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Porcine As a Training Module for Head and Neck Microvascular Reconstruction
Published on: September 29, 2018
Microsurgical head and neck reconstruction in patients with coronary artery disease: A perioperative assessment
Marie-Therese Scaglioni1,2, Pietro Giovanoli1, Mario F Scaglioni1,2
1Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.
Insights
Patients with coronary artery disease (CAD) undergoing head and neck microsurgery face high risks. A standardized cardiac assessment algorithm can improve outcomes for these complex cases.
Area of Science:
- Cardiovascular Surgery
- Head and Neck Surgery
- Microsurgery
Background:
- Increasing number of elderly patients undergoing microsurgical procedures.
- Coronary artery disease (CAD) management in this population is challenging.
- Limited evidence exists regarding morbidity and mortality in these patients.
Purpose of the Study:
- To present experiences with elderly CAD patients undergoing head and neck microsurgery.
- To propose a preoperative cardiac assessment algorithm.
- To describe perioperative risks and outcomes.
Main Methods:
- Retrospective analysis of 57 patients with CAD undergoing 58 free flap reconstructions.
- Detailed recording of patient characteristics and comorbidities.
- Focus on preoperative cardiac assessment including medical history, risk assessment, Doppler-echocardiography, and myocardial perfusion assessment.
Main Results:
- 54.4% of patients underwent cardiac catheterization based on preoperative cardiac assessment.
- High flap survival rate (96.6%).
- Overall surgical complication rate was 28.1%, with wound infections and partial flap necrosis as common issues. Mortality rate was 5.2%.
Conclusions:
- Head and neck microsurgery in CAD patients carries significant perioperative risks.
- The microsurgical community should share experiences to establish evidence-based risk statements.
- A standardized perioperative cardiac assessment and treatment algorithm is introduced for improved patient management.
Background:
With the rising number of patients in advanced age receiving microsurgical procedures, coronary artery disease (CAD) and its challenging management is of increasing importance. Evidence based data concerning morbidity and mortality are rare. We present our experiences with this highly selected patient population and propose a preoperative assessment algorithm.
Patients And Methods:
Between January 2006 and May 2016, a total of 57 patients with CAD received 58 free flaps. Median age of our patients was 64 years (interquartile range 57.5-70.0). Squamous cell carcinoma was the reason for reconstruction in all cases. Defect of the buccal, gum, tongue, lip, trigone, palatal, and hypopharyngeal regions were reconstructed. Patient characteristics and comorbidities were recorded. We especially focused on the preoperative cardiac assessment and treatment of patients who were scheduled for microsurgical free tissue transfer such as medical history, cardiac risk assessment, and further cardiac testing such as Doppler-echocardiography and myocardial perfusion assessment. Intraoperative course as well as postoperative morbidity and mortality was described.
Results:
About 54.4% of the selected cohort received cardiac catheterization due to a clinical preoperative cardiac assessment performed individually by the cardiologist on duty. In total, 52 fasciocutaneous anterolateral thigh flaps, four osteocutaneous fibula flaps, and two radial forearm flaps were performed. The flap survival rate was 96.6%. The overall surgical complication rate was 28.1% (16 patients), mostly due to wound infections (seven cases) and partial flap necrosis (four cases). Three patients died, resulting in a mortality rate of 5.2%.
Conclusion:
CAD patients receiving head and neck microsurgical reconstructions are still at high risk for adverse consequences due to surgery. The microsurgical community is requested to share the experience of those cases in order to develop reliable and evidence based statements of the perioperative risks and prognosis for these patients. We additionally introduce a standardized perioperative cardiac assessment and treatment algorithm for head and neck surgery patients with CAD.
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