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When it comes to patients who have already experienced a thrombotic event or patients who are likely to
have an underlying hypercoagulable condition, the use of therapeutic anticoagulation remains controversial.
A retrospective review by Senchenkov et al. described an algorithm of anticoagulation for patients both with
[25]
and without a history of hypercoagulability . They concluded that in patients without hypercoagulable
history, additional anticoagulation beyond routine VTE prophylaxis is not indicated. Based on available
data in the cardiovascular literature, Senchenkov et al. recommend that in patients with a hypercoagulable
history, a heparin bolus prior to flap ischemia, ex-vivo irrigation of the flap with heparinized saline prior to
[25]
anastomosis, and systemic anticoagulation should be considered . Additionally, in the setting of recurrent
flap thrombosis, heparin drip, intraoperative ASA, Plavix via nasogastric tube, and dextran-40 infusion
[25]
should be considered .

The use of thrombolytic agents after free flap failure can be considered, but their efficacy has not been well
established. Thrombolytic agents used in free flap salvage include streptokinase, urokinase, and tissue-
plasminogen activator (tPA) [29,36,37] . tPA is the most commonly used agent and is generally injected via the
arterial pedicle at a concentration of 1 mg/mL . Urokinase is generally infused in an anterograde manner
[37]
through the arterial pedicle at a concentration of 5,000 units/mL. Streptokinase can be injected into the
arterial pedicle at 7,500 to 250,000 units diluted in 10-30 cc of normal saline . Thrombolytics should be
[37]
used with caution and only as a last resort due to their associated complications, including bleeding events
and allergic reactions. With this in mind, they can be injected just proximal to the arterial anastomosis to
increase their bioavailability at the site of the thrombus. Some have also reported taking down the venous
anastomosis to avoid the systemic spread of the thrombolytic agent, though the risk of complications from
systemic spread of the doses used in flap salvage is not entirely clear .
[37]

SALVAGE FREE FLAP: RECIPIENT VESSEL SELECTION
A significant challenge facing the reconstructive surgeon following the failure of free flaps for breast
reconstruction is the availability of recipient vessels in the chest. There is no consensus on the optimal
timing of secondary free flap reconstruction following the failure of the initial flap, though some surgeons
advocate for immediate free flap reconstruction at the time of debridement of the original flap as the
mammary arteries and veins may still be salvageable. Hamdi et al. advocate for color Duplex imaging to
[17]
assess the internal mammary system following free flap failure if considering another flap . If the
anterograde system is thrombosed, the retrograde system should be interrogated as it is a robust and reliable
recipient vessel option for secondary free flap reconstruction [38,39] . Alternative vessel choices can be based on
the subscapular system, which comes off of the axillary vessels, namely the thoracodorsal or serratus
vessels [Figure 2]. To identify the thoracodorsal and serratus vessels, the lateral pectoralis border is first
[40]
found. Within the axillary fat, the lateral thoracic vein is found and can be followed proximally to the
axillary vein. Carefully dissecting bluntly through the axillary fat posterior to the origin of the lateral
thoracic vein reveals the proximal thoracodorsal vessels. The serratus branch can be found two to three cm
from the origin of the thoracodorsal artery, supplying the serratus muscle . The thoracodorsal artery must
[40]
be ligated distally to avoid a caliber mismatch of secondary flap pedicle . Moran et al. conducted a
[41]
prospective cohort study and found no significant outcome differences between the internal mammary and
thoracodorsal vessels as recipient sites for autologous breast reconstruction, concluding that both are safe
[42]
options with acceptable results .
Other less common venous outflow options have been described, such as the cephalic and external jugular
veins . Additionally, if the failure is not due to thrombosis of the pedicle and the anastomosis remains
[43]
patient, the initial flap artery and vein can be used for secondary flap salvage recipient vessels [44,45] . The
thoracoacromial vessels have also been described for recipient vessels for autologous breast reconstruction,