Pharmacological salvage of a combined distal bypass and free flap with catheter-directed thrombolysis

Transcription

1 British Journal of Plastic Surgery (2002), 55, The British Association of Plastic Surgeons doi: /bjps BRITISH JOURNAL OF ~ PLASTIC SURGERY CASE REPORTS Pharmacological salvage of a combined distal bypass and free flap with catheter-directed thrombolysis D. J. Parry, P. Byme, D. Kessel*, I. Robertson*, J. Patel*, A. Batchelort and D. J. A. Scott Departments of Vascular Surgery, *Vascular Interventional Radiology, and t Plastic Surgery, St James's University Teaching Hospital Leeds, UK SUMMARY. With recent improvements in microvascular techniques, the use of combined distal bypass and free-flap transfer has been advocated for salvaging the critically ischaemic limb in extreme conditions. Distal bypass, however, carries an inherent risk of graft failure due to thrombosis, and this may threaten the viability of the free flap and, indeed, the lower limb. We present the case of a 66-year-old man with acute-on-chronic ischaemia of his left leg and rectus abdominis free flap. Despite a prolonged ischaemic time of 72 h, both were successfully salvaged using catheterdirected recombinant tissue plasminogen activator. This is previously unreported in the literature The British Association of Plastic Surgeons Keywords: microvascular free flap, critical limb ischaemia, thrombosis, thrombolysis, recombinant tissue plasminogen activator, no-reflow phenomenon. In the ischaemic lower limb an aggressive policy of distal revascularisation has, at least in part, been shown to improve limb salvage. 1-3 In extreme cases, however, the chance of successful lower-limb salvage may be low. Arterial bypass alone is unlikely to heal large soft-tissue defects where tendon, bone or joint is exposed. Furthermore, wound complications resulting in the exposure and/or infection of an underlying distal bypass graft have conventionally required graft excision, with amputation the probable outcome. More recently, the use of microvascular free tissue transfer has been advocated to enhance limb-salvage rates in these extreme situations. 4'5 This may be performed in combination with arterial reconstruction to provide adequate inflow to the free flap. With a 5 year patency rate of around 70%, distal bypass carries an inherent risk of failure due to thrombosis. 6 Graft failure may return the lower limb to its preoperative ischaemic state, threaten the viability of a free flap or even further threaten lower-limb viability due to the division of collateral vessels during graft implantation. Over the past few years, catheter-directed thrombolysis has become established as a treatment modality in acute limb ischaemia, with successful lysis in 69%-100% of cases. 7-9 Limb-salvage rates of 86% at 6 months and 75% at 12 months have been reported. 7'8 There is no consensus, however, on the role of lyric agents in the salvage of free flaps. We present the case of a 66-year-old man who presented with acute-on-chronic ischaemia of his left leg and rectus abdominis free flap. Despite a prolonged ischaemic time of 72h, both were successfully salvaged using catheter-directed recombinant tissue plasminogen activator (rt-pa). This is previously unreported in the literature. Case report In 1997, a 66-year-old diabetic man was admitted to another hospital with a critically ischaemic left leg. He underwent a left superficial femoral to posterior tibial artery bypass using an ipsilateral reversed long saphenous vein graft. Postoperatively he developed a wound infection related to the incision through which the vein had been harvested on the anteromedial aspect of the left leg, which subsequently broke down. The resultant chronic ulcer was treated conservatively for 18 months. He then presented to our vascular unit with a large secondary haemorrhage from the ulcer base. His haemoglobin was 5.2 g dl-1 on admission. The ulcer was not clinically infected and was noted to be overlying the distal portion of his previous vein graft. He was resuscitated and taken to theatre. The source of the bleeding was found to be a 2 mm hole in the femoroposterior tibial vein graft beneath the ulcer base. This defect was 5 cm above the distal anastomosis, which was intact and well incorporated in a mass of dense fibrous tissue. Following wide debridement, an 8 cm portion of the vein graft was excised and replaced with an interpositional graft from the right basilic vein. Coverage of the soft-tissue defect and the graft was achieved using a rectus abdominis free flap. The inferior epigastric artery was anastomosed to a side branch of the basilic vein interpositional graft, and the inferior epigastric vein was anastomosed to a superficial leg vein. Intraoperative wound swabs and the excised vein graft cultured methicillin-resistant Staphylococcus aureus. This was treated with a 2 week course of intravenous vancomycin according to sensitivities. Split-skin grafts to the muscle flap were performed after 3 days, using the right thigh as the donor site. Postoperatively, he made a good recovery, and after 2 weeks he was discharged with routine Duplex surveillance of his bypass graft. After 6 weeks both the donor and skin-graft sites had fully healed. After 4 months Duplex ultrasound showed the presence of an 'at risk' graft with monophasic flow throughout. Admission 140

2 Pharmacological salvage of a combined distal bypass and free flap with catheter-directed thrombolysis 141 Figure 1--Dusky cyanosed critically ischaemic (A) left leg and (B) free flap 72 h after graft thrombosis. for angiographic assessment was arranged. However, 7 days prior to the planned admission, he presented acutely to another hospital with a 2 day history of ischaemic rest pain in his left foot. He was referred back to our unit the following day. On arrival his left foot and flap were cool and dusky (Fig. 1). The viability of the limb was marginally threatened, with a mild sensory deficit only. He was commenced on intravenous heparin. Urgent angiography, performed via an antegrade left femoral puncture, showed that both his bypass graft and the free flap had occluded. Propagated thrombus extended up to the common femoral bifurcation, and no run-off was visible (Fig. 2). Given this and the 72 h duration of ischaemia it was decided to proceed with catheter-directed thrombolysis. A guide wire was successfully passed through his vein graft, and a catheter was advanced over this. A 5 mg bolus of rt-pa was given, followed by a slow infusion at 0.5 mg h - 1. Follow-up angiograms every 6 h demonstrated progressive clot lysis (Fig. 3A). Thrombolysis was continued for 24h; there were no complications. Completion angiograms show successful lysis of the thrombosed graft and a patent free flap (Fig. 3B). A run-off stenosis was present in the posterior tibial artery at the level of the ankle (arrow), which was treated by angioplasty. Clinically, his leftleg ischaemia resolved, and 8 h after lysis his free flap was pink and well perfused (Fig. 4). Intravenous heparin was continued for 48 h, and the patient was warfarinised. He made a good recovery and was discharged after 1 week. Duplex ultrasound 3 months later showed a long stenosis in the body of the vein graft, distal to the muscle-flap pedicle and just proximal to the interpositional graft. This may have been related to ischaemic endothelial injury, and was treated with a left cephalic vein interpositional graft to the lateral plantar artery. After a further 12 months the patient remains well, with a patent graft, and is fully mobile. Figure 2---Digital subtraction arteriogram showing thrombosis of the left femoroposterior tibial bypass, Propagated thrombus is present to the level of the common femoral bifurcation, with no run-off visible below this.

3 142 British Journal of Plastic Surgery Figure (A)Follow-up angiogram after 18 h of thrombolysis, showing progressive clot dissolution with re-canalisation of the femoroposterior tibial bypass graft to the pedicle of the free flap (arrow). (B) Angiogram after completion of lysis shows successful re-canalisation of the vein graft to the level of the ankle. The pedicle of the free flap can be seen to be patent, as can some of the microcirculatory vessels. A run-off stenosis in the posterior tibial artery is present (arrow). Discussion Catheter-directed thrombolysis involves the passage of a catheter into a thrombus and delivery of a lyric agent to the point of intent, thus reducing the therapeutic dose and systemic lyric effect. It is the method of choice for the administration of lyric agents within the peripheral arterial tree. Recombinant tissue plasminogen activator is a secondgeneration plasminogen activator whose activity is specific for fibrin. Fibrin possesses t-pa binding sites close to the plasminogen binding sites and therefore promotes plasminogen activation and, thus, lysis on an active clot. Being relatively clot selective, rt-pa produces less fibrinogen depletion and systemic lyric effect than do other lyric agents. Unlike streptokinase and urokinase, it has no anfigenicity and does not result in febrile or allergic reactions. The use of rt-pa has been shown to be more efficacious than streptokinase in the treatment of acute limb ischaemia, 9 The STILE study showed rt-pa and urokinase to be equally efficacious and to have similar complication rates, although the treatment regimes were not directly comparable. 7 The thrombolytic agent of choice in our unit is rt-pa. This is based on our experience with the drug, and acceptable complication rates and cost as compared with urokinase. Although catheter-directed thrombolysis is an established treatment for acute limb ischaemia, there is no consensus about the role of fibrinolytics in salvaging failing free flaps. Some authors, using animal thrombotic models, have shown lyric agents to be efficacious in the treatment of microanastomotic thrombosis. 1~Over recent years, it has become apparent that prompt anastomoric revision and/or surgical thrombectomy are not always sufficient to salvage failing free flaps and body-part replantations. Microcirculatory thrombosis may result in total perfusion failure of the free flap despite successful thrombectomy; this is known as the 'no-reflow' phenomenon. Proposed pathogenic mechanisms include anastomoric platelet microembofisarion and ischaemia-reperfusion injury, culminating in widespread endothelial injury and secondary microcirculatory thrombosis, it In 1995 Weinzweig and Gonzalez postulated that free-flap failure was not invariably an 'all-or-none' phenomenon with

4 Pharmacological salvage of a combined distal bypass and free flap with catheter-directed thrombolysis 143 Figure 4---Both (A) the leg and (B) the free flap are clearly viable, being pink and well perfnsed 8 h after lysis. sudden anastomotic thrombosis resulting in invariable tissue necrosis. Instead, they noted that some flaps die a slow, progressive and partial death due to secondary thrombosis of the microcirculation. 12 As such, there are several reports advocating the use of local thrombolytic agents to salvage failing free flaps when conditions for no-reflow have been established~ Much of this work, however, involves the intraoperative or early postoperative use of a lytic agent as an adjunct to vascular revision and/or manual thrombectomy. In 1991 Parkhouse and Smith described the successful salvage of a replanted thumb, 30 days postoperatively, by the instillation of streptokinase directly into a radial-artery catheter. 16 We describe the successful salvage of a combined distal bypass and free flap using catheter-directed thrombolysis in the late postoperative period. This is previously unreported in the literature. Our patient had a long history of lower-limb ischaemia and, as such, had developed a collateral supply to the lower limb. This is visible on the pre-lysis angiograms, which show it extending down the thigh (Fig. 2). It seems likely that a stenosis in the posterior tibial artery precipitated sudden occlusion of the bypass graft, with subsequent propagation of thrombus into the pedicle of the free flap. Graft thrombosis resulted in an 'acute-on-chronic' ischaemic insult to the lower limb. Collateral blood flow may have reduced this insult, thus delaying the onset of irreversible change. It was, however, insufficient to maintain lower-limb viability, even in the short term, and the viability of both the lower limb and the flap were immediately threatened. With a prolonged ischaemic time of 72 h, it seems likely that widespread endothelial injury with secondary thrombosis within the free-flap microcirculation would have taken place to some extent. Angiograms failed to demonstrate the presence of a collateral supply to the flap, although, in states of very low flow, even delayed films may fail to demonstrate patent vessels. Under these circumstances, the chances of a successful surgical thrombectomy would seem to be low, and we believe that conditions for no-reflow were likely to have been established. Ultimately, the absence of suitable run-off vessels below the common femoral artery bifurcation precluded surgical intervention. In the absence of major contraindications or advanced sensori-motor deficit, thrombolysis seemed the most realistic option to achieve both free-flap and lower-limb salvage. Although successful graft and flap re-canalisation was achieved using rt-pa, long-term graft patency is dependant upon the treatment of any underlying causative lesion. 17 For this reason, the patient underwent a posterior tibial artery angioplasty and a subsequent interpositional vein graft. Over the past few years, we have witnessed increasing use of combined bypass and free-flap procedures to achieve limb salvage under extreme conditions of critical limb ischaemia. Distal bypass carries an inherent risk of graft thrombosis, which can threaten the viability of both

5 144 British Journal of Plastic Surgery the free flap and the lower limb. We have written this case report to emphasise that successful salvage of a combined distal bypass and free flap can be achieved using catheter-directed thrombolysis in the late postoperative period. A successful outcome using rt-pa can be obtained after prolonged ischaemia when conditions for no-reflow may have been established. References 1. Mattes E, Norman PE, Jamrozik K. Falling incidence of amputations for peripheral occlusive arterial disease in Western Australia between 1980 and Eur J Vasc Endovasc Surg 1997; 13: Luther M. The influence of arterial reconstructive surgery on the outcome of critical leg ischaemia. Eur J Vasc Surg 1994; 8: Pell JP, Fowkes FGR, Ruckley CV, Clarke J, Kendrick S, Boyd JH. Declining incidence of amputation for arterial disease in Scotland. Eur J Vasc Surg 1994; 8: Illig KA, Moran S, Serletti J, et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001; 33: Lermusiaux P, Laurent B, Fisher R. Distal bypass and vascutarised skin flap for limb salvage in extreme situations. Crit Ischaemia 2000; 10: Dormandy JA, Rutherford RB. TransAtlantic Inter-Society Consensus on Peripheral Arterial Disease. J Vasc Surg 2000; 31: $ The STILE Investigators. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. Ann Surg 1994; 220: Ouriel K, Veith FJ, Sasahara AA. Thrombolysis or peripheral arterial surgery: phase I results. J Vasc Surg 1996; 23: Berridge DC, Gregson RHS, Hopkinson BR, Makin GS. Randomized trial of intra-arterial recombinant tissue plasminogen activator, intravenous recombinant tissue plasminogen activator and intra-arterial streptokinase in peripheral arterial thrombolysis. Br J Surg 1991; 78: Rohrich RJ, Handren J, Kersh R, Hergrueter CA, May JW Jr. Prevention of microvascular thrombosis with short term infusion of human tissue-type plasminogen activator. Plast Reconstr Surg 1996; 98: Esclamado RM, Carroll WR. The pathogenesis of vascular thrombosis and its impact in microvascular surgery. Head Neck 1999; 21: t2. Weinzweig N, Gonzalez M. Free tissue failure is not an all-or-none phenomenon. Plast Reconstr Surg 1995; 96: Atiyeh BS, Fuleihan NS, Musharafleh RS. Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-pa). J Reconstr Microsurg 1999; 15: Atiyeh BS, Hashim HA, Hamdan AM, Musharafieh RS. Local recombinant tissue plasminogen activator (rt-pa) thrombolytic therapy in microvascular surgery. Microsurgery 1999; 19: Serletti JM, Moran SL, Orlando GS, O'Connor T, Herrera HR. Urokinase protocol for free-flap salvage following prolonged venous thrombosis. Plast Reconstr Surg 1998; 102: Parkhouse N, Smith PJ. The use of streptokinase in replant salvage. J Hand Surg 1991; 16B: Dormandy JA, Rutherford RB. TransAtlantic Inter-Society Consensus on Peripheral Arterial Disease. J Vasc Surg 2000; 31: S159. The Authors Duncan Parry FRCSEd, Vascular Research Fellow Peter Byrne FRCS, Vascular Research Fellow D. Julian A. Scott MD, FRCS, FRCSEd, Consultant Vascular Surgeon Department of Vascular Surgery, David Kessel MRCP, FRCR, Consultant Vascular Radiologist lain Robertson MRCP, FRCR, Consultant Vascular Radiologist Jai Patel MRCP, FRCR, Consultant Vascular Radiologist Department of Vascular Interventional Radiology, Andrew Batchelor FRCS, Consultant Plastic Surgeon Department of Plastic Surgery, St James's University Teaching Hospital, United Leeds Hospital Trust, Beckett Street, Leeds LS9 7TF, UK. Correspondence to Mr D. J. A. Scott. Paper received 23 March Accepted 28 September 2001, after revision. British Journal of Plastic Surgery (2002) The British Association of Plastic Surgeons doi: /bjps Autosomal dominant craniometaphyseal dysplasia with atypical features D. R. McKay and J. A. Fialkov Division of Plastic Surgery, Department of Surgery, Sunnybrook and Women's College Health Science Centre, Toronto, Ontario, Canada SUMMARY. Craniometaphyseal dysplasia (CMD) is a rare genetic disorder of bone modelling characterised by hyperostosis and sclerosis of the craniofacial bones, and abnormal modelling of the metaphyses. Clinically, autosomal dominant (AD) CMD is characterised by facial distortion and cranial-nerve compression. The goals of surgical treatment for AD CMD are cosmetic recontouring of the sclerotic craniofacial bones, correction of nasal obstruction and correction or prevention of neurological manifestations. We describe the successful correction of AD CMD craniofacial manifestations in an individual with atypical findings, and outline an approach for correcting the craniofacial deformities associated with this rare disorder The British Association of Plastic Surgeons Keywords: craniometaphyseal dysplasia, autosomal dominant, bony craniodysplasia, corrective recontouring, case report.