Outcomes of Free-Flap Breast Reconstruction With Vasopressor Use: A Database-Driven Propensity Score-Matched Analysis

Autologous breast reconstruction with free tissue transfer is an integral component of treatment for breast cancer patients. Utilizing agents such as vasopressors for hemodynamic management during free flap surgery remains controversial, as vasoconstriction could decrease tissue perfusion and threaten the viability of the flap. However, the true effects of vasopressor use on microsurgical outcomes are unknown, and existing literature has found mixed results. Therefore, our study aims to analyze the outcomes of free-flap breast reconstruction in the setting of perioperative vasopressor use.

The TriNetX LLC National Health Research database was utilized to identify breast cancer patients who underwent free-flap reconstruction between 2004 and 2024. The database was further queried for those who did and did not receive vasopressors within 5 days of surgery, and the 2 cohorts were matched for their demographics and comorbidities. Diagnosis and current procedural terminology codes were then used to assess for flap complications within 7 days postoperatively. Primary outcomes included flap complications requiring revision of the microvascular anastomosis, vessel repair, and flap revision. Secondary outcomes included sepsis, venous thromboembolism, and hematoma evacuation.

Of the 15,548 patients who underwent free-flap breast reconstruction, a total of 8,392 patients were associated with vasopressor use and 7,156 were not. When the two groups were matched, 6,416 patients were identified in each cohort. There was a significantly lower primary outcome rate in the group that received vasopressors (14.4% vs 16.0%; P  = 0.011). Secondary outcome rates were very low in both groups (2.21% vs 1.48%; P  = 0.002). When examining primary and secondary outcomes, there was no significant difference in total complication rate (16.6% vs 17.5%; P  = 0.084).

Our study demonstrates that perioperative vasopressor use does not significantly impact the complication rate associated with free-flap breast reconstruction. Interestingly, we found that patients who received vasopressors experienced a lower rate of flap-related complications. However, when analyzing all primary and secondary outcomes, there was no significant difference between the groups. These results suggest that vasopressor use is safe when clinically indicated in the autologous breast reconstruction population.