Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery.

BACKGROUND:  Postoperative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and also the pathophysiology of this phenomenon has not been elucidated.

METHODS:  An email survey of American Society for Reconstructive Microsurgery (ASRM) and World Society for Reconstructive Microsurgery (WSRM) members regarding their experiences with postoperative arterial vasospasm was conducted, returning 116 responses. A comprehensive literature search was conducted regarding the current body of knowledge on this entity.

RESULTS:  Sixty-five percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia. The majority (62%) of surgeons believed a damaged segment of the artery was responsible for the spasm, with technical issues cited as the most likely cause. Sixty-two percent and 50% of surgeons used segmental resection of the recipient and donor vessels, respectively.Rated for proclivity to vasospasm, superficial inferior epigastric artery (SIEA) was the flap, superior thyroid artery (STA) the recipient vessel, and the lower limb the anatomic region most frequently mentioned.Most widely used management strategies were: topical vasodilators (91%), adventitial stripping (82%), and dilation of recipient and donor vessels (76%). Over 50% of surgeons used some type of vessel resection technique.

CONCLUSIONS:  When flap ischemia is encountered without mechanical issues or thrombus, vasospasm can be the root cause. Certain vessels (SIEA, STA) and anatomic regions (lower limb) pose a higher risk for this phenomenon. When a vessel is affected, it is common practice to excise the questionable segment and use a graft as needed. Vessel resection as part of a multimodal approach can result in a reasonable salvage rate.