The Use of Fibrinolytic Agents in the Salvage of Free Flaps: A Systematic Review

Abstract

Background: Microvascular thrombosis following free tissue transfer presents a complex challenge for surgeons and carries the potential risk of flap failure. The application of fibrinolytic agents represents a robust therapeutic option. The aim of this systematic review is to provide a comprehensive overview of the clinical use of fibrinolytic drugs in the rescue of compromised free flaps.

Methods: A systematic literature search for clinical studies detailing the utilization of fibrinolytic agents for salvaging free flaps was conducted using the PubMed and Web of Science databases. The inclusion criteria encompassed English-language publications that specifically addressed the clinical application of fibrinolytic agents for free-flap salvage.

Results: A total of 331 articles were screened after excluding duplicates, with 56 meeting the inclusion criteria. Among these, 21 were clinical trials (evidence level III), and 35 were case studies (evidence level IV/V). In total, 459 flaps underwent treatment with fibrinolytic agents.

Conclusion: The application of fibrinolytic agents appears to be a valuable intervention for rescuing compromised free flaps attributable to microvascular compromise. Notably, no prospective randomized trials have been published on this subject, and the evidence within the existing literature is characterized by its limited and heterogeneous nature. Further research is imperative to gather data on the efficacy, dosage, and safety profile of fibrinolytic agents.

Keywords: fibrinolytic agents; free-flap; microvascular compromise; salvage.

Figure 1

PRISMA Flow Diagram. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Distribution of salvaged and lost flaps regarding used fibrinolytic. Streptokinase was used in 14, urokinase in 48, and tPa in 118 flap cases. tPa: tissue plasminogen activator.