Johansen Anna, Halle Martin, Rittri Stina
From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden.
Plast Reconstr Surg Glob Open. 2025 Jun 11;13(6):e6856. doi: 10.1097/GOX.0000000000006856. eCollection 2025 Jun.
Flap thrombosis is a challenging complication in free flap surgery, which if untreated will lead to flap failure. Besides mechanical thrombectomy, the potential benefit of thrombolytic therapy with tissue plasminogen activator (tPA) in flap salvage surgery remains uncertain. We hypothesized that extracorporeal tPA administration combined with surgical revision would lead to fewer flap necroses without increased bleeding complications.
A retrospective study involving 1308 free flaps was conducted, including 42 patients who underwent surgical revision due to established flap thrombosis. The administration of tPA was analyzed in relation to the outcome variables: total and partial flap necrosis, secondary blood transfusion, and exploration for a hematoma or a new thrombosis.
Twenty-two patients received tPA during reexploration, and 20 patients did not. In the tPA group, 9 (41%) total flap failures occurred, and 4 (18%) flaps experienced partial flap necrosis. By comparison, in the tPA naive group, there were 4 (20%) total flap failures and 2 (10%) with partial flap necrosis (not significant). No differences were found in terms of the need for blood transfusion, secondary reexploration for bleeding, or a new thrombosis between the tPA and tPA naive groups.
We did not find that tPA reduced the risk for flap necrosis, nor did it increase the risk for secondary bleeding-related adverse effects. We believe that there was a selection bias toward more severely compromised flaps receiving tPA. We consider extracorporeally administrated tPA in the flap to be safe and a valuable tool in flap salvage surgery.
皮瓣血栓形成是游离皮瓣手术中一项具有挑战性的并发症，若不治疗将导致皮瓣坏死。除了机械性血栓切除术外，在皮瓣挽救手术中使用组织纤溶酶原激活剂（tPA）进行溶栓治疗的潜在益处仍不明确。我们假设体外给予tPA联合手术修复可减少皮瓣坏死，且不会增加出血并发症。
进行了一项涉及1308例游离皮瓣的回顾性研究，其中包括42例因已确诊的皮瓣血栓形成而接受手术修复的患者。分析tPA的使用与以下结局变量的关系：皮瓣完全坏死和部分坏死、二次输血以及探查血肿或新的血栓形成。
22例患者在再次探查时接受了tPA治疗，20例患者未接受。在tPA组中，发生了9例（41%）皮瓣完全坏死，4例（18%）皮瓣出现部分坏死。相比之下，在未使用tPA的组中，有4例（20%）皮瓣完全坏死，2例（10%）皮瓣部分坏死（差异无统计学意义）。在tPA组和未使用tPA的组之间，在输血需求、因出血进行二次探查或新的血栓形成方面未发现差异。
我们未发现tPA降低了皮瓣坏死的风险，也未发现它增加了与二次出血相关的不良反应风险。我们认为，对于接受tPA治疗的皮瓣，存在对更严重受损皮瓣的选择偏倚。我们认为在皮瓣中体外给予tPA是安全的，并且是皮瓣挽救手术中的一种有价值的工具。
