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Salvage Rate of Late Anastomotic Thrombosis in Microvascular Reconstruction
John G. Fernandez, MD, Peter W. Henderson, MD, MBA, Yeliz Cemal, MD, Babak J. Mehrara, MD, Andrea Pusic, MD, MHS, FRCSC, Colleen McCarthy, MD, FRCSC, Evan Matros, MD, MMSc, Peter G. Cordeiro, MD, FACS, Joseph J. Disa, MD, FACS
Memorial Sloan Kettering Cancer Center, New York, NY, USA

BACKGROUND: Thrombosis at either the venous or arterial anastomosis following free tissue transfer (FTT) is an extremely serious complication that often leads to flap failure. Although most thrombotic events occur in the first 48 hours following surgery, thrombosis can occur days or even weeks later. Thrombosis on post-operative day 5 or later is commonly deemed “late thrombosis,” and the salvage rate for this group is reported to be exceedingly low, as low as 0% in some series, though anecdotal experience suggests it could in fact be higher. This study sought to better define the salvage rate in late thrombosis after FTT.
METHODS: A retrospective chart review was performed on all free flaps (breast, head and neck, trunk, and extremity) performed at Memorial Sloan-Kettering Cancer Center between 1986 and 2010. All patients that required emergent take-backs for anastomotic thrombosis were identified. Events were then categorized as early or late thrombosis, with late thrombosis defined as thrombosis occurring on post-operative day 5 or later. The incidence and salvage rates were then analyzed.

RESULTS: A total of 2650 free flaps were performed during the study time period, and 72 operations were performed for thrombosis in 61 patients (2.7%). The mean day of thrombosis was 3.9 days (SD ± 3.1 days). The overall salvage rate was 75% (46 patients). Thirty six patients suffered a thrombotic event between POD 0 to POD 4. Salvage rates for arterial and venous thrombosis were 71 % and 95% respectively. In five cases, both arterial and venous thrombosis were noted, with a salvage rate of 60%. Twenty five patients suffered a thrombotic event on POD 5 or later. Thirteen of those 25 (52%) were salvaged. Salvage rates for arterial and venous thrombosis were 63 % and 67% respectively. In five cases, both arterial and venous thrombosis were noted, however the salvage rate was 0 %. The salvage rates for head and neck flaps, breast flaps and extremity flaps were 61% (11/18), 50% (3/6) and 100% (1/1). The latest day at which thrombosis occurred was POD 17, and the latest day at which a flap that suffered a thrombotic event was salvaged was POD 9.
CONCLUSIONS: Despite previous reports that suggest salvage is extremely rare for free flaps that suffer thrombosis (either arterial or venous) on or after post-operative day 5, our data indicates that the salvage rate can in fact be much higher. Early identification and emergent reexploration is essential for possible salvage. Further analysis is ongoing to elucidate factors relating to flap salvage and flap loss in late thrombosis.

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