Salvage of free-flaps in vessel-depleted mandibular osteoradionecrosis cases using catheter-directed thrombolysis and angioplasty.

Objectives: To evaluate the efficacy of highly selective catheter-directed thrombolysis (CDT) and angioplasty for salvage of compromised free flaps that were performed for treatment of mandibular osteoradionecrosis (ORN).

Design: Case series

Setting: University of California, Los Angeles (UCLA) Medical Center

Patients: Two patients with ORN who underwent highly selective CDT to salvage threatened free flaps are reported. One patient experienced arterial thrombosis on postoperative day 8 and underwent arterial CDT and angioplasty. A second patient underwent central venous CDT for a subclavian vein thrombosis that was diagnosed during the immediate postoperative period.Interventions Highly selective CDT and angioplasty for salvage of compromised free flaps

Main Outcomes Measured: Flap survival, patient survival, hemorrhagic complications.

Results: Both patients underwent successful thrombolysis. One patient required two CDT procedures over a 48-hour period; the other patient received continuous CDT infusion of tissue plasminogen activator (TPA) for 24 hours. There were no procedure-related complications. Long-term follow-up demonstrated complete flap survival with no flap necrosis.

Conclusion: Free flaps performed for mandibular ORN have increased complication rates, and the surgical options for salvage of flap ischemia are often limited in patients with a heavily radiated, vessel-depleted neck. Aggressive CDT and angioplasty appears to be a useful modality in managing difficult cases of free-flap salvage in patients with mandibular ORN.