Management of free flap salvage using thrombolytic drugs: A systematic review

Microvascular free tissue transfer is a reliable method for reconstructive surgery. However, pedicle thrombosis remains a serious complication following free tissue transfer as no consensus has been reached on the optimal management of failing flaps. The purpose of this systematic review is to examine the current evidence on the use of thrombolytic drugs and their effects on microvascular flap salvage rates.

A systematic literature search was performed using Medline, Embase, and, PubMed databases to identify scientific literature published between January 1987 and January 2019. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles of English language studies reporting on free flap salvage procedures or protocols using thrombolytic drugs were included and reviewed by one author.

Of 105 articles screened, 27 studies and case reports were included and qualified for data extraction. Overall, the level of evidence of the current literature is low. Thirteen retrospective studies tried to demonstrate a systemic approach for thrombolysis in flap salvage. The other 14 case reports presented clinical use of thrombolytic drugs to salvage free flaps. None of the thrombolytic agents presented had superior salvage outcomes.

A review on the current literature did not provide satisfactory and consistent evidence for the optimal management of patients with microvascular thrombosis, since no consensus has been reached on the optimal management of failing flaps. Prospective randomized studies are needed regarding their indications, dosages, and methods of administration, efficacy, and safety.