Intraoperative Vasopressor Use in Free Flap Reconstruction Is Safe and Reduces Postoperative Flap Congestion

PURPOSE: Despite decades of experience, the use of vasopressors in free flap reconstruction remains controversial. A national survey in 2014 by Vyas et al. found that many microsurgeons still avoid the use of vasopressors to treat hypotension during free flap reconstruction¹. Experimental evidence suggests the use of vasopressors has a negative impact on flap survival due to peripheral vasoconstriction^2,3, but these findings have not been borne out in clinical research^4,5. The purpose of this large single institution study was to evaluate the relationship between vasopressor use and breast free flap complications.

 

MATERIALS & METHODS: A retrospective review was conducted of all patients who underwent autologous free flap breast reconstruction between 2000-2017 with a follow-up of greater than one year after surgery. Postoperative flap complications including failure, hematoma, and congestion, as well as other postoperative complications including acute blood loss anemia, pulmonary edema, and number of revision surgeries were recorded.

 

RESULTS: A total of 780 autologous breast free flaps were reviewed, with 16 (2.0%), 369 (46.8%) and 291 (36.9%) receiving intraoperative epinephrine, phenylephrine, and ephedrine, respectively. Flap failure was observed in 15 (1.9%), venous thrombosis in 13 (1.6%) and flap congestion in 37 (4.7%) free flaps. Vasopressor use was not associated with flap failure (p = 0.345) or other complications, but was significantly associated with a decreased risk of postoperative flap congestion (p = 0.001). However, in a multivariate analysis, vasopressor use was associated with an increased risk of postoperative acute blood loss anemia (p = 0.012).

 

CONCLUSION: Consistent with previous clinical studies, there was no statistical difference in free flap failure between patients who received and did not receive vasopressors intraoperatively. In contrast to previous concerns that vasopressor use compromises flap viability, our study demonstrated intraoperative use of vasopressors was significantly associated with a decreased risk of postoperative flap congestion. These benefits must be balanced with the potential increased risk of postoperative anemia. Further research is necessary to elucidate the optimal type, dosing and schedule of vasopressor administration and which populations may benefit most from intraoperative vasopressor use.

 

REFERENCES:

1. Vyas K, Wong L. Intraoperative management of free flaps: current practice. Ann Plast Surg. 2014;72(6):S220-223.
2. Godden DR, Little R, Weston A, Greenstein A, Woodwards RT. Catecholamine sensitivity in the rat femoral artery after microvascular anastomosis. Microsurgery. 2000;20(5):217-220.
3. Massey MF, Gupta DK. The effects of systemic phenylephrine and epinephrine on pedicle artery and microvascular perfusion in a pig model of myoadipocutaneous rotational flaps. Plast Reconstr Surg. 2007;120(5):1289-1299.
4. Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg. 2015;135(1):290-299.
5. Szabo Eltorai A, Huang CC, Lu JT, Ogura A, Caterson SA, Orgill DP. Selective intraoperative vasopressor use is not associated with increased risk of DIEP flap complications. Plast Reconstr Surg. 2017;140(1):70e-77e.