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Arch Hand Microsurg > Volume 29(2); 2024 > Article
Kim, Kwon, Kim, Song, Oh, and Ha: Improved flap perfusion and hemostasis after postoperative embolization in free flap surgery: a case report

Abstract

This study aims to present a novel use of coil embolization in managing postoperative bleeding after free flap surgery, a technique typically reserved for other medical complications. We report the case of a 77-year-old female patient who underwent muscle-sparing latissimus dorsi free flap surgery for recurrent myxofibrosarcoma on her left thigh. Although hemostasis was achieved hemostasis during surgery, the patient experienced postoperative bleeding, which was initially managed with compression and blood transfusions. Upon a critical drop in the hemoglobin level, coil embolization was performed at the proximal segment of the descending branch of the lateral circumflex femoral artery. Coil embolization successfully controlled bleeding, while preserving blood flow to the flap. The patient’s hemoglobin levels stabilized, and the flap’s perfusion improved post-procedure. This approach proved effective in managing bleeding in areas other than the anastomosis site, with the patient showing a satisfactory recovery and no significant complications in the 30-day postoperative period. Coil embolization, a method commonly used for gastrointestinal bleeding and other vascular issues, can be a viable and effective option for controlling postoperative bleeding after free flap surgery. This case demonstrates its potential as a lifesaving intervention while preserving flap viability. However, further research with more cases is needed to evaluate the generalizability and long-term outcomes of this technique in similar surgical contexts.

Introduction

Free flap reconstruction is commonly regarded as a safe surgical intervention [1,2]. Meticulous hemostasis during surgery is crucial for maintaining a clear surgical field and for postoperative management [3]. Despite achieving perfect hemostasis, postoperative bleeding can occur, postoperative bleeding may still occur due to factors such as the dislodgement of clips or ties, or elevations in blood pressure during the recovery from general anesthesia [4].
In the majority of instances, minor postoperative bleeding is effectively managed through close observation and compression. However, persistent bleeding can pose a significant threat to both flap viability and patient survival, necessitating extensive blood transfusions [5].
The literature contains limited reports on the utilization of coil embolization for managing bleeding in the context of free flap surgery. This paper aims to present a case where coil embolization was effectively employed to not only preserve flap viability but also ensure the maintenance of critical patient vitals following postoperative hemorrhage.

Case report

This study was approved by the Institutional Review Board (IRB) of Chungnam National University Hospital (CNUH IRB 2024-04-027). Written informed consent was obtained from the patient for the publication of this report including all clinical images.
A 77-year-old female patient with a history of recurrent myxofibrosarcoma on the left thigh underwent wide excision and muscle-sparing latissimus dorsi (LD) free flap reconstruction. The orthopedic surgeons performed the wide excision, which included the removal of skin, subcutaneous tissue, and parts of the vastus medialis, intermedius, lateralis, and sartorius muscles. Following this, the plastic surgeons conducted the muscle-sparing LD free flap procedure. End-to-end anastomosis was successfully performed on the descending branch of the lateral circumflex femoral artery (LCFA). The surgery proceeded without significant complications, and postoperative flap circulation was satisfactory.
Four hours after surgery, the patient’s hemoglobin (Hb) was noted to be 8.8, with moderate oozing from the wound, necessitating compression and the transfusion of one pack of packed red cells (PRC). The bleeding was likely caused by a clip dislodging postoperatively, following clipping performed during the tumor excision surgery. On the morning of postoperative day (POD) 1, despite continuous transfusions maintaining Hb levels to some extent, severe oozing and flap swelling necessitated a hematoma evacuation and exploration under local anesthesia. However, the deep surgical site and the patient’s significant discomfort prevented the identification of a clear bleeding point, leading to the decision to proceed with compression and observation.
Transitioning from POD 1 to 2, the oozing remained at a similar level to the previous day, with no significant changes in vital signs. Observation continued, but a laboratory test in the early hours revealed a critical drop in Hb to 3.7 g/dL, leading to an emergency embolization alongside the transfusion of three packs of PRC. Given the patient’s unstable hemodynamic state and continuous bleeding, coupled with the significant risk of failing to locate the bleeding point, embolization was selected as a safer and more effective method to control the hemorrhage, rather than attempting multiple explorations under general anesthesia. Angiography identified the bleeding point at the proximal segment of the descending branch of the LCFA. Prepared for the potential loss of the flap, an embolization was performed using five Nester Embolization Coils (Cook Medical, Bloomington, IN, USA) at the site above the active bleeding point (Figs. 1, 2). While preserving the blood flow to the flap as much as possible, coil embolization was performed on the proximal segment of the LCFA and the branch artery with bleeding. In the post-procedural phase, apprehensions were raised regarding potential flap necrosis. However, these concerns were mitigated as hemostasis was achieved at the bleeding sites, and the vascular supply to the flap was preserved. As a result, the perfusion to the flap was notably enhanced (Fig. 3).

Discussion

A significant challenge in this case was the occurrence of bleeding near the flap pedicle. This proximity made selective control of the bleeding through coiling particularly difficult. Prior to the procedure, extensive discussions were held with interventional radiologists to devise a strategy that would both preserve the flap and control the bleeding point. It was acknowledged and communicated to the patient that although maximum efforts would be directed towards saving the flap, there remained a possibility that redoing the free flap might be necessary.
Fortunately, postoperative outcomes differed positively from the expectations based on computed tomography and angiography images. The procedure successfully managed to stop the bleeding while maintaining blood flow to the flap. Following the reestablishment of systemic hemodynamic stability, there was a dramatic improvement in the perfusion of the flap.
The successful application of selective embolization in this case can be attributed to the bleeding point being relatively distant from the anastomosis and a considerable distance from the bifurcation site. If the stump had been too short, it would have necessitated occluding the entire proximal segment to block the bleeding point, potentially leading to flap ischemia. Therefore, when discussing embolization with an interventional radiologist, it is crucial to thoroughly analyze the vascular anatomy. It is particularly important to attempt selective embolization as distally as possible to minimize the risk of compromising the flap’s blood supply. This strategy promotes both effective hemorrhage control and the preservation of tissue viability.
Transcatheter arterial microcoil embolization is recognized as a safe and effective procedure for the curative treatment of gastrointestinal bleeding, extrahepatic pseudoaneurysms of the hepatic arteries, coronary artery perforation, and arterial injuries of the lower limbs.
To our knowledge, this case appears to be the first instance of using coil embolization to control postoperative bleeding following free flap surgery. In the existing literature, the application of coil embolization in free flap procedures is mainly documented in the context of preoperative feeding vessel embolization to minimize perioperative bleeding [6], or for addressing postoperative complications such as pseudoaneurysms or arteriovenous fistulas that occur more than a month after the surgery [7-10].
Based on the findings in our paper, it has been demonstrated that in cases of free flap surgery, when bleeding occurs in areas other than the anastomosis site, it is possible to control bleeding and preserve the flap through selective embolization. While it is not always feasible to save the flap and control bleeding in every case, this approach seems to be a viable option as a last resort.
This case report, while providing novel insights into the use of coil embolization in free flap surgery, does have its limitations. Firstly, the findings are based on a single case, which limits the generalizability of the results. The unique anatomical and physiological characteristics of the patient may have contributed to the successful outcome, which may not be replicable in all patients. Additionally, the long-term effects and potential complications of using coil embolization in this context are not fully understood and require further observation. As shown in the Fig. 3, the flap was well-preserved on the 30th day after surgery. However, since the coil is located at the anastomosis proximal portion, the possibility of future embolization or occlusion cannot be ruled out. Continuous observation of the flap is necessary to monitor for these risks. Future research should focus on conducting larger, more comprehensive studies to evaluate the generalizability and long-term outcomes of coil embolization in free flap surgery.

Conflicts of interest

The authors have nothing to disclose.

Notes

Funding

None.

Acknowledgements

This work was supported by Chungnam National University Hospital Research Fund, 2022. This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (NRF-2021R1G1A1013694).

Fig. 1.
Post-embolization angiography and computed tomography angiography. (A) The image displays a bleeding point indicated by the arrow, alongside the pedicle that points toward the flap anastomosis, marked by a asterisk. (B) It features a computed tomography angiography image, which clearly demonstrates the patency of the vessel leading to the flap anastomosis, as denoted by a asterisk, even after embolization. The arrow indicates the site where the bleeding point was occluded using a coil.
ahm-24-0005f1.jpg
Fig. 2.
Schematic illustration depicting the vascular anatomy relevant to the case, with the femoral artery leading to the lateral circumflex femoral artery. The site of coil embolization is shown proximal to the bleeding point, which is depicted in relation to the anastomosis site of the flap.
ahm-24-0005f2.jpg
Fig. 3.
Gross photographic documentation of surgical and postoperative progress (A) Extensive defect following excision. (B) Muscle-sparing latissimus dorsi flap measuring 20×15 cm harvested. (C) Immediate postoperative appearance. (D) The flap prior to embolization, noted for its pale color. (E) The flap after embolization, with noticeable color improvement. (F) Appearance of the reconstructed site at 30 days after operation.
ahm-24-0005f3.jpg

References

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