Free flap salvage with subcutaneous injection of tissue plasminogen activator in head and neck patients

In this report, we present our experience with subcutaneous rt‐PA injection for salvage of free radial forearm flaps with vascular compromise. Three patients underwent reconstruction of defects of the soft palate or the lateral tongue with a free radial forearm flap. Patients underwent on average two attempted operative revisions with thrombectomy and intravenous heparin injections. After recurrent venous thrombosis 3–6 days after surgery, rt‐PA (Alteplase 2 mg; 1,160,000 IE) was injected subcutaneously at multiple sites into the compromised flap as final attempt. In all three patients, successful thrombolysis with no or only partial soft tissue loss was achieved after subcutaneous injection of rt‐PA. We therefore suggest subcutaneous rt‐PA injection as an additional tool in managing difficult and recurrent cases of venous thrombosis in free flap head and neck reconstruction. © 2013 Wiley Periodicals, Inc. Microsurgery 33:478–481, 2013.     

Vascular complications and microvascular free flap salvage: the role of thrombolytic agents

Background: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. Methods: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991–2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. Results: Seventy‐four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). Conclusions: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Late salvage of a free TRAM flap.

We present the case of a patient with arterial thrombosis of a free TRAM flap 11 days after surgery. Initial salvage involved thrombectomy through an arteriotomy using a Fogarty catheter. Subsequent return to the operating theatre was necessary because of further vascular compromise. Thrombectomy was combined with flap thrombolysis and anticoagulation, and the flap remained viable at 6 months. Although rates of successful salvage vary, the literature indicates that flaps are rarely saved if signs of compromise present later than 2 days postoperatively. This case demonstrates that aggressive salvage may be successful even in cases of 'late' vascular compromise.     

Pharmacological thrombolysis: the last choice for salvaging free flaps

Abstract

Microvascular free flap transfer has become a prevailing surgery with a failure rate of <5%. However, pedicle thrombosis occurs more frequently than indicated by the failure rate. This difference is due to the successful salvage of failing flaps. During exploration, thrombi are often encountered at anastomotic sites, whereas these causes could not explain vascular compromise in other patients. Thus, we hypothesized that thrombogenic processes might occur at remote sites, specifically within microvessels of the transferred flap. This study retrospectively evaluated 323 patients who underwent microvascular free flap transfer between March 2012 and October 2016 at Korea University Guro Hospital. All patients requiring emergency exploration within 7?days after surgery were retrospectively reviewed. Of patients, 15 required explorative surgery for suspected circulatory compromise. Eight were diagnosed with thrombosis at the perianastomotic site and salvaged in accordance with our protocol. There was no detectable thrombosis at the anastomotic site in seven patients, including one patient in whom thrombosis resolved with topical papaverine application and heparinization. The remaining six patients were diagnosed with intra-flap microthrombosis without discernable thrombosis at the anastomotic site. All patients were treated following our urokinase administration protocol and salvaged without complications. Possible external causes should first be evaluated when salvaging free flaps; in the absence of such evidence, urokinase administration may be utilized as a last resort. This study is the first report describing the effectiveness of pharmacological thrombolysis in resolving intra-flap microthrombosis. Furthermore, a safe and efficient urokinase administration protocol is suggested for perianastomotic thrombosis and intra-flap microthrombosis.     

The efficacy of postoperative monitoring: A single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps

Background: An important element in achieving high success rates with free flap surgery has been the use of different techniques for monitoring flaps postoperatively as a means to detecting vascular compromise. Successful monitoring of the vascular pedicle to a flap can potentiate rapid return to theater in the setting of compromise, with the potential to salvage the flap. There is little evidence that any technique offers any advantage over clinical monitoring alone. Methods: A consecutive series of 547 patients from a single plastic surgical unit who underwent a fasciocutaneous free flap operation for breast reconstruction [deep inferior epigastric artery perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) flap, or superior gluteal artery perforator (SGAP) flap] were included. A comparison was made between the first 426 consecutive patients in whom flap monitoring was performed using clinical monitoring alone and the subsequent 121 patients in whom monitoring was achieved with the Cook‐Swartz implantable Doppler probe. Outcome measures included flap salvage rate and false‐positive rate. Results: There was a strong trend toward improved salvage rates with the implantable Doppler probe compared with clinical monitoring (80% vs. 66%, P = 0.48). When combined with the literature (meta‐analysis), the data prove statistically significant (P < 0.01). There was no statistical difference between the groups for false‐positive rates. Conclusion: Flap monitoring with the implantable Doppler probe can improve flap salvage rates without increasing the rate of false‐positive takebacks. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Lower extremity free flap reconstruction outcomes using venous coupler

Background: Microvascular anastomotic coupling devices have been available to microsurgeons for over 20 years. Many studies have validated the efficacy of these devices for venous anastomosis. To date, there have been no large reports of their success in the anatomical region with the highest free flap failure rate, the lower extremity. Methods: A retrospective review of 67 consecutive patients who underwent lower extremity microvascular reconstruction performed from August 2003 to September 2010 was performed. Patient charts were reviewed for age, sex, medical comorbidities, etiology of defect, location of defect, flap type, anastomotic technique, complications, flap survival, and limb salvage outcome. Results: No patients returned to the operating room to have an arterial or venous anastomosis revised. Despite 100% vascular anastomosis patency rates in 67 consecutive lower extremity free flaps, flap survival rate was 95.5%. Total complication rate (13.4%) was due to two partial and one complete flap loss, three infections, two skin graft loses, and one hematoma. There were no intraoperative or perioperative complications involving the use of a microvascular anastomotic coupling device itself. Thirty‐day and long term limb salvage rate was 97% and 92.5%, respectively. Conclusion: Microvascular anastomotic coupling devices create effective venous anastomoses in lower extremity microvascular reconstruction. Thus, it presents an important tool in the armamentarium for lower extremity microsurgical reconstruction. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Postoperative monitoring of lower limb free flaps with the Cook–Swartz implantable Doppler probe: A clinical trial

Background: Free flaps to the lower limb have inherently high venous pressures, potentially impairing flap viability, which may lead to limb amputation if flap failure ensues. Adequate monitoring of flap perfusion is thus essential, with timely detection of flap compromise able to potentiate flap salvage. While clinical monitoring has been popularized, recent use of the implantable Doppler probe has been used with success in other free flap settings. Methods: A comparative study of 40 consecutive patients undergoing microvascular free flap reconstruction of lower limb defects was undertaken, with postoperative monitoring achieved with either clinical monitoring alone or the use of the Cook‐Swartz implantable Doppler probe. Results: The use of the implantable Doppler probe was associated with salvage of 2/2 compromised flaps compared to salvage of 2/5 compromised flaps in the group undergoing clinical monitoring alone (salvage rate 100% vs. 40%, P = 0.28). While not statistically significant, this was a strong trend toward an improved flap salvage rate with the use of the implantable Doppler probe. There were no false positives or negatives in either group. One flap loss in the clinically monitored group resulted in limb amputation (the only amputation in the cohort). Conclusion: A trend toward early detection and salvage of flaps with anastomotic insufficiency was seen with the use of the Cook–Swartz implantable Doppler probe. These findings suggest a possible benefit of this technique as a stand‐alone or adjunctive tool in the clinical monitoring of free flaps, with further investigation warranted into the broader application of these devices. © 2009 Wiley‐Liss, Inc. Microsurgery 30:354–360, 2010.     

Cold ischemia in microvascular breast reconstruction

Introduction: A major drawback to microvascular free flap breast reconstruction is the length of operation—up to 9 hours or more for bilateral reconstruction. This takes a significant mental and physical toll on the surgical team, producing fatigue that may compromise surgical outcome. To facilitate the operation we have incorporated a period of cold ischemia of the flaps such that members of the surgical team can alternate a brief respite during the operation. Methods: We retrospectively reviewed our series of microvascular free flap breast reconstructions performed over a four‐year period in which cold ischemia of the flaps were induced. Results: Seventy patients underwent free flap breast reconstruction with 104 flaps. Mean cold ischemia time for all flaps was 2 hours 36 min. Average rest time per surgeon per case was 35 min. Complications included two total flap losses (1.9%), one partial flap loss (1.0%), one anastomotic thrombosis (1.0%), two hematomas (1.9%), three fat necrosis (2.9%), and two delayed healing (1.9%). Statistical analysis revealed that the probability of complications is inversely related to cold ischemia time (P = 0.0163). Conclusion: Cold ischemia facilitates breast reconstruction by allowing the surgical team to alternate breaks during the operation. This helps reduce surgeon fatigue and is well tolerated by the flap. Thus, we believe that the use of cold ischemia is safe and advantageous in microvascular breast reconstruction. © 2010 Wiley‐Liss, Inc. Microsurgery 30:361–367, 2010.     

Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion

OBJECTIVE: The purpose of this study was to determine the clinical outcome of patients undergoing catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion. METHODS: A retrospective review was performed of two university-based practices from 1988 to 2001. All patients with LEAB occlusion (<14 days by history) undergoing CDT as initial treatment were included. Technical success, complications, secondary patency, and limb salvage were examined. Additional analysis examined secondary procedures performed for residual lesions or failed CDT and the number of LEABs that were replaced or that became infected. RESULTS: One hundred four patients (77% male; mean age, 65 years) had 109 LEAB occlusions. CDT restored patency in 77%. Of the 25 LEABs that failed initial CDT, 15 underwent surgical thrombectomy/revision, four were replaced, and six underwent no further interventions. Of the 84 LEABs successfully lysed, 51 had residual lesions that underwent revision with interventional (n = 30) or surgical (n = 15) techniques or both (n = 6). Median hospital stay was 8 days with three periprocedural deaths. One quarter of CDT procedures had bleeding or thrombotic complications or both. The mean follow-up period was 45 months. Secondary patency rates on an intention-to-treat basis (attempted thrombolysis) were 32% and 19% at 1 and 5 years, respectively. After successful CDT, the 1-year secondary patency rate was comparable in LEABs with or without residual lesions (42% versus 45%). Overall, the limb salvage rates were 73% and 55% at 1 and 5 years, respectively. The survival rate was 56% at 5 years. Ten of the 54 LEABs (19%) that eventually failed after successful CDT had three or more reocclusive episodes. Seven LEABs (8.3%) salvaged with CDT eventually became infected from recurrent interventions; six of these necessitated major amputation. Twenty LEABs initially salvaged with CDT were replaced (four immediately and 16 after episodes of recurrent ischemia). Two patients died during hospitalization for treatment of recurrent ischemia. CONCLUSION: Despite relatively high initial technical success for LEAB thrombolysis, eventual failure is the rule rather than the exception. Recurrent LEAB occlusions lead to significant morbidity, including recurrent interventions, eventual graft infection/replacement, and limb loss. However, LEAB replacement has substantial problems associated with limited conduit, reoperative anatomy, and subsequent wound complications. We therefore advocate an initial attempt at CDT with liberal use of graft replacement for early and late failures or as an initial strategy in those with favorable remaining conduit.     

Salvage of a free radial forearm flap by creation of an arteriovenous fistula at the distal arterial pedicle

Interdisciplinary approaches with infrainguinal bypass grafts and free flaps between the plastic and vascular surgery may well offer an opportunity for diabetic patients with peripheral vascular disease to salvage their critically affected limbs. A free flap transfer combined with an autologous vein graft can cover large tissue defects and simultaneously improve distal perfusion even in patients with arterial occlusive disease. We are presenting a case of bypass‐free radial forearm flap used to cover a foot defect in an old diabetic patient with peripheral arterial disease. The flap perfusion deteriorated significantly during the early postoperative period. The patient was brought back to the operating room with acute thrombosis of the popliteal‐radial venous graft and the arterial pedicle of the flap. The flap was salvaged by thrombectomy and creation of an additional arteriovenous fistula at the distal arterial pedicle. The procedure improved the flap perfusion and decreased the high internal resistance that was noticed in the flap when trying to flush the radial artery during the revision surgery and was evident by continuous wave ‐Doppler sonography. The successful salvage of the flap in the presented case and the convenient long‐term follow up suggest that this technique may be safe and helpful as a last effort to salvage a bypass‐free flap with a suspected high internal resistance. © 2013 Wiley Periodicals, Inc. Microsurgery 33:391–395, 2013.     

Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction

Background.

The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction.

Methods.

We retrospectively reviewed 1310 free flap reconstructions for head and neck defects performed between July 1995 and June 2006.

Results.

Forty‐nine cases of flap compromise due to vascular obstruction (3.7%) were identified, and 27 flaps were lost (2%). Arterial occlusions occurred in 12 flaps, with a salvage rate of 33%. Eight flaps failed within the first 24 hours, and only 1 of these was salvageable. Five of the 8 flaps had intraoperative thrombosis due to technical difficulties. Venous occlusions occurred in 31 flaps, with a salvage rate of 58%. Twenty‐two venous occlusions occurred within the first 72 hours. The main reason for venous failure was mechanical obstruction due to compression, twisting, kinking, or stretching of the vein. The most common cause of late failures (after 7 days) was unrecognized failure of a buried flap owing to the lack of reliable monitoring. Overall, there was no correlation between surgeon experience and flap failure, but the flap failure rate was lower in surgeons who had performed more than 70 free flap procedures.

Conclusion.

Precise surgical techniques, avoidance of mechanical obstruction, and better monitoring of buried flaps may further improve the success rate of free tissue transfer in complex head and neck reconstruction. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

Predictive risk factors of free flap thrombosis in breast reconstruction surgery

Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage. © 2014 Wiley Periodicals, Inc. Microsurgery 34:589–594, 2014.     

Short-term augmentation of venous drainage with extra-corporeal shunt and simultaneous auto-transfusion,for salvaging a congested free flap

Adequate drainage of venous blood is the most critical part of successful free tissue transfer. We report a case of anterolateral thigh flap used for covering open communited tibial fracture. The flap was salvaged with short term augmentation of venous drainage with external shunt. The drainage was continued for six days. It was confirmed that there is no more congestion after blocking the catheter and then the drainage was discontinued on seventh day. The flap was successfully salvaged. This method has potential applications in multiple situations for successful salvage of free tissue transfer.KEY WORDS: Extracorporeal drainage, external shunt, salvage of congested flaps, venous obstruction in free flap     

Sequential free tissue transfers for simultaneous upper and lower limb salvage

Background: The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. Methods: All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free‐flap limb salvage cohorts. Results: Seventy‐four free flap limb salvage cases were performed over the 10‐year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). Conclusions: The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients. © 2013 Wiley Periodicals, Inc. Microsurgery 33:447–453, 2013.     

Acute leg ischaemia from thrombosed popliteal artery aneurysms: role of preoperative thrombolysis.

OBJECTIVE: to evaluate early and long term results of thrombolysis and surgery in acutely thrombosed popliteal artery aneurysms. SETTING: retrospective study; teaching hospital. MATERIALS: between 1990 and 2000, 109 popliteal artery aneurysms were operated on. In 24 patients acute leg ischaemia due to thrombosis of aneurysm was present. METHODS: ten patients underwent urgent surgical intervention (group 1); and 14 thrombolysis with urokinase, until patency of popliteal and tibial vessels was achieved or for a maximum of 3 days (group 2). Ultrasonographic follow-up was performed at 1, 3, 6 and 12 months and then annually. Early results and follow-up data were analysed by chi-square test and life-table analysis (Kaplan-Meier curve) and late results were compared by mean of log rank test. RESULTS: in group 1 early limb salvage was 70%; in group 2 it was 86% (p=n.s.). When thrombolysis was successful, patency and limb salvage were 100%. There was no local or systemic complications during thrombolysis nor worsening of ischaemia. Follow-up was completed in 91 cases, with a mean duration of 26 months. Forty-eight months primary patency rate was better, even if not statistically significant, in group 2 than in group 1. CONCLUSIONS: in patients with acute leg ischaemia due to thrombosis of popliteal artery aneurysms, preoperative thrombolysis can be considered a safe and effective alternative to urgent surgery.     

The intrinsic transit time of free microvascular flaps: Clinical and prognostic implications

Background: Microscope‐integrated indocyanine green near‐infrared videoangiography (ICGA) is a new method for the intraoperative assessment of vascular flow through microvascular anastomoses. The intrinsic transit time (ITT) describes the time period from the dye appears at the arterial anastomosis (t₁) till it reaches the suture line of the venous anastomosis (t₂). As the transit time reflects blood flow velocity within the flap, prolonged ITT might correlate with low blood flow and a higher rate of postoperative thrombosis. We performed a clinical trial evaluating the association between intraoperative free flap transit time and early anastomotic complications in elective microsurgery. Methods: One hundred consecutive patients undergoing elective microsurgical procedures underwent intraoperative ICG angiography (ICGA). In patients with anastomotic patency, angiograms were retrospectively reviewed and the intrinsic transit time was calculated. Postoperative outcome was registered and compared with the ITT. End points included early reexploration surgery and flap loss within the first 24 hours after surgery. Results: Fourteen patients were excluded from the study due to technical anastomotic failure. The overall flap failure rate was 6% (5/86); the incidence of early re‐exploration surgery was 10% (9/86). With a median of 31 seconds patients with an uneventful postoperative course showed significantly shorter ITTs than patients with flap loss or early postoperative reexploration (median: >120 seconds). An optimal cut‐off value of ITT > 50 seconds was determined to be strongestly associated with a significantly increased risk of at least one positive end point. Conclusions: This study demonstrates a significant predictive value of the intrinsic flap transit time for the development of flap compromise and early re‐exploration surgery. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Free tissue transfer in reconstruction following soft tissue sarcoma resection

Background: Radical surgical resection remains the single‐most important treatment in the curative multimodal therapy of soft tissue sarcomas. Refinements in surgical techniques have resulted in the development of function preserving approaches increasingly avoiding limb amputation. Patients and methods: The records of all patients (n = 34) who underwent microsurgical soft tissue coverage subsequent to primary resection of soft tissue sarcoma of the upper or lower limb from 1999 to 2009 are reviewed regarding postoperative complications, time until start of adjuvant radiation and functional outcome (Toronto Extremity Salvage Score, TESS). Results: Thirty‐four patients (range: 21–86 years) received a total of 35 free flaps. Complete tumor resection was obtained in 33 patients, one patient required re‐excision ultimately resulting in tumor‐free margin status (R0 resection). Major complications were encountered in four cases including one patient with complete flap loss requiring an additional free flap and three patients with partial flap loss requiring split‐thickness skin graft procedures. Minor complications were observed in three patients (9%). Extremity salvage could be achieved in 33 patients with adequate postoperative ambulation (TESS 84 ± 18) and adequate use of the upper extremity (TESS 80 ± 22). One patient underwent amputation. Mean time until start of adjuvant radiotherapy was 37 days (range 24–56 days). Conclusion: A synergetic center‐based interdisciplinary approach is crucial in therapeutical management of soft tissue sarcomas with the aim of R0 resection status and limb preservation. Plastic surgery contributes by offering microsurgical reconstruction using free tissue transfer, thus broadening surgical possibilities. This increases the chance of both adequate oncosurgical resection and limb preservation. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

导管接触溶栓治疗四肢非开放性外伤后动脉血栓形成

目的：探讨应用导管接触溶栓（CDT）治疗四肢外伤（非开放性）后动脉血栓形成的临床效果。 方法：回顾性分析2005年3月—2013年3月收治的152例四肢外伤后动脉血栓形成行CDT治疗患者（152条肢体）的临床资料。患者均接受CDT治疗,其中单纯CDT 89例,CDT+腔内球囊扩张成形（PTA）51例,CDT+PTA+支架置入12例。 结果：全组导管溶栓时间为1~7 d,平均（4±1.5）d。治愈105例（69.1%）,其中单纯CDT 72例,CDT+PTA 21例,CDT+PTA+支架置入12例;有效30例（19.7%）,均施行CDT+PTA治疗;无效17例（11.2%）,其中一期截肢15例（9.9%）。5例（3.3%）溶栓过程中发生二次栓塞,调整导管位置后继续溶栓;23例（15.1%）术后发生小腿骨筋膜室综合征行骨筋膜室切开减压术,均保肢成功。随访132例（86.8%）,随访时间12~108个月,平均（50±22）个月。除2例行二期截肢外,余随访患者均无症状加重或复发。 结论：CDT治疗四肢外伤后动脉血栓形成是一种安全、有效、微创的方法。     

Free flap reconstruction for diabetic foot limb salvage

Background: Although free flap is gaining popularity for the reconstruction of diabetic foot ulcers, it is unclear whether free flap reconstruction increases the chances of postoperative independent ambulation. The aim of this study is to evaluate the relationship between free flap success and postoperative ambulation.

Methods: This study reviewed 23 cases of free flap reconstruction for diabetic foot ulcers between January 2007 and March 2014. Free rectus abdominis, latissimus dorsi, and anterolateral thigh flaps were used in ten, eight, and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher’s exact test.

Results: Two patients developed congestive heart failure with fatal consequences within 14 days postoperatively, resulting in an in-hospital mortality rate of 8.7%. Five patients lost their flaps (21.7%). Of the 16 patients who had flap success, 12 achieved independent ambulation. Five patients with flap loss did not achieve independent ambulation, except one patient who underwent secondary flap reconstruction using a distally based sural flap. Fisher’s exact test revealed that independent ambulation was associated with free flap success (p?=?0.047).

Conclusion: The present study indicates that free flap reconstruction may increase the possibility of independent ambulation for patients with extensive tissue defects due to diabetic ulcers. Intermediate limb salvage rates and independent ambulation rates were favourable in patients with successful reconstruction. The use of foot orthoses and a team approach with pedorthists were effective to prevent recurrence.     

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Purpose. The delay phenomenon has been used for breast reconstruction with pedicled flaps but has not been widely reported with free flaps. Our goals were to (1) describe our operative technique for vascular delay of deep inferior epigastric artery perforator (DIEP) flaps when a large percentage of the contralateral hemiabdomen would be needed for added volume of a breast reconstruction, (2) document any clinical improvement in flap vascularization after the delay period, and (3) develop a patient selection algorithm for this procedure. Methods. From August 2008 through July 2009, six patients at The Johns Hopkins Breast Center underwent autologous breast reconstruction with vascularly delayed DIEP flaps, a technique that preserves lateral skin bridges to the flap. This technique was used based on preoperative three‐dimensional computed tomography angiograms showing potential vascular compromise. We assessed length of delay, flap weight, length of stay, and outcome. Results. Transfer delay averaged 15.8 ± 4.1 days from the original surgery. Transferred flap weight averaged 620.2 ± 156.7 g. The flaps in all six patients developed adequate arterial inflow and/or venous drainage on reassessment at final transfer. Preoperative screening with three‐dimensional computed tomography angiography of the abdominal wall and modification of the flap harvest technique, including use of the clamp test to establish need for delay, were thought to be paramount for patient selection. Conclusion. In a very select group of patients undergoing breast reconstruction whose DIEP flaps showed vascular compromise before detachment, the delay phenomenon successfully enhanced vascularity and prevented fat necrosis. © 2010 Wiley‐Liss, Inc. Microsurgery 30:526–531, 2010.