Maitani Kosuke, Tomita Koichi, Tashima Hiroki, Nomori Michiko, Taminato Mifue, Kubo Tateki
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
Plast Reconstr Surg Glob Open. 2020 Dec 17;8(12):e3299. doi: 10.1097/GOX.0000000000003299. eCollection 2020 Dec.
While the use of free flaps has become routine and is associated with a low complication rate, pedicled flaps remain a solid reconstructive option in various clinical situations. Pedicled flaps provide a reliable vascular supply and involve a simple surgical procedure. Although the procedure is advantageous from the standpoint of a low rate of flap ischemia, thrombosis, and total flap loss, these complications are still occasionally observed due to intraoperative pedicle injury, postoperative torsion, or compression. Here we report on a case of severe venous thrombosis in a pedicled latissimus dorsi (LD) flap used for breast reconstruction. The patient was a 52-year-old woman who underwent mastectomy and immediate breast reconstruction with a LD flap for left breast cancer. Postoperatively, the color of the skin paddle became dark blue over time. Emergent surgical exploration revealed kinking and narrowing of the thoracodorsal vessels and extensive venous thrombi. The kinked pedicles were repaired and selective thrombolytic therapy was performed. A thrombolytic agent was administered through the serratus anterior branch of the thoracodorsal artery in retrograde fashion while the thoracodorsal vessels were clamped just cephalad to the bifurcation. This allowed for draining of the thrombolytic agent and thrombi through the serratus anterior branch of the thoracodorsal vein without flowing into the systemic circulation. To the best of our knowledge, this is the first report of selective thrombolysis using a pedicle branch to treat venous thrombosis in a pedicled flap. If major vascular branches are available in a pedicled flap, selective thrombolytic therapy may be possible without disconnecting the pedicle, as in the present case.
尽管游离皮瓣的应用已成为常规操作，且并发症发生率较低，但带蒂皮瓣在各种临床情况下仍是一种可靠的重建选择。带蒂皮瓣提供可靠的血供，手术操作简单。虽然从皮瓣缺血、血栓形成及皮瓣完全坏死发生率低的角度来看该手术具有优势，但由于术中蒂部损伤、术后扭转或受压，这些并发症仍偶尔会出现。在此，我们报告一例用于乳房重建的带蒂背阔肌（LD）皮瓣发生严重静脉血栓形成的病例。患者为一名52岁女性，因左乳腺癌接受了乳房切除术，并立即采用LD皮瓣进行乳房重建。术后，皮瓣皮肤颜色随时间逐渐变为深蓝色。急诊手术探查发现胸背血管扭结、变窄以及广泛的静脉血栓形成。对扭结的蒂部进行了修复，并实施了选择性溶栓治疗。在胸背血管分叉上方进行钳夹时，通过胸背动脉的前锯肌支逆行注入溶栓剂。这样可使溶栓剂和血栓通过胸背静脉的前锯肌支引流，而不会流入体循环。据我们所知，这是首例利用蒂部分支进行选择性溶栓治疗带蒂皮瓣静脉血栓形成的报告。如果带蒂皮瓣中有主要血管分支，如本例所示，在不切断蒂部的情况下进行选择性溶栓治疗或许是可行的。
