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Page 10 of 26 Chen et al. Plast Aesthet Res 2023;10:24 https://dx.doi.org/10.20517/2347-9264.2022.136

Figure 3. Algorithm for intraoperative management of free flap vessel insufficiency. (A) arterial insufficiency; (B) venous insufficiency;
This figure is adapted from Khansa et al. published in Microsurgery by Wiley Periodicals, Inc., copyright 2013 [90] . Adapted with
permission from JohnWiley and Sons.

Arterial flow absent
Time to re-exploration and anastomotic revision is critical to flap survival. If the arterial flow is absent or
does not respond to treatment for vasospasm, the anastomosis should be opened and promptly explored. If
a thrombus is identified upon opening the arterial anastomosis, heparin irrigation and mechanical
thrombectomy or chemical thrombolysis may be necessary in addition to revision of the anastomosis. In
cases of arterial thrombosis, heparinized saline is used liberally in a 100 I.U./mL concentration to flush the
flap and the anastomosis. A review by Couteau et al. supports this practice, with 9 of 11 animal studies
showing improved free flap survival rates with the use of intraoperative heparin irrigation compared to
saline .
[99]

The simplest form of mechanical thrombectomy is the direct removal of the thrombus with standard
microforceps. If the thrombosis is detected prior to propagation, direct removal at the proximal end of the
anastomosis can be sufficient. However, if thrombus is suspected to be in the distal pedicle, Fogarty
[100]
catheter-assisted thrombectomy may be necessary . We typically use a Fogarty catheter with a 1- or 2-mm