Panchapakesan Vivek, Addison Patrick, Beausang Eamon, Lipa Joan E, Gilbert Ralph W, Neligan Peter C
Division of Plastic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
J Reconstr Microsurg. 2003 Nov;19(8):523-30. doi: 10.1055/s-2004-815638.
Approximately 5 percent of microvascular free-tissue transfers fail; often this is due to microvascular or peri-anastomotic thrombosis. Various reports have advocated the use of thrombolytics for salvage of these flaps, although clinical evidence supporting this approach is sparse. The authors attempted to review their own and other published results and present an algorithm for the use of thrombolytics in the management of failing free flaps. A retrospective review of 590 free flaps, revealed 71 (12 percent) requiring re-exploration for impending flap failure, determined by standard clinical indicators. Forty-four (62 percent) were found to have pedicle thrombosis and 20 (28 percent) received thrombolysis with streptokinase or urokinase. All 44 flaps were grouped by final outcome and thrombolytic use for comparison. In 24 (55 percent) of the flaps with evidence of thrombosis, the use of thrombolytics was felt to be inappropriate or unnecessary; 13 (54 percent) of these were salvaged. Twenty flaps, however, did receive thrombolysis and 6 (30 percent) of these were salvaged. There was no statistically significant difference among groups with respect to preoperative risk factors, age, gender, flap type, and site of anastomotic thrombosis. There was a twofold higher use of vein grafts in the failed vs. salvaged flaps (36 percent vs. 15.7 percent), and no flaps with vessel grafts were salvaged with thrombolytics. Despite the fact that all flaps were re-explored within 3 hr of a problem being detected, the mean time from the initial operation to re-exploration was significantly higher in flaps that did not respond to thrombolytics (63. 8 vs. 32.8 hr, respectively, p=0.0457). Also, the mean time to re-exploration was significantly higher in the salvaged flaps receiving thrombolysis vs. those that did not (32.8 vs. 22.3 hr, respectively, p=0.0264). While early detection and re-exploration are crucial for salvaging failing free flaps, those flaps unresponsive to other standard interventions may benefit from the selective use of thrombolytics.
约5%的游离组织微血管移植失败；这通常是由于微血管或吻合口周围血栓形成。各种报告主张使用溶栓剂挽救这些皮瓣，尽管支持这种方法的临床证据很少。作者试图回顾他们自己以及其他已发表的结果，并提出一种在处理失败的游离皮瓣时使用溶栓剂的算法。对590例游离皮瓣进行回顾性研究，发现71例（12%）因皮瓣即将失败而需要再次手术探查，这是根据标准临床指标确定的。44例（62%）被发现有蒂部血栓形成，20例（28%）接受了链激酶或尿激酶溶栓治疗。所有44例皮瓣根据最终结果和溶栓剂使用情况进行分组以作比较。在24例（55%）有血栓形成证据的皮瓣中，使用溶栓剂被认为不合适或不必要；其中13例（54%）得以挽救。然而，有20例皮瓣确实接受了溶栓治疗，其中6例（30%）得以挽救。在术前危险因素、年龄、性别、皮瓣类型和吻合口血栓形成部位方面，各分组之间没有统计学上的显著差异。失败皮瓣与挽救皮瓣相比，静脉移植的使用频率高出两倍（分别为36%和15.7%），并且没有使用血管移植的皮瓣通过溶栓剂得以挽救。尽管所有皮瓣在检测到问题后3小时内都进行了再次手术探查，但对溶栓剂无反应的皮瓣从初次手术到再次手术探查的平均时间显著更长（分别为63.8小时和32.8小时，p = 0.0457）。此外，接受溶栓治疗的挽救皮瓣与未接受溶栓治疗的皮瓣相比，再次手术探查的平均时间也显著更长（分别为32.8小时和22.3小时，p = 0.0264）。虽然早期检测和再次手术探查对于挽救失败的游离皮瓣至关重要，但那些对其他标准干预措施无反应的皮瓣可能会从选择性使用溶栓剂中受益。
