Intraoperative Vasopressor Therapy Does Not Affect Free Flap Viability: A Myth Busted

Introduction: The microvascular free flap is a powerful tool for tissue reconstruction developed over decades of surgical experience and outcomes. As medicine moves toward evidence based approaches to dictate therapy, the dogma that once dominated microsurgical technique is now being revisited. One such principle is the contraindication of intraoperative vasopressor therapy use. Despite multiple animal models demonstrating that systemic vasoconstriction does not lead to diminished flap oxygenation, there is scarce evidence of actual clinical data supporting the safe use of vasopressors intraoperatively. Here we evaluate the effect intraoperative vasopressors therapy use on microvascular free flap viability.

Methodology and Material: A retrospective review of 400 hundred microvascular free flap recipients were divided between patients receiving vasopressor therapy to maintain adequate blood pressure and those who did not. Anesthesia records divided patients between those receiving any vasopressors and those not receiving any medication. Patients’ clinical records were then reviewed for intraoperative and post-operative flap specific complications (ischemia, take back, partial flap loss and total flap loss). Patients receiving vasopressors were also subdivided into the duration and dose they were receiving.

Results: Equivalent rates of flap specific complications were found between both patient populations. The use of vasopressors for any duration or dose did not increase the rate of flap related complications.

Conclusions: The use of extended intraoperative vasopressor therapy in microvascular free flap surgery does not lead to increased post-operative complication rates. This work opens the foundation to future studies focusing on the use of vasopressors, instead of volume which is shown to increase thrombotic complications, to maintain optimal mean arterial pressures.