Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Oregon Health & Science University, Portland.
School of Medicine, Oregon Health & Science University, Portland.
JAMA Otolaryngol Head Neck Surg. 2022 Jun 1;148(6):555-560. doi: 10.1001/jamaoto.2022.0793.
Incidence of perioperative free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown.
To assess the outcomes of a second revascularization attempt for compromised free flaps.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage.
Flaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts.
A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage.
In this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.
游离皮瓣术中并发症的发生率较低，成功挽救率高达 70%。当皮瓣再次出现并发症时，干预的价值尚不清楚。
评估游离皮瓣第二次再血管化的结果。
设计、地点和参与者：这项多中心回顾性病历回顾包括 6 家美国医疗中心 2000 年 1 月 1 日至 2020 年 12 月 30 日期间接受头颈部重建的游离皮瓣患者。患者年龄 18 岁或以上，有头颈部癌症、放射性骨坏死或其他创伤导致的缺陷史。在确定的 3510 个皮瓣中，79 个皮瓣首次成功挽救，再次出现并发症，并进行了挽救尝试。
最初出现并发症并成功再血管化的皮瓣，出现第二次并发症，随后进行第二次挽救尝试。
共有 79 名患者（平均年龄 64 岁；61 [77%] 名男性）纳入分析。在接受第二次挽救尝试的 79 个皮瓣中，24 个（30%）存活，55 个（70%）出现坏死。在 24 个存活的皮瓣中，有 17 个（71%）进行了动脉或静脉血栓切除术，在 55 个出现坏死的皮瓣中，有 23 个（42%）进行了动脉或静脉血栓切除术（比值比，3.38；95%CI，1.21-9.47）。当遇到静脉并发症时，与不改变静脉相比，改变吻合静脉与存活率降低相关（55 个皮瓣中有 29 个[53%]和 24 个皮瓣中有 10 个[42%]）；在 24 个存活的皮瓣中，有 1 个（4%）将静脉修正到另一个分支，在 55 个坏死的皮瓣中有 19 个（35%）（比值比，0.08；95%CI，0.00-0.60）。第二次挽救尝试后皮瓣存活的相关因素包括皮瓣类型、皮瓣失败原因、术后并发症、患者合并症和第二次挽救后的肝素使用。
在这项队列研究中，游离皮瓣的第二次挽救成功率为 30%。进行动脉或静脉血栓切除术的皮瓣显示出更好的存活结果，而将静脉修正到邻近的分支静脉与皮瓣结果恶化相关。
