Impact of Norepinephrine Use on Free Flap Survival in Breast Reconstructive Microsurgery

The optimal method for maintaining intraoperative blood pressure during microsurgical procedures remains controversial. While intravenous fluid administration is essential, overfilling can lead to complications. Vasopressor agents are used cautiously due to their vasoconstrictive effects, which could potentially lead to flap failure. Numerous studies have explored the possible link between amine administration and free flap failure, yielding inconsistent results. This study aims to determine whether intraoperative norepinephrine administration increases the flap failure rate in microsurgical breast reconstructions.

All women (n = 335) who underwent breast reconstruction using DIEP or PAP flaps (n = 400) in 2018 and 2022 in the Plastic Surgery Department of Georges-Pompidou European Hospital (Paris, France) were included in the study. These patients were classified into two groups based on the intraoperative administration of norepinephrine: the N+ group (50 patients) and the N- group (285 patients). Norepinephrine was administered when systolic blood pressure fell below 90 mmHg or mean arterial pressure (MAP) dropped below 65 mmHg, following fluid resuscitation in 2018, or without prior fluid loading in 2022. The primary endpoint was total flap loss. Secondary endpoints included arterial and venous thrombosis and the need for revision surgeries.

Norepinephrine administration significantly increased the risk of total flap loss in DIEP and PAP flap surgeries (p < 0.001). It also heightened the risk of arterial thrombosis (p = 0.002) and venous thrombosis (p = 0.04), and led to a greater number of revision surgeries (p < 0.001). Subgroup analysis indicated that PAP flaps are more sensitive to norepinephrine compared to DIEP flaps.

Our study suggests that the intraoperative administration of any dose of norepinephrine is associated with an increased risk of flap failure in breast reconstructive microsurgery using DIEP and PAP flaps.