We present a case of a 57-year-old male patient who presented with squamous cell carcinoma
on his mouth floor with cervical and mandibular metastases. Wide glossectomy with
intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous
free flap were planned. When the anastomosis between the peroneal artery of the fibular
free flap and the right lingual artery was performed, no venous flow was observed
at the vena comitans. Then re-anastomosis followed by topical application of papaverine
and lidocaine was attempted. However, the blood supply was not recovered. Warm saline
irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels
were clinically suspected, so a solution of 100,000 units of urokinase was infused
once through a 26-gauge angiocatheter inserted into the recipient artery just at the
arterial anastomotic site, until the solution gushed out through the flap vena comitans.
Immediately after the application of urokinase, arterial flow and venous return were
restored. There were no complications during the follow-up period of 11 months. We
believe that vibrating injuries from the reciprocating saw during osteotomies and
flap insetting might be the cause of microvascular thromboses. The use of urokinase
may provide a viable option for the treatment of suspicious intraoperative arterial
thrombosis.
Keywords
Salvage therapy - Free tissue flaps - Tissue plasminogen activator
