
    CrossrefPubMedGoogle Scholar
  • 19 Woodside KJ, Goldfarb DA, Rabets JC. et al. Enhancing kidney function with thrombolytic therapy following donation after cardiac death: a multicenter quasi-blinded prospective randomized trial. Clin Transplant 2015; 29 (12) 1173-1180
    CrossrefPubMedGoogle Scholar
  • 20 Serletti JM, Moran SL, Orlando GS, O'Connor T, Herrera HR. Urokinase protocol for free-flap salvage following prolonged venous thrombosis. Plast Reconstr Surg 1998; 102 (06) 1947-1953
    CrossrefPubMedGoogle Scholar
  • 21 Yii NW, Evans GR, Miller MJ. et al. Thrombolytic therapy: what is its role in free flap salvage?. Ann Plast Surg 2001; 46 (06) 601-604
    CrossrefPubMedGoogle Scholar
  • 22 D'Arpa S, Cordova A, Moschella F. Pharmacological thrombolysis: one more weapon for free-flap salvage. Microsurgery 2005; 25 (06) 477-480
    CrossrefPubMedGoogle Scholar
  • 23 Nelson JA, Kim EM, Eftakhari K. et al. Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity. Plast Reconstr Surg 2012; 129 (01) 8e-15e
    CrossrefPubMedGoogle Scholar
  • 24 Namgoong S, Yang JP, Jeong SH, Han SK, Kim WK, Dhong ES. Pharmacological thrombolysis: the last choice for salvaging free flaps. J Plast Surg Hand Surg 2018; 52 (06) 367-374
    CrossrefPubMedGoogle Scholar
  • 25 Lipton HA, Jupiter JB. Streptokinase salvage of a free-tissue transfer: case report and review of the literature. Plast Reconstr Surg 1987; 79 (06) 977-981
    CrossrefPubMedGoogle Scholar
  • 26 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 (03) 117-121
    CrossrefPubMedGoogle Scholar
  • 27 Goldberg JA, Pederson WC, Barwick WJ. Salvage of free tissue transfers using thrombolytic agents. J Reconstr Microsurg 1989; 5 (04) 351-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Wechselberger G, Schoeller T, Ohler K, Anderl H, Ninković M. Flap salvage in a “flow-through” flap by manual thrombectomy plus thrombolytic therapy. J Reconstr Microsurg 1998; 14 (02) 127-129
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Panchapakesan V, Addison P, Beausang E, Lipa JE, Gilbert RW, Neligan PC. Role of thrombolysis in free-flap salvage. J Reconstr Microsurg 2003; 19 (08) 523-530
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Bäumer W, Herrling GM, Feige K. Pharmacokinetics and thrombolytic effects of the recombinant tissue-type plasminogen activator in horses. BMC Vet Res 2013; 9: 158
    CrossrefPubMedGoogle Scholar
  • 31 Seifried E, Tanswell P, Rijken DC, Barrett-Bergshoeff MM, Su CA, Kluft C. Pharmacokinetics of antigen and activity of recombinant tissue-type plasminogen activator after infusion in healthy volunteers. Arzneimittelforschung 1988; 38 (03) 418-422
    PubMedGoogle Scholar
  • 32 Kruit AS, Schreinemachers MJM, Koers EJ, Zegers HJH, Hummelink S, Ulrich DJO. Successful long-term extracorporeal perfusion of free musculocutaneous flaps in a porcine model. J Surg Res 2019; 235: 113-123
    CrossrefPubMedGoogle Scholar
  • 33 Fernandez EJ, Nadal RD, Gonzalez SM, Caffee HH. The effect of stasis on a microvascular anastomosis. Microsurgery 1983; 4 (03) 176-177
    CrossrefPubMedGoogle Scholar
  • 34 Thomson JG, Kim JH, Syed SA, Reid MA, Madsen J, Restifo RJ. The effect of prolonged clamping and vascular stasis on the patency of arterial and venous microanastomoses. Ann Plast Surg 1998; 40 (04) 436-441
    CrossrefPubMedGoogle Scholar
  • 35 Wessler S, Reimer SM, Sheps MC. Biologic assay of a thrombosis-inducing activity in human serum. J Appl Physiol 1959; 14: 943-946
    CrossrefPubMedGoogle Scholar
  • 36 Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV. Quantitative assessment of perfusion and vascular compromise in perforator flaps using a near-infrared fluorescence-guided imaging system. Plast Reconstr Surg 2009; 124 (02) 451-460
    CrossrefPubMedGoogle Scholar
  • 37 Cornelissen AJM, van Mulken TJM, Graupner C. et al. Near-infrared fluorescence image-guidance in plastic surgery: a systematic review. Eur J Plast Surg 2018; 41 (03) 269-278
    CrossrefPubMedGoogle Scholar
  • 38 Muggeo VM. Segmented: an R package to fit regression models with broken-line relationships. R News 2008; 8: 20-25
    PubMedGoogle Scholar
  • 39 Didisheim P. Animal models useful in the study of thrombosis and antithrombotic agents. Prog Hemost Thromb 1972; 1: 165-197
    PubMedGoogle Scholar
  • 40 Mousa SA. In vivo models for the evaluation of antithrombotics and thrombolytics. Methods Mol Biol 2010; 663: 29-107
    CrossrefPubMedGoogle Scholar
  • 41 Hitier M, Cracowski JL, Hamou C, Righini C, Bettega G. Indocyanine green fluorescence angiography for free flap monitoring: a pilot study. J Craniomaxillofac Surg 2016; 44 (11) 1833-1841
    CrossrefPubMedGoogle Scholar
  • 42 Holm C, Tegeler J, Mayr M, Becker A, Pfeiffer UJ, Mühlbauer W. Monitoring free flaps using laser-induced fluorescence of indocyanine green: a preliminary experience. Microsurgery 2002; 22 (07) 278-287
    CrossrefPubMedGoogle Scholar
  • 43 Betz CS, Zhorzel S, Schachenmayr H. et al. Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited indocyanine green: preliminary results. J Plast Reconstr Aesthet Surg 2009; 62 (12) 1602-1608
    CrossrefPubMedGoogle Scholar
  • 44 Ludolph I, Horch RE, Arkudas A, Schmitz M. Enhancing safety in reconstructive microsurgery using intraoperative indocyanine green angiography. Front Surg 2019; 6: 39
    CrossrefPubMedGoogle Scholar
  • 45 Pruimboom T, van Kuijk SMJ, Qiu SS. et al. Optimizing indocyanine green fluorescence angiography in reconstructive flap surgery: a systematic review and ex vivo experiments. Surg Innov 2019; •••: 1553350619862097
    PubMedGoogle Scholar
  • 46 Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg 2009; 25 (01) 21-26
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Munabi NC, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial. J Plast Reconstr Aesthet Surg 2014; 67 (04) 449-455
    CrossrefPubMedGoogle Scholar
  • 48 To C, Rees-Lee JE, Gush RJ. et al. Intraoperative tissue perfusion measurement by laser speckle imaging: a potential aid for reducing postoperative complications in free flap breast reconstruction. Plast Reconstr Surg 2019; 143 (02) 287e-292e
    CrossrefPubMedGoogle Scholar
  • 49 Smit JM, Negenborn VL, Jansen SM. et al. Intraoperative evaluation of perfusion in free flap surgery: a systematic review and meta-analysis. Microsurgery 2018; 38 (07) 804-818
    CrossrefPubMedGoogle Scholar
  • 50 Shaw GJ, Dhamija A, Bavani N, Wagner KR, Holland CK. Arrhenius temperature dependence of in vitro tissue plasminogen activator thrombolysis. Phys Med Biol 2007; 52 (11) 2953-2967
    CrossrefPubMedGoogle Scholar
  • 51 Blinc A, Francis CW. Transport processes in fibrinolysis and fibrinolytic therapy. Thromb Haemost 1996; 76 (04) 481-491
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Kotamarti VS, Shiah E, Rezak KM, Patel A, Ricci JA. Does anticoagulation improve flap outcomes in hypercoagulable patients? A systematic review. J Reconstr Microsurg 2020; 36 (03) 204-212
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Bene NC, Minasian RA, Khan SI, Desjardins HE, Guo L. Ethnic disparities in thrombotic and bleeding diatheses revisited: a systematic review of microsurgical breast reconstruction across the East and West. J Reconstr Microsurg 2022; 38 (01) 84-88
    Article in Thieme ConnectPubMedGoogle Scholar