Thrombolytic therapy: What is its role in free flap salvage?

Thrombolytic agents have been demonstrated to improve free flap salvage in animal models. However, clinical evidence regarding their efficacy has been scant. The authors reviewed their experience with flap salvage using throm bolytic therapy in 1,733 free flaps from February 1990 to July 1998. Patien ts with intraoperative pedicle thrombosis were excluded from this review. F orty-one of the 55 free flaps that were reexplored emergently were identifi ed as having pedicle thrombosis. Of these 41 flaps, 28 free flaps were salv aged (flap salvage group, 68%) and 13 free flaps failed (flap failure group , 32%). Thrombolytic therapy (urokinase in 7 patients, tissue plasminogen a ctivator in I patient) was used in six flaps in the flap salvage group and two flaps in the flap failure group. Statistical analysis demonstrated no d ifference between the two groups with regard to thrombolytic therapy. There was also no difference between the two groups with regard to use of system ic heparin (100-500 U per hour) at the time of pedicle thrombosis or with r egard to whether Fogarty catheters were used. Smoking, preoperative radioth erapy, and the use of interpositional vein grafts during initial flap recon struction had no impact on the outcome of flap salvage. The flap salvage gr oup was reexplored at a mean of 1.5 days compared with the flap failure gro up, which was reexplored at a mean of 4.2 days (p = 0.007). Early detection of pedicle thrombosis remains the most important factor in the salvage of free flaps. Although these numbers are small and definitive statements' can not be made, the role of thrombolytic agents in free flap salvage requires further clinical evaluation.