Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-PA)

Despite all the technical improvements in microvascular surgery and the experience gained in clinical practice, thrombosis at the site of microanastomosis remains a significant problem and a continuous source of frustration to most microsurgeons. Early recognition of vascular complications and prompt reexploration with vascular revision remain an essential and standard conduct for salvage. However, in situations where conditions for no-reflow have been established due to severe vasospasm or prolonged ischemia time, it becomes obvious that surgical reexploration alone is not enough to salvage a failing flap or a replanted limb. In such situations, the loss of the revascularized tissues seems to be inevitable. The authors describe their experience in partially salvaging a failing free flap with recombinant tissue plasminogen activator (rt-PA), reversing an established state of no-reflow. Pharmacologic manipulation of the complex and variable factors influencing anastomotic patency in microvascular tissue transfer seems to offer a new hope for preventing failures, as well as for salvaging failing flaps. It appears also that free-tissue transfer failure is not an all-or-none phenomenon.