Tall Jael, Björklund Tinna Christersdottir, Skogh Ann-Charlott Docherty, Arnander Claes, Halle Martin
From the *Department of Surgery, Norrtälje Hospital; Departments of †Molecular Medicine and Surgery, Section of Reconstructive Plastic Surgery and ‡Medicine, Center for Molecular Medicine, Karolinska Institutet; and §Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm Sweden.
Ann Plast Surg. 2015 Sep;75(3):309-15. doi: 10.1097/SAP.0000000000000081.
Radiotherapy as a risk factor for free flap failure has been widely debated. The purpose of this study was to investigate vascular complications in free flap surgery at a center advocating preoperative radiotherapy. On the basis of previous experimental studies, we also aimed to investigate temporal aspects of vascular complications in both arteries and veins. Furthermore, we aimed to study the effect of tissue plasminogen activator (tPA), because irradiated microvascular recipient vessels are associated with impaired fibrinolysis.A retrospective review was conducted for 344 consecutive head and neck microvascular reconstructions. Radiotherapy was administered previously in 283 (82%) of the cases, median dose 64 Gy. Flap outcome, vascular complications, and salvage attempts were identified, along with time elapsed from completed radiotherapy, described as early (<6 weeks), delayed (6-15 weeks) and late (>15 weeks) reconstructions.Total flap loss was more common in irradiated cases (P = 0.035), among which flap failure increased with time elapsed from the last radiotherapy session to surgery (P = 0.021). Among 30 registered vascular complications, venous thrombosis was the most common type and increased in delayed, compared to early, reconstructions (P = 0.012). Increased salvage rates were observed when tPA was administered intraoperatively (P = 0.015).The present study indicates that previous radiotherapy is a risk factor for head and neck free flap failure, especially in delayed reconstructions. This may be linked to previous findings of impaired fibrinolysis in irradiated microvascular recipient veins, which is further supported by the beneficial effect of tPA during salvage surgery. We emphasize the importance of early reconstruction after radiotherapy and suggest that there is a role for fibrinolytic agents during free flap salvage surgery in previously irradiated subjects.
放射治疗作为游离皮瓣失败的一个风险因素一直存在广泛争议。本研究的目的是在一个提倡术前放疗的中心调查游离皮瓣手术中的血管并发症。基于先前的实验研究，我们还旨在研究动脉和静脉血管并发症的时间方面。此外，我们旨在研究组织纤溶酶原激活剂（tPA）的作用，因为受照射的微血管受区血管与纤维蛋白溶解受损有关。
对344例连续的头颈部微血管重建手术进行了回顾性研究。其中283例（82%）先前接受过放射治疗，中位剂量为64 Gy。确定了皮瓣结果、血管并发症和挽救措施，以及从放疗结束到手术的时间，分为早期（<6周）、延迟（6 - 15周）和晚期（>15周）重建。
在接受放疗的病例中，皮瓣完全坏死更为常见（P = 0.035），其中从最后一次放疗到手术的时间间隔越长，皮瓣失败的几率越高（P = 0.021）。在30例记录的血管并发症中，静脉血栓形成是最常见的类型，与早期重建相比，延迟重建中静脉血栓形成增加（P = 0.012）。术中使用tPA时挽救成功率增加（P = 0.015）。
本研究表明，先前的放射治疗是头颈部游离皮瓣失败的一个风险因素，尤其是在延迟重建中。这可能与先前关于受照射的微血管受区静脉纤维蛋白溶解受损的研究结果有关，tPA在挽救手术中的有益作用进一步支持了这一点。我们强调放疗后早期重建的重要性，并建议在先前接受过放疗的患者进行游离皮瓣挽救手术时，纤溶药物可能发挥作用。
