Rhobaye Saif, Malahias Marco N, Youssif Sherif, Alsharkawy Kareem, Kalkat Maninder, Khalil Haitham H
Department of Plastic and Reconstructive Surgery, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom.
Department of Thoracic Surgery, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom.
Plast Reconstr Surg Glob Open. 2021 Feb 17;9(2):e3400. doi: 10.1097/GOX.0000000000003400. eCollection 2021 Feb.
The anterioabdominal wall is the most common site for low molecular weight heparin administration for anticoagulation, either for prophylactic or for therapeutic indications. Occasionally, this could be associated with damage of the abdominal pannus microvasculature, which could possibly jeopardize the reliability of free abdominal flaps as deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle, especially with therapeutic anticoagulation therapy. These flaps are reliant on a highly intricate complex vascular anatomy and perforasomes for their adequate perfusion and survival. The authors report a case of nonobstructive microvascular failure of a free muscle sparing transverse rectus abdominis muscle utilized for soft tissue coverage following resection of a chest wall breast cancer recurrence on a background of portacath-induced deep venous thrombosis of the axillary and subclavian vein whilst on chemotherapy. History of long-term therapeutic low molecular weight heparin administration in the abdomen resulted in microangiopathic densities evident on computerized tomography scan with subsequent flap failure due to possible jeopardization of the flap microvasculature and perfusion. Following exclusion of common local and systemic factors that can cause vascular compromise, a debridement and salvage re-reconstruction procedure utilizing a contralateral free latissimus dorsi flap was performed. Reconstructive surgeons should be cautious when planning to utilize free abdominal-based flaps on the background of long-term therapeutic low molecular weight heparin administration in the abdomen and may possibly explore other alternative options of using non-abdominal free flaps from the reconstructive armamentarium within this unique context.
腹壁前部是用于抗凝的低分子量肝素给药最常见的部位，无论是用于预防性还是治疗性指征。偶尔，这可能与腹部赘肉微血管的损伤有关，这可能会危及游离腹壁皮瓣（如下腹部深穿支皮瓣和保留肌肉的腹直肌肌皮瓣）的可靠性，尤其是在进行治疗性抗凝治疗时。这些皮瓣依赖于高度复杂的血管解剖结构和穿支体来实现充分的灌注和存活。作者报告了一例病例，在化疗期间，一名患者因输液港导致腋静脉和锁骨下静脉深静脉血栓形成，在切除胸壁乳腺癌复发灶后，使用保留肌肉的游离腹直肌肌皮瓣进行软组织覆盖，但出现了非阻塞性微血管功能衰竭。长期在腹部给予低分子量肝素进行治疗，导致计算机断层扫描显示微血管密度明显，随后皮瓣因微血管和灌注可能受到损害而失败。在排除了可能导致血管受损的常见局部和全身因素后，采用对侧游离背阔肌皮瓣进行了清创和挽救性重建手术。重建外科医生在计划在长期腹部给予低分子量肝素进行治疗的背景下使用游离腹壁皮瓣时应谨慎，在这种特殊情况下，可能需要探索使用重建手术器械库中其他非腹部游离皮瓣的替代方案。
