Salvage of Free-Flaps in Vessel-Depleted Mandibular Osteoradionecrosis Cases Using Catheter-Directed Thrombolysis and Angioplasty

Abstract

Objectives To evaluate the efficacy of highly selective catheter-directed thrombolysis (CDT) and angioplasty for salvage of compromised free flaps that were performed for treatment of mandibular osteoradionecrosis (ORN).

Design Case series

Setting University of California, Los Angeles (UCLA) Medical Center

Patients Two patients with ORN who underwent highly selective CDT to salvage threatened free flaps are reported. One patient experienced arterial thrombosis on postoperative day 8 and underwent arterial CDT and angioplasty. A second patient underwent central venous CDT for a subclavian vein thrombosis that was diagnosed during the immediate postoperative period.

Interventions Highly selective CDT and angioplasty for salvage of compromised free flaps

Main Outcomes Measured Flap survival, patient survival, hemorrhagic complications.

Results Both patients underwent successful thrombolysis. One patient required two CDT procedures over a 48-hour period; the other patient received continuous CDT infusion of tissue plasminogen activator (TPA) for 24 hours. There were no procedure-related complications. Long-term follow-up demonstrated complete flap survival with no flap necrosis.

Conclusion Free flaps performed for mandibular ORN have increased complication rates, and the surgical options for salvage of flap ischemia are often limited in patients with a heavily radiated, vessel-depleted neck. Aggressive CDT and angioplasty appears to be a useful modality in managing difficult cases of free-flap salvage in patients with mandibular ORN.

Keywords

osteoradionecrosis - salvage - catheter-directed thrombolysis

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