Barhoum Fatima, Tschaikowsky Klaus, Koch Michael, Kapsreiter Markus, Sievert Matti, Müller Sarina, Goncalves Miguel, Traxdorf Maximilian, Scherl Claudia
Department of Otorhinolaryngology, Head and Neck Surgery, Waldstrasse 1, 91054, Erlangen, University of Erlangen-Nuremberg, Germany.
Department of Anesthesiology, Krankenhausstrasse 12, 91054, Erlangen, University of Erlangen-Nuremberg, Germany.
Int J Surg Case Rep. 2020;75:398-402. doi: 10.1016/j.ijscr.2020.09.035. Epub 2020 Sep 18.
Microvascular free tissue transfer is a technique for reconstruction of large defects in head and neck surgery. Failure due to microvascular thrombosis can lead to microvascular damage or flap loss. Recombinant tissue-type plasminogen activator (Alteplase) is still an off-label use but it can help to rescue free flaps when embedded in a salvage algorithm.
A 39-year-old patient with received a tumor resection and reconstruction by a radial forearm flap of the left palate. Postoperatively a venous flap thrombosis occurred and immediate surgical revision was done. Initially eperfusion of the flap could not be achieved even after mechanical removal of the thrombus. Then a thrombolysis with Alteplase, which was applied directly into the radial artery, was done. The flap was salvaged and is now completely integrated into the mucosa. Flap salvage procedure was performed according to our free flap salvage algorithm.
Thrombolysis with Alteplase for free flap salvage is not a common method. Pedicle thrombosis cannot be predicted. Important procedures during surgical intervention when thrombosis occurs are careful reopening, removal of thrombus, flushing with heparin. Since these procedures failed, surgeons decided to employ Alteplase to optimally rescue the flap.
The present case shows that pharmacological thrombolysis with Alteplase is an effective ultima ratio in free flap salvage with venous thrombosis, although it is still considered offlabel use. Early detection of flap failure and a clear salvage algorithm are important for successful surgical revisions.
微血管游离组织移植是头颈外科用于修复大面积缺损的一项技术。微血管血栓形成导致的失败可引起微血管损伤或皮瓣坏死。重组组织型纤溶酶原激活剂（阿替普酶）仍属超说明书用药，但在纳入挽救方案后有助于挽救游离皮瓣。
一名39岁患者接受了左腭肿瘤切除并采用桡侧前臂皮瓣进行重建。术后发生静脉皮瓣血栓形成并立即进行了手术翻修。最初，即使在机械清除血栓后皮瓣仍无法再灌注。随后，将阿替普酶直接注入桡动脉进行溶栓治疗。皮瓣得以挽救，目前已完全融入黏膜。皮瓣挽救手术是根据我们的游离皮瓣挽救方案进行的。
用阿替普酶进行溶栓以挽救游离皮瓣并非常用方法。蒂部血栓形成无法预测。血栓形成时手术干预的重要步骤包括小心重新打开、清除血栓、用肝素冲洗。由于这些操作均告失败，外科医生决定使用阿替普酶以最佳方式挽救皮瓣。
本病例表明，尽管阿替普酶进行药物溶栓仍被视为超说明书用药，但它是挽救静脉血栓形成的游离皮瓣的一种有效终极手段。早期发现皮瓣失败以及明确的挽救方案对于成功的手术翻修很重要。
