Direct visualization and measurement of microsurgically induced thromboembolism

A common cause of free flap and replant failure is thrombotic occlusion of the anastomosed pedicle vessel(s). Clinical observations and subsequent experimental studies showed that platelet emboli generated at the arterial anastomosis caused significant alterations in the downstream microcirculation. To study both the thrombogenic arterial (anastomosis) site and the downstream microcirculation, we developed an animal model (the isolated rat cremaster) in which we could directly view and quantitatively analyze thrombus formation and the appearance of emboli in the downstream microcirculation. Using this model we studied the effect that reducing blood flow across the arterial anastomotic site had on thrombus formation at the anastomotic site and the appearance of emboli in the downstream microcirculation. In 40 male Sprague-Dawley rats we found that reducing blood flow velocity to approximately half of normal during reperfusion nearly eliminated emboli appearing in the downstream microcirculation compared with controls, 43.9 +/- 31.5 vs. 259.5 +/- 117.8 emboli, respectively. We also found that the same low flow had no effect on thrombus size at the pedicle artery injury site yet significantly decreased the rate at which thrombus formation occurred (time to maximum thrombus size; low flow = 25.3 +/- 8 minutes, normal flow = 6.6 +/- 3 minutes). From these studies we conclude that reducing pedicle artery blood flow in our rat model during reperfusion can protect the down-stream microcirculation from platelet emboli-induced injury; however, the same reduction in flow does not affect thrombus formation in the pedicle artery. Further studies using direct observation/measurement techniques are needed for a better understanding of the mechanisms regulating free flap and replant failure.