Upload
efstathios-g-lykoudis
View
220
Download
3
Embed Size (px)
Citation preview
VASCULAR PEDICLE AVULSION IN FREE FLAP BREASTRECONSTRUCTION: A CASE OF DIEP FLAP SALVAGEFOLLOWING EARLY AVULSION OF VENOUS ANASTOMOSISAND LITERATURE REVIEW
EFSTATHIOS G. LYKOUDIS, M.D., Ph.D.,* DIMOSTHENIS E. ZIOGAS, M.D., and GEORGE E. PAPANIKOLAOU, M.D.
Free flap vascular pedicle avulsion represents an extremely rare complication in reconstructive microsurgery. Very few cases have beenreported in the literature, most of them identified in free flap breast reconstruction. As a result, little data is currently available on the etiol-ogy and treatment of this rare complication. Herein, we report a unique case of early venous anastomosis avulsion following free DIEPflap transfer for delayed breast reconstruction. Venous outflow was successfully restored with the use of an interposition vein graft, and theflap survived completely. In addition, the relevant literature is reviewed; and the possible causes, preventive strategies, and managementoptions are analyzed. VVC 2010 Wiley-Liss, Inc. Microsurgery 30:233–237, 2010.
Free tissue transfer is considered the workhorse for
breast reconstruction. These methods have high success
rates and most importantly are associated with excellent
cosmetic outcomes and great patient satisfaction. The use
of a variety of flaps, mostly from the lower abdomen but
also from other areas of the body, has been reported.1,2
Regardless of the flap to be used, patency as well as
integrity of the vascular anastomoses is crucial for a
successful outcome especially in the early postoperative
period.3,4
Free flap failure in most cases is the result of anasto-
motic occlusion. Nevertheless, other aetiologies resulting
in disruption of vascular continuity, such as pedicle avul-
sion or anastomotic aneurysm rupture, although extremely
rare, have been reported.5,6 Vascular pedicle avulsion
appears to be a very rare complication, although some
cases might have been undiagnosed or not reported. Very
few cases have been reported in the literature to date; not
only in free flap breast reconstruction, but also in other
fields of free flap transfer.7,8 As a result, little data is cur-
rently available on its causes and management.
Herein, we report a unique case of early venous anas-
tomosis avulsion following free DIEP flap transfer for
delayed breast reconstruction. Venous outflow was suc-
cessfully restored with the use of an interposition vein
graft, and the flap survived completely. The relevant liter-
ature is also reviewed and guidelines for the prevention
as well as the treatment of free flap vascular pedicle
avulsion are suggested.
CASE REPORT
A 45-year-old nonsmoking woman underwent a DIEP
flap for secondary reconstruction of her left breast. The
flap was based on one medial perforator deriving from
the left deep inferior epigastric vessels. On removal of
the third costal cartilage, a duplicate venous system was
encountered on either side of internal mammary artery.
Each vein measured less than 0.5 mm in diameter, so
both of them were deemed unsuitable for use. Despite
removal of the second costal cartilage the veins had no
greater diameter. An effort to expose the ipsilateral thora-
codorsal vessels revealed that they were ligated and
encased in a scar as a result of previous axillary dissec-
tion, and were also deemed unsuitable for use. On the
basis of our previous experience with the use of the
external jugular vein for supplementary venous outflow
of DIEP flaps, this vein was selected as the primary
recipient. The external jugular vein was dissected through
three small neck incisions at natural neck creases, ligated
distally, flipped over the clavicle, tunneled into the breast
pocket, and anastomosed to the deep inferior epigastric
vein. The deep inferior epigastric artery was anastomosed
to the internal mammary artery. Although the immediate
postoperative period was uneventful, 24 hours later, the
patient while vomiting felt an abnormal stretch sensation
under the reconstructed breast and the flap became con-
gested. On exploration, partial avulsion with thrombosis
of the venous anastomosis was noted. Torn vessel wall
with intact suture loops and knots were found, indicating
mechanical force as the cause of avulsion. The anasto-
motic site was resected, the clot was removed, and retro-
grade isolated flap perfusion with 2.5 mg of rt-PA was
performed. Then, an additional 3 mm traumatized seg-
ment of the inferior epigastric and external jugular vein
was resected. To accommodate the resulted vein defect
and perform a tension free anastomosis, a segment of the
right great saphenous vein was harvested. This was used
Department of Plastic Surgery, Ioannina University School of Medicine,Ioannina, Greece
*Correspondence to: Efstathios G. Lykoudis, M.D., Ph.D., Department ofPlastic Surgrery, Ioannina University School of Medicine, University Campus,45110, Ioannina, Greece. E-mail: [email protected]
Received 13 October 2009; Accepted 2 November 2009
Published online 20 January 2010 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20738
VVC 2010 Wiley-Liss, Inc.
as an interposition graft and anastomosed to the external jug-
ular vein proximally and the deep inferior epigastric vein dis-
tally (see Fig. 1). On completion of the anastomoses 5,000
IU of heparin were administered IV, microclamps were
released, venous outflow was restored and flap congestion
was relieved. The patient was subsequently maintained on
3,500 IU low-molecular weight heparin and 100 mg acetyl-
salicylic acid each day until she was discharged uneventfully
on the 10th day after the avulsion. The flap survived com-
pletely, although a small area of skin blistering was noted,
which healed spontaneously within few days. At three-month
follow-up, the flap was soft and supple without any signs of
fat necrosis (see Fig. 2).
DISCUSSION
Microvascular free tissue transfer is a reliable method
for breast reconstruction with high success rates, ranging
from 92% to 99%. These methods primarily include the
use of the transverse rectus abdominis musculocutaneous
(TRAM) flap and the deep inferior epigastric perforator
(DIEP) flap. However, the use of a variety of other flaps,
such as the superficial inferior epigastric artery (SIEA)
flap, the superior gluteal artery perforator (S-GAP) flap
etc, has been reported.1,2,3,9
Despite the aforementioned high success rates, there is
still a small risk of flap compromise due to major
Figure 1. Intraoperative photograph, demonstrating the stumps
(arrows) of the deep inferior epigastric and external jugular vein
(A); and the saphenous vein graft used for restoration of venous
outflow (B). [Color figure can be viewed in the online issue, which
is available at www.interscience.wiley.com.]
Figure 2. Photographs of the flap at 15 days (A) and 3 months (B)
postoperatively. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
234 Lykoudis et al.
Microsurgery DOI 10.1002/micr
complications. The most commonly encountered major
complications are venous thrombosis, arterial thrombosis,
and bleeding/hematoma.3,4,10,11 Vascular pedicle avulsion
represents another serious complication, not only in breast
reconstruction but also in other fields of free tissue transfer.
Although extremely rare, disruption of the vascular pedicle
can lead not only to flap failure but may also threaten the
patient’s life, as a result of massive bleeding.12,13
A MEDLINE search of papers referring to free flap
vascular pedicle avulsion was followed by an extensive
manual search on the same topic, using references from
relevant published papers. A total of nine cases were
found, seven of which occurred in free flap breast recon-
structions, and are listed in detail in Table 1. Most of
them were case reports, although some sporadic cases
were identified in retrospective studies of breast recon-
struction with the use of free flaps.5,12–17
Vascular pedicle avulsion was encountered in four
different types of free flaps used for breast reconstruction.
In four cases both the artery and vein of the pedicle were
avulsed,13–16 while in three only the artery.5,12,17 Interest-
ingly our case represents the first and only report in the
literature, in which only the vein of the pedicle was
avulsed. Complete vessel avulsion was noticed in all
except for two cases, one of partial arterial avulsion5 and
our case of partial vein avulsion. Interestingly, pedicle
avulsion occurred almost exclusively at the site of anasto-
moses; which represents the area of minimal resistance to
injury. However in one case, the artery of the pedicle
was not avulsed at the anastomosis site but close to its
insertion into the flap.17 Vascular pedicle avulsion
occurred with the use of three different recipients: the
circumflex scapular,5 the thoracodorsal,12 and the internal
mammary vessels.13–17 In the majority of cases, five
including our case, the internal mammary vessels were
used. However, the small number of cases prevents us
from making any conclusive statement relating the inter-
nal mammary vessels with higher avulsion rates.
The aetiology of avulsion probably was the application
of excessive traction on the vascular pedicle. The mecha-
nism of the injury was evident in two cases of iatrogenic
aetiology that happened intraoperatively, and was the result
of high levels of strain exerted by the surgeon to the vascu-
lar pedicle.13,15 In the other five cases, there was no clear
avulsion mechanism.5,12,14,16,17 Nevertheless, possible
mechanisms seemed to be as follows: (1) inadvertent
abrupt forceful movements of the patient resulting in the
development of excessive traction forces on the vascular
pedicle of the flap, (2) inadequate support of a heavy and
pendulous flap exerting considerable traction on the pedi-
cle, and (3) a combination of the aforementioned mecha-
nisms. In our case, we suppose that neck hyperextension
during vomiting strained the vein against the clavicle and
resulted in partial avulsion of the anastomosis.
Table
1.VascularPedicle
Avulsionin
FreeFlapBreast
Reconstruction
Authors
Typeofflap
Recipientve
ssels
Avulsiontype
Tim
ePresentingsign
Treatm
ent
Complications
Outcome
Elliottetal.12(1990)
Lateraltransve
rse
thigh
Thoracodorsal
Complete
arterial
3rd
day
Flapischemia
None
–Flaploss
Gahankarietal.5
(2001)
DIEP
Circumflex
scapular
Partialarterial
5th
day
Flapischemia
Anastomosis
revision
Anastomosisocclusion—
successfulrevision
Complete
survival
Saldagoetal.1
3(2002)
TRAM
Notreported
Complete
arterial
andve
nous
3rd
month
Bleeding
None
–Partialflaploss
Heymansetal.1
4(2003)
S-G
AP
Internalmammary
Complete
arterial
andve
nous
8th
day
Notreported
None
–Complete
survival
Munhozetal.1
5(2004)
DIEP
Internalmammary
Complete
arterial
andve
nous
Intra-op
Bleeding
Anastomoses
revision
–Complete
survival
Geary
etal.16(2006)
DIEP
Internalmammary
Complete
arterial
andve
nous
15th
day
Bleeding
(hematoma)
Interposition
vein
grafts
Smallareaofbreakdown
Complete
survival
Enajatetal.17(inpress)
SIEA
Internalmammary
Complete
arterial
(notat
anastomosis
site)
11th
day
Bleeding
(hematoma)
Anastomosis
at
avulsionsite
Re-avulsionwithno
furthertreatm
ent
Partialflaploss
Free Flap Vascular Pedicle Avulsion 235
Microsurgery DOI 10.1002/micr
Vascular pedicle avulsion was associated either with
bleeding or vascular thrombosis. However, a sensation of
abnormal stretch or detachment of the flap was reported
in some patients.14,17 Bleeding, often associated with he-
matoma formation and acute swelling of the reconstructed
breast, was the most common presenting sign.13,15–17 In
one patient there was massive bleeding with signs of
acute hypovolemia.16 Flap ischemia due to early throm-
bosis of the ruptured vessel(s) was another presenting
sign.5,12 However in our case, flap congestion due to
early thrombosis of the partially avulsed venous anasto-
mosis was the presenting sign.
According to the data collected, emergency explora-
tion was almost exclusively performed aiming at bleeding
control in case of hemorrhage, flap salvage in case of
compromised blood supply, or both. In case of normal
blood perfusion of the flap, as a result of neovasculariza-
tion from the recipient area, ligation of the avulsed ves-
sel(s) was performed. Whereas in the case of flap com-
promise, restoration of vascular continuity was attempted
by means of direct anastomosis at the avulsion site5,15,17;
or the interposition of vein grafts.16 In one case, local
flap infusion with streptokinase was performed prior to
vascular continuity reconstruction.5 In our case, the treat-
ment aimed primarily at restoration of venous outflow.
Also, measures for prevention of rethrombosis, due to
intima damage inflicted by the avulsion injury mecha-
nism, were taken.18,19 On this basis, resection of the
anastomosis with an additional vein segment on either
side was performed, followed by local administration of a
thrombolytic agent for lysis of the established clot and
prevention of re-thrombosis. A vein graft was used to
restore vascular continuity in order to perform a tension
free anastomosis. Finally, antithrombotic agents were sys-
temically administered.
As for flap survival, four survived completely. Three of
them as a result of successful restoration of vascular conti-
nuity,5,15,16 and one as a result of neovascularization from
the recepient, despite failure to re-establish axial perfusion
on the 8th post-op day, which is not a common finding.14
However, there are certain reports, which have shown that
a period of 9 to 14 days allows for flap survival through
neovascularization, despite the loss of axial blood sup-
ply.8,14,20,21 Two flaps underwent partial necrosis after fail-
ure to re-establish axial blood supply at 11 days and 3
months respectively.13,17 A possible explanation of partial
flap necrosis at three months post-op was the presence of a
refractory to multiple aspirations seroma, that probably pre-
vented the development of adequate flap neovascularization
from the recipient bed. Finally, one flap failed since late
diagnosis of pedicle avulsion prevented any operative treat-
ment.12
Appropriate treatment for free flap vascular pedicle
avulsion is not well established in the literature because of
lack of case series. Nevertheless, according to data col-
lected from the literature and our case, although too small
and not well supported, certain guidelines are proposed for
the proper management of vascular pedicle avulsion on the
basis of the presenting sign, the degree of neovasculariza-
tion of the flap, as well as the condition and the quality of
the recipient bed. In the presence of clinical signs of pedi-
cle avulsion immediate surgical exploration should be per-
formed. Both the incision and dissection should be minimal
in order to disrupt as little as possible flap neovasculariza-
tion. In case of bleeding, microvascular clamps should be
applied at the stumps of the avulsed vessels to cease the
hemorrhage. If flap circulation is compromised, restoration
of vascular continuity should be performed by means of
anastomosis at the site of avulsion or by interposition of a
vein graft. Systemic anticoagulation should be adminis-
tered during the early postoperative period. With respect to
the use of local thrombolytic agents, such as streptokinase,
rt-Pa etc., the exact indication has not been clearly defined.
However, in the presence of an extensive established clot,
not easily removed during the exploration; local adminis-
tration of these agents may prove beneficial.4,22–24 When
flap circulation is not compromised, as a result of neovas-
cularization, ligation of the avulsed vessels is the only mea-
sure to be taken. However, in our opinion, restoration of
vascular continuity should be attempted in case of a poten-
tially poor recipient area (heavily irradiated, excessively
scarred, presence of chronic seroma etc.), since late loss of
flaps has been reported despite adequate intraoperative flap
circulation.25,26 It is also worth highlighting the value of
preventive strategies, which are gentle intraoperative flap
handling by the surgeon; as well as postoperative restrain
of the patient from abrupt forceful movements, and appli-
cation of adequate flap support, in order to prevent the de-
velopment of excessive traction forces on the vascular ped-
icle. Finally, the prophylactic use of interposition vein
grafts should be considered, if undue tension on the anasto-
moses is thought likely or is present during flap inset.
In conclusion, free flap vascular pedicle avulsion is an
extremely uncommon complication, which is associated
with bleeding and/or vascular pedicle thrombosis. Flap is-
chemia predominates in case of early avulsion of the ar-
tery or both the artery and the vein of the pedicle. How-
ever, if only the vein is avulsed, then flap congestion is
the presenting sign. The treatment aims at the control of
the bleeding, if present, as well as the salvage of compro-
mised flaps by means of restoration of vascular continuity.
REFERENCES
1. Lipa JE. Breast reconstruction with free flaps from the abdominaldonor site: TRAM, DIEAP, and SIEA flaps. Clin Plast Surg 2007;34:105–121.
2. Nahabedian MY. Breast reconstruction: A review and rationale forpatient selection. Plast Reconstr Surg 2009;124:55–62.
236 Lykoudis et al.
Microsurgery DOI 10.1002/micr
3. Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J,Metzinger SE, Dupin CL, Allen RJ. A 10-year retrospective reviewof 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg2004;113:1153–1160.
4. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Freeflap reexploration: indications, treatment, and outcomes in 1193 freeflaps. Plast Reconstr Surg 2007;119:2092–2100.
5. Gahankari D, Malyon A, Weiler-Mithoff EM. Avulsion of vascularanastomosis in free-flap breast reconstruction. Br J Plast Surg 2001;54:167–168.
6. Lykoudis EG, Papanikolaou GE, Katsikeris NF. Microvascular anas-tomotic aneurysms in the clinical setting: Case report and review ofthe literature. Microsurgery 2009;29:293–298.
7. Branford OA, Davis M, Schreuder F. Free flap survival after trau-matic pedicle avulsion in an obese diabetic patient. J Plast ReconstrAesthet Surg 2008;61:999–1000.
8. Skrbic S, Stanec Z. Early rupture of the arterial anastomoses withfree flap survival. Injury 1995;26:494–496.
9. Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ.Breast reconstruction with gluteal artery perforator (GAP) flaps: Acritical analysis of 142 cases. Ann Plast Surg 2004;52:118–125.
10. Vijan SS, Tran VN. Microvascular breast reconstruction pediclethrombosis: How long can we wait? Microsurgery 2007;27:544–547.
11. Sullivan SR, Fletcher DR, Isom CD, Isik FF. True incidence of allcomplications following immediate and delayed breast reconstruc-tion. Plast Reconstr Surg 2008;122:19–28.
12. Elliott LF, Beegle PH, Hartrampf CR Jr. The lateral transverse thighfree flap: An alternative for autogenous-tissue breast reconstruction.Plast Reconstr Surg 1990;85:169–178.
13. Geary PM, Connolly CM, Milner RH, O’Donoghue J. Successfulflap revascularization following late pedicle avulsion. J ReconstrMicrosurg 2006;22:385–386.
14. Salgado CJ, Smith A, Kim S, Higgins J, Behnam A, Herrera HR,Serletti JM. Effects of late loss of arterial inflow on free flap sur-vival. J Reconstr Microsurg 2002;18:579–584.
15. Heymans O, Lemaire V, Preud’Homme L, Nelissen X, Verhelle N.Perte du pedicule nourricier d’un lambeau libre : etude clinique sur
8 cas [Free flap pedicle loss: Clinical study on 8 cases]. Ann ChirPlast Esthet 2003;48:205–210.
16. Munhoz AM, Ishida LH, Montag E, Sturtz GP, Saito FL, RodriguesL, Gemperli R, Ferreira MC. Perforator flap breast reconstructionusing internal mammary perforator branches as a recipient site: Ananatomical and clinical analysis. Plast Reconstr Surg 2004;114:62–68.
17. Enajat M, Rozen WM, Whitaker IS, Audolfsson T, Acosta R. Howlong are fasciocutaneous flaps dependant on their vascular pedicle:A unique case of SIEA flap survival. J Plast Reconstr Aesthet Surg(in press).
18. Mitchell GM, Morrison WA, Papadopoulos A, O’Brien BM. A studyof the extent and pathology of experimental avulsion injury in rabbitarteries and veins. Br J Plast Surg 1985;38:278–287.
19. Lykoudis E, Panayotou P, Stamatopoulos C, Frangia K, Papalois A,Ioannovich J. Microvascular repair following a modified crush-avul-sion injury in a rat model: Effect of recombinant human tissue-typeplasminogen activator on the patency rate. Microsurgery 2000;20:52–58.
20. Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps:Route and timing. Plast Reconstr Surg 1980;66:85–90.
21. Godden DR, Thomas SJ. Survival of a free flap after vascular dis-connection at 9 days. Br J Oral Maxillofac Surg 2002;40:446–447.
22. Lykoudis E, Contodimos G, Tsoutsos D, Frangia K, Papalois A, Sta-matopoulos C, Ioannovich J. Microsurgical repair after crush-avul-sion injury of the femoral vein in rats: Prevention of microvascularthrombosis with recombinant human tissue-type plasminogen activa-tor (rt-PA). Microsurgery 2001;21:357–361.
23. Bonde CT, Heslet L, Jansen E, Elberg JJ. Salvage of free flaps aftervenous thrombosis: Case report. Microsurgery 2004;24:298–301.
24. Rinker BD, Stewart DH, Pu LL, Vasconez HC. Role of recombinanttissue plasminogen activator in free flap salvage. J Reconstr Micro-surg 2007;23:69–73.
25. Fisher J, Wood MB. Late necrosis of a latissimus dorsi free flap.Plast Reconstr Surg 1984;74:274–281.
26. Moolenburgh SE, van Huizum MA, Hofer SO. DIEP-flap failureafter pedicle division three years following transfer. Br J Plast Surg2005;58:1000–1003.
Free Flap Vascular Pedicle Avulsion 237
Microsurgery DOI 10.1002/micr