No abstract availableWe read with great interest the article entitled “Forty Years of Lower Extremity Take-Backs: Flap Type Influences Salvage Outcomes” by Stranix et al.1 The authors compared take-back and salvage rates between fasciocutaneous and muscle free flaps for lower extremity trauma reconstruction. They concluded that in fasciocutaneous tissue, visual recognition of vascular compromise is easier. We agree fully with this, and these apparent signs of vascular compromise sometimes present intraoperatively. We would like to share our experience with intraoperative flap congestion caused by vasopressors that were refractory to conventional vasospasm-reversing procedures.The use of vasopressors during free flap surgery has been controversial because it could potentially lead to vascular thrombosis and flap failure. A recent high-power study reported that intraoperative use of vasopressors does not increase flap compromise or failure rates.2 However, we experienced a case in which a transferred flap became congestive intraoperatively because of phenylephrine-induced refractory vasospasm, and we succeeded in reversing the vasospasm by high-pressure injection of heparinized saline.
A 26-year-old woman underwent resection of epithelioid sarcoma on the right forearm. The defect was reconstructed using a free superficial circumflex iliac perforator flap. The superficial circumflex iliac artery was anastomosed to the radial artery in an end-to-end fashion. The superficial circumflex iliac vein and the vena comitans of the superficial circumflex iliac artery were anastomosed to two different subcutaneous veins in an end-to-end fashion, respectively, proximal to the defect. The transferred flap became congested after flap inset, and the anastomosis sites were explored. The anastomosis sites were all patent, but both recipient veins were affected with severe vasospasm (Fig. 1). Neither topical application of vasodilating agents (papaverine) nor warming up the veins with warm saline could reverse the vasospasm. Indocyanine green angiography demonstrated no flow in either vein. The anastomosis sites were cut open, and the distal ends of the recipient veins were cannulated. High-pressure injection of heparinized saline finally opened up the recipient veins. After reanastomoses, vasospasms did not occur, and the flap congestion improved. The postoperative course was uneventful and the flap survived completely.
The anesthesia chart was reviewed retrospectively, and 5 g of phenylephrine was injected intravenously immediately before the episode of flap congestion. Phenylephrine directly stimulates α1-adrenergic receptors, resulting in vasoconstriction. It evokes stronger venoconstriction than arterial constriction.3 It is reported that intraoperative use of phenylephrine does not increase flap compromise and failure rates.2 In our case, however, indocyanine green angiography demonstrated no flow in either flap vein, and the skin paddle demonstrated apparent signs of congestion; leaving the static venous flow unaddressed could have resulted in thrombus formation at the anastomosis site.
There are several methods of addressing vasospasm: applying topical vasodilators,4 warming up the vessels, and removing the adventitia.5 As in this case, high-pressure injection with heparinized saline into the spastic vessels may also be a feasible method of reversing refractory vasospasm. We postulate that dilatation caused by the injection may disrupt the adventitia, which is responsible for vasospasm, although further investigation is needed to elucidate the mechanism.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this communication.
Ryo Karakawa, M.D.
Hidehiko Yoshimatsu, M.D.
Erisa Maeda, M.D.
Tomoyoshi Shibata, M.D.
Hiroki Miyashita, M.D.
Kenta Tanakura, M.D.
Tomoyuki Yano, M.D.
Masayuki Sawaizumi, M.D.
Department of Plastic and Reconstructive Surgery
Cancer Institute Hospital of the Japanese Foundation for
Cancer Research
Tokyo, Japan
REFERENCES
1. Stranix JT, Lee ZH, Jacoby A, et al. Forty years of lower extremity take-backs: Flap type influences salvage outcomes. Plast Reconstr Surg. 2018;141:1282–1287.
2. Fang L, Liu J, Yu C, Hanasono MM, Zheng G, Yu P. Intraoperative use of vasopressors does not increase the risk of free flap compromise and failure in cancer patients. Ann Surg. 2018;268:379–384.
3. De Mey J, Vanhoutte PM. Uneven distribution of postjunctional alpha 1- and alpha 2-like adrenoceptors in canine arterial and venous smooth muscle. Circ Res. 1981;48:875–884.
4. Vargas CR, Iorio ML, Lee BT. A systematic review of topical vasodilators for the treatment of intraoperative vasospasm in reconstructive microsurgery. Plast Reconstr Surg. 2015;136:411–422.
5. González MC, Arribas SM, Molero F, Fernández-Alfonso MS. Effect of removal of adventitia on vascular smooth muscle contraction and relaxation. Am J Physiol Heart Circ Physiol. 2001;280:H2876–H2881.
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