Original Article

Reconstructive
Flap Venous Congestion and Salvage Techniques:
A Systematic Literature Review
Florian Boissiere, MD*

Silvia Gandolfi, MD† Background: Venous congestion is a frequent problem in flap surgery. Other than
Samuel Riot, MD‡ surgical revision, there are a multitude of procedures in the literature to tackle
Nathalie Kerfant, MD§ this problem, but their effectiveness is not clear. Through a systematic review, we
Abdesselem Jenzeri, MD¶ aimed to identify and evaluate the different interventions available for managing
Sarah Hendriks, MD║ flap venous congestion.
Jean-Louis Grolleau, MD‡ Methods: The MEDLINE, PubMed central, Embase, and Cochrane databases were
Myriam Khechimi, MD¶ searched. The study selection process was adapted from the PRISMA statement. All
Christian Herlin, MD, PhD* English and French original articles describing or comparing a method for manag-
Benoit Chaput, MD, PhD‡ ing flap venous congestion were included. For each article, a level of evidence was
assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we
specifically analyzed the effectiveness of postoperative non-surgical methods. No
formal analysis was performed.
Results: Through literature searches carried out in various databases, we identified
224 articles. Finally, 72 articles were included. The majority of these studies had a
low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10
postoperative) were found. Concerning non-surgical methods, the most represented
were leeches, local subcutaneous injection of heparin with scarification, venocutane-
ous catheterization, negative pressure therapy, and hyperbaric oxygen therapy.
Conclusions: Risks of venous congestion of flaps must always be present in a sur-
geon’s mind, at every stage of flap surgery. Apart from studies on the use of leeches,
which have a significant follow-up and large enough patient numbers to support
their efficacy, the low-level evidence associated with studies of other methods of
venous congestion management does not allow us to draw a scientifically valid con-
clusion about their effectiveness. (Plast Reconstr Surg Glob Open 2021;9:e3327; doi:
10.1097/GOX.0000000000003327; Published online 22 January 2021.)

INTRODUCTION Other than surgical revision, there are a multitude of pro-

Regardless of whether it affects pedicled flaps or free cedures available to surgeons; however, their effectiveness
flaps, venous congestion is often difficult to manage. is not clear.
A clinical diagnosis of venous insufficiency of a flap
From the *Department of Plastic, Reconstructive and Aesthetic is made, which showed the following findings: purplish
Surgery, Burns and Wound Healing Units, CHRU Lapeyronie, color, shortening refill time (<3 seconds), dark blood
Montpellier, France; †Department of Plastic, Reconstructive at pin prick, venous bleeding on the flap edges, and
and Hand Surgery, Charles Nicolle University Hospital, Rouen, increased edema. This constitutes an emergency because
France; ‡Department of Plastic, Reconstructive, Aesthetic Surgery severe microvascular lesions will develop that become
and Burns, University Hospital Rangueil-Larrey, Toulouse, irreversible within 6–8 hours. For this reason, monitoring
France; §Department of Plastic and Reconstructive surgery, CHRU under strict guidelines by a well-trained team is essential.
Brest. Bretagne Occidentale University, Brest, Brittany, France; We must distinguish between early venous insufficiency,
¶Department of Plastic, Reconstructive and Aesthetic Surgery, which frequently concerns the entire flap (large vessel
CHU LA RABTA, Tunis, Tunisia; and ║Department of Plastic, thrombosis), and late venous insufficiency, which often
Reconstructive and Aesthetic Surgery, University Hospital of affects the flap only in its distal part (small vessel throm-
Strasbourg, France. bosis) and rheological adaptation phenomena that are
Received for publication April 7, 2020; accepted October 28, 2020. not real congestion (flows redistribution, new turbulence,
Copyright © 2021 The Authors. Published by Wolters Kluwer Health, choke vessels opening, modification of drainage direc-
Inc. on behalf of The American Society of Plastic Surgeons. This tion involving hyperemia and diminution of the transient
is an open-access article distributed under the terms of the Creative skin recoloration time). With the ever-increasing use of
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the Disclosure: The authors have no financial interest to
work provided it is properly cited. The work cannot be changed in declare in relation to the content of this article. No funding
any way or used commercially without permission from the journal. was received for this study.
DOI: 10.1097/GOX.0000000000003327

www.PRSGlobalOpen.com 1
 PRS Global Open • 2021

flaps, management of venous congestion is key to avoiding reading abstracts (they did not deal with venous con-
sequelae or loss of flap. gestion). Of the remaining 86 articles, 8 were excluded
When a mechanical cause has been identified, surgi- because they were written in a language other than
cal revision with exploration of the venous pedicle in the English or French. Finally, 72 articles were included. The
operating room is essential.1–3 If necessary, the hematoma entire review process is illustrated as a flowchart (Fig. 1)
is drained, the pedicle is unkinked, the propeller flap is (See also Table  1). Most of these studies had a low-level
replaced to the original position by untwisting, venous evidence (level 3 or 4).
anastomosis for a free flap is repaired, and a second drain- A total of 17 different methods (7 pre- and intraop-
age vein is added. erative, and 10 postoperative) were found. The meth-
However, surgical revision is sometimes impossible, ods reported in the literature for managing primary and
or the cause cannot be identified. It is precisely in these secondary prevention are classified in Table  2. However,
situations that medical therapies come into play.4 For the Because our analysis focused on secondary prevention,
most part, they consist of venous offloading techniques1,2,5 the relevant methods were classified as surgical and non-
to increase tissue perfusion and reduce congestion until surgical methods.
venous neovascularization can occur (approximately
between the fifth and seventh postoperative day).2,6 Secondary Prevention of Venous Insufficiency by Surgical
We analyzed all the data from the international litera- Procedures
ture dealing with the management of flaps with venous The earlier that venous congestion is detected, the
congestion to propose an inventory of the available proce- faster the management and the better the results in terms
dures. We then evaluated the effectiveness of all the meth- of flap survival.7,8 Emergency return to the operating
ods available to reduce venous congestion when surgical room aims to identify a compressive mechanical etiology
revision is impossible or does not seem justified. and to treat it. Pedicled flaps can benefit from removing
the pedicle compression or from venous supercharging,
especially for retrograde flaps,9 even if this procedure can
MATERIALS AND METHODS
be difficult in second-intention because a vein must be
This review was conducted according to the recom-
preserved during the first surgical procedure in anticipa-
mendations specified in the Cochrane Handbook for
tion of possible congestion (Fig. 2).
Systematic Reviews of Interventions (version 5.1.0), is
Propeller flaps have the option of being replaced to
AMSTAR compliant, and is reported in line with the
original position for 48 hours to promote venous return,10
PRISMA statement: Preferred Reporting Items for
as shown in Figure  3. Moreover, pedicle release can be
Systematic Reviews and Meta-Analysis. Searches were con-
improved with or without repositioning of the latter. To
ducted in MEDLINE via PubMed, Cochrane Library, and
avoid this revision, a 2-stage procedure (or “delayed pro-
Embase databases using the following keywords: “venous
cedure”)11 allows opening of the choke vessels and aval-
complication” OR “venous suffering” OR “venous throm-
vular (oscillating) veins during a flap autonomization
bosis” OR “venous insufficiency” OR “venous suffering
period.12–15 Finally, we can also perform venous super-
AND “flap management.” The title, summary, and full text
charging in propeller flaps.16
of the identified articles were examined.
Regarding free flaps, the main cause of venous con-
All English and French original articles describing or
gestion is venous thrombosis.7,17 The first step during
comparing a method for managing venous congestion in
surgical revision of a free flap is to look for thrombosis
flaps were included. Clinical cases, case series, observa-
on the anastomosis. If venous flow is not restored despite
tional studies (retrospective and prospective), controlled
correcting potential extrinsic compression and after
clinical trials, and randomized controlled trials were
performing thrombectomy, it means the thrombosis is
included. Items were excluded when found in duplicate
in the flap microcirculation. This is a high-risk situation
or when they did not address the management of venous
where administration of thrombolytic agents remains
congestion. Detailed and critical reading of the entire
the ultimate solution. Recent studies have shown that
texts of each article was carried out to collect data about
thrombolytics are effective at rescuing flaps with clots in
authors, date of publication, place of study, type of study,
microvessels.18–20 An intra-arterial injection (leaving the
and method used to manage venous congestion. For
vein open to avoid any systemic diffusion) of 2 mg Actilyse
each article, a level of evidence was assigned, as defined
diluted in 2 cc 0.9% NaCl is administered and repeated
by the Oxford Centre for Evidence-based Medicine.
once after 10–15 minutes if ineffective thrombolysis
Lastly, we specifically analyzed the effectiveness of post-
occurs after the first dose.
operative non-surgical methods. No formal analysis was
performed.
Secondary Prevention of Venous Insufficiency by Medical
Procedures
RESULTS When surgical revision is impossible, or the cause of
Searches carried out among the various databases venous congestion cannot be identified, medical thera-
identified 224 articles. After adding studies identified by pies can be effective in improving or resolving venous
reviewing the bibliographies and deleting duplicates, we congestion (Fig.  4). Before implementing them, simple
obtained a total of 264 articles. After reviewing the titles, measures can be used to remove extrinsic compression:
96 articles were eligible. Of these, 10 were excluded after redoing a dressing that is too tight,21 removing a splint or

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Boissiere et al. • Flap Venous Congestion and Salvage Techniques

Fig. 1. Flowchart summarizing the search strategy and selection of included articles.

compressive garment, or removing sutures that contribute blood will be actively extracted. Once active suction is
to a flap’s tourniquet effect.22 complete, passive blood loss will occur. Anticoagulants,
inhibitors of platelet aggregation, and other vasodilators
Leeches produced by leeches will allow blood flow at the bite site to
There are 27 articles in the literature on medicinal continue even after the leech is detached. About 20–50 ml
leeches. The effectiveness of hirudotherapy in relieving will then be extracted passively. Thanks to these 2 mech-
venous congestion is due to both mechanical and bio- anisms, the venous flow and microcirculation in the flap
logical effects. Blood suction following a bite will tempo- will improve, and consequently the venous congestion will
rarily improve tissue perfusion by actively draining blood decrease (Fig. 5).
from congested tissue (mechanism demonstrated by laser Several literature reviews have been conducted on
Doppler analysis by Knobloch et al).23 About 5–15 ml of this topic, with the most recent ones by Whitaker et al24

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Table 1. Presentation of the 72 Articles Included in the Review

Authors Year Method Used Type of Study Level of Evidence* Country
Derganc and Zdravic 1960 Leech Case series 4 Slovenia
Williams 1973 Delayed procedure Case series 4 Ireland
Batchelor et al 1984 Leech Case series 4 UK
Wieslander et al 1986 Systemic antithrombotic Case-control study 3 Sweden
Hayden et al 1988 Leech Case series 4 USA
Barnett et al 1989 “Chemical” leech Case series 4 Australia
Smoot et al 1990 Leech Case-control study 3 USA
Lee et al 1992 Leech Comparative test 4 Canada
Dabb et al 1992 Leech Case series 4 USA
Gross and Apesos 1992 Leech Case series 4 USA
Rodgers et al 1992 Leech Case series 4 USA
Miller et al 1993 Surgical revision Retrospective study 4 USA
Soucacos et al 1994 Leech Case-control study 3 Greece
Haycox et al 1995 Leech Case series 4 USA
Smoot et al 1995 Leech Case series 4 USA
Takamatsu et al 1996 Recipient vessels choice Retrospective study 4 Japan
Wheatley and Meltzer 1996 Surgical revision Case series 4 USA
Pantuck et al 1996 Leech Case series 4 USA
Kamei et al 1997 Venocutaneous catheterization Case series 4 Japan
Ritter et al 1998 Systemic antithrombotic Case series 4 USA
Serletti et al 1998 Surgical revision Retrospective study 4 USA
Mortenson et al 1998 Leech Case series 4 USA
Utley et al 1998 Leech Case series 4 USA
Robinson 1998 “Chemical” leech Case series 4 USA
Iglesias and Butron 1999 “Chemical” leech Case series 4 Mexico
Lozano et al 1999 Hyperbaric oxygen therapy Case-control study 3 USA
Kirschner et al 1999 “Chemical” leech Case-control study 3 USA
Davis et al 1999 Skin topicals Case series 4 USA
Weinfeld et al 2000 Leech Case series 4 USA
MacGill 2000 “Chemical” leech Case series 4 USA
Yii et al 2001 Surgical revision Retrospective study 4 USA
Chalian et al 2001 Recipient vessels choice Retrospective study 4 USA
Ulkür et al 2002 Hyperbaric oxygen therapy Case-control study 3 Turkey
Gampper et al 2002 Hyperbaric oxygen therapy Case-control study 3 USA
Chepeha et al 2002 Leech Case series 4 USA
Connor et al 2002 Leech Case series 4 USA
Panchapakesan et al 2003 Surgical revision Retrospective study 4 Canada
Namba et al 2003 Surgical revision Case series 4 Japan
Eker et al 2003 Venocutaneous catheterization Case series 4 Turkey
Gideroglu et al 2003 Leech Retrospective study 4 Turkey
Tuncali et al 2004 Leech Case series 4 Turkey
Ahmed et al 2005 Delayed procedure Case series 4 Pakistan
Tan et al 2005 Venous supercharging Case series 4 Turkey
Yazar 2007 Recipient vessels choice Case series 4 Turkey
Chung et al 2007 Systemic antithrombotic Randomized study 2 USA
Ogawa and Hyakusoku 2008 Super thin flaps Case series 4 Japan
Gürsoy et al 2008 Venocutaneous catheterization Case series 4 Turkey
Uygur et al 2008 NPT Case series 4 Turkey
Chen et al 2008 Systemic antithrombotic Comparative test 2 USA
Draenert et al 2010 Surgical revision Case series 4 Germany
Ali et al 2010 Double venous anastomosis Retrospective study 4 UK
Enajat et al 2010 Double venous anastomosis Retrospective study 4 Sweden
Mozafari et al 2011 Venocutaneous catheterization Randomized study 2 Iran
Whitaker et al 2011 Leech Retrospective study 4 UK
Lorenzo et al 2011 Recipient vessels choice Retrospective study 4 Taiwan
Jones et al 2011 Venocutaneous catheterization Case series 4 USA
Reiter et al 2012 Systemic antithrombotic Retrospective study 4 Germany
Ono et al 2012 Venous supercharging Case series 4 Japan
Whitaker et al 2012 Leech Retrospective study 4 UK
Koch et al 2012 Leech Retrospective study 4 USA
Nguyen et al 2012 Leech Case series 4 USA
Han et al 2013 Double venous anastomosis Retrospective study 4 China
Vaienti et al 2013 NPT Case series 4 Italy
Kashiwagi et al 2013 Leech Case series 4 Japan
Damen et al 2013 Double venous anastomosis Cohort study 2 Netherlands
Pérez et al 2014 “Chemical” leech Retrospective study 4 Spain
Pannucci et al 2014 Leech Cohort study 2 USA
Lee et Mun 2015 Systemic antithrombotic Case-control study 3 South Korea
Jose et al 2015 Leech Case series 4 India
Herlin et al 2016 Leech Case series 3 France
Qui et al 2016 NPT Case series 4 Taiwan
Chaput et al 2017 Delayed procedure Case series 4 France
*Oxford Center for Evidence-Based Medicine 2011 levels of evidence.

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Boissiere et al. • Flap Venous Congestion and Salvage Techniques

Table 2. Articles on Primary Prevention and Secondary heparins were used initially, but were gradually replaced
Prevention by low-molecular-weight heparins given their superior
pharmacokinetics.
No. Level of
Articles on the use of low-molecular-weight heparins
Methods Articles Evidence
for managing venous congestion of flaps are still quite
Primary prevention rare. The largest study on low-molecular-weight hepa-
  Delayed procedure 3 4
  Venous supercharging 2 4 rins is that of Pérez et al,35 with 15 flaps supported by this
  Super thin flaps 1 4 method. Success rates presented in the literature are high
  Double venous anastomosis 4 2 to 4
  Systemic antithrombotic 6 2 to 4 but based on small cohorts.6,31,32,35
  Recipient vessels choice 4 4 Various usage patterns have been described, including
 Total 20   the protocol of Pérez et al, which is fairly reproducible35
Secondary prevention
 Leeches 27 4 (Table  3). Concomitant use of systemic anticoagulants
  Surgical revision (repair of anastomoses, 7 4 such as intravenous heparin, dextran, or aspirin has not
pedicle thrombectomy, venous bypass, been shown to be effective and may even be harmful to
pedicle thrombolysis)
  Local injection of LMWH + scarification 6 3 to 4 patients with a higher risk of bleeding.31 Treatment is initi-
  Venocutaneous catheterization 5 2 to 4 ated for a minimum of 5–7 days and continued depending
  Hyperbaric oxygen therapy 3 3 on whether signs of venous congestion persist.
 NPT 3 4
  Skin topicals 1 4 Various complications have been reported, but the
 Total 52   major complication is blood loss and need for transfu-
sion. According to various authors, chemical leeching will
achieve identical results with fewer associated complica-
in 2012 and Herlin et al25 in 2016. The overall success
tions, particularly in terms of infection. This technique
rate was 77.98% according to Whitaker, and between 65% requires nursing care, but it is available immediately
and 80% according to Herlin. In general, the success rate and easy to implement in case of venous congestion of a
in the included studies was close to 70%.24–28 One of the flap. It seems practical in a case where treatment could
limitations of leech therapy seems to be the flap volume. be delayed due to leech constraints, to begin with a local
The success rate falls to around 30% for high-volume flaps injection of LMWH and then to set up the leeches sec-
such as TRAM or DIEP.28,29 ondarily. Depending on the center, control and delivery
Studies on hirudotherapy have a relatively low-level of leeches can delay treatment for several hours,36 which is
evidence, but they are numerous, with a large series of critical in a situation where earlier treatment improves the
patients and a significant effect. For this reason, it is cur- chances of survival.8
rently the only validated treatment for managing acute
venous insufficiency of pedicled or free flaps when sur- Venocutaneous Catheterization
gical revision is not appropriate. Hirudo medicinalis was There are 5 articles in the literature on this topic. This
approved by the FDA as a medical device in 2004.30 technique involves introduction of a catheter into the
lumen of a superficial vein in the flap and externalizing
Local Subcutaneous Injection of Heparin with Scarification: it so that venous offloading can be performed on demand
Chemical Leeches by opening a valve37 (Fig. 6).
There are 6 articles in the literature on this topic. This There are few studies on the use of venocutane-
procedure was first described by Barnett et al in 198931 ous catheterization and only a small number of patients
as a treatment for venous congestion in the context of have been treated.33,38–40 The largest study describes 28
digital reimplantation. It is also called “chemical leech- neurocutaneous sural flaps.41 The overall success rate
ing.”6,31–33 It was proposed as an alternative to hirudother- is close to 100% in each of the available studies. Only
apy, when leeches were not available.6,31–34 Unfractionated Mozafari’s team41 has reported 1 case of partial necrosis

Fig. 2. A 40-year-old man presented with chronic osteitis following a tibial fracture. A venous-super-
charged PTAP flap was planned with a racquet-shaped design. A, The skin paddle was centered on the
great saphenous vein, which was detected using Doppler ultrasound. B, The great saphenous vein was
transected and harvested with the flap. A 90 degree rotation was performed. After debridement, the
defect was covered by the flap and a distal venous anastomosis was performed using magnification. C,
Neither congestion nor flap necrosis occurred, and the wound healed after 3 weeks.

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Fig. 3. Anterior tibial artery perforator f lap (ATAP) for bone coverage. A, B, Rapid venous congestion, 3 hours after flap. C, The flap was
urgently replaced to original position and left for 48 hours before replicating the rotation. D, At 1.5 months, the flap was completely healed
and did not have necrosis because the untwisting was performed within 6 hours.

Fig. 4. Example of venous thrombosis of a DIEP flap. Revision surgery was performed but venous conges-
tion persisted; therefore, hirudotherapy was undertaken (A, B). This provided effective decongestion, but
after the treatment was discontinued on D5, the flap became completely necrotic in 48 hours (C).

Fig. 5. Example of postoperative congestion of a distally-based medial plantar flap in a 44-year-old

man. A, Immediate postoperative. B, Introduction of leeches over 5 days. C, Complete flap salvage.

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Boissiere et al. • Flap Venous Congestion and Salvage Techniques

Table 3. Dosing Protocol for Enoxaparin Sodium (Lovenox) et al43 used NPT as a preventive measure to reduce edema
according to Pérez et al35 and prevent appearance of venous congestion in 17 local
flaps for defect coverage in the ankles.
Days Congestive Area < 75 cm2 Congestive Area > 75 cm2
According to Morgan et al,46 the depression induced
1–3 20 mg/4–6 h 40 mg / 4–6 h by NPT may create compression of the pedicle and
4–6 10 mg/8 h 20 mg / 8 h
7–9 10 mg/12 h 20 mg / 12 h cause arterial insufficiency of flap. In addition to induc-
10–14 10 mg/24 h 20 mg / 24 h ing depression, NPT also induces a compressive effect.
Consequently, it seems advisable to use the discontinuous
suction mode to avoid any worsening of flap congestion
of a neurocutaneous sural flap out of 28 flaps treated or ischemia. The other complication is blood loss sec-
(3.6%). All protocols mention that the heparinized serum ondary to aspiration, which can sometimes be significant
catheter must be rinsed; lumen obstruction by a venous and require a transfusion. However, the transfusion rates
thrombus remains the main problem. The second compli- are much lower than when using leeches. The difficulty
cation highlighted is the need for blood transfusion. The of viewing the skin paddle once the dressing has been
volume of drained blood is nevertheless much lower than applied must also be mentioned.
with leech treatment.
According to Mozafari et al,41 the use of a venous Hyperbaric Oxygen Therapy
catheter is associated with significantly lower blood loss, There are 3 articles in the literature on Hyperbaric
lower local infection rate, and higher nurse and patient Oxygen Therapy (HBOT). However, there is little data
satisfaction than leech therapy. Also, the cost of treatment available because studies are almost exclusively animal
is much lower than medicinal leech therapy. The first
studies,47–52 the results are contradictory, and no protocol
drawback is that it can only be implanted in an operating
has been defined for managing venous congestion. In
room; therefore, it must be planned during initial surgery.
addition, the studies do not focus on pure venous conges-
In addition, a vein of good caliber could be used more
tion but rather on mixed ischemia. No benefit could be
judiciously by performing an additional venous anastomo-
demonstrated when HBOT was applied in humans: in a
sis to obtain a supercharged flap.9 However, if no recipient
prospective randomized study53 on the use of HBOT in
vein is present or if this vein is thrombosed, this technique
seems to be an interesting alternative. Manual drainage free flap surgery, no difference between the 2 groups were
by opening the catheter should be done every hour dur- found in the venous congestion rate but also survival rate,
ing the first few days; the soiled dressing will need to be edema, and duration of healing. HBOT does not appear
drained several times a day. to be suitable for managing venous congestion of a flap. It
even seems to be ineffective when used alone. In addition,
Negative Pressure Therapy access to this therapy is very difficult, given the low avail-
There are 3 articles in the literature on negative pres- ability of hyperbaric chambers and its expense.
sure therapy (NPT). NPT acts on venous congestion
through 3 different mechanisms: increased local blood Topical Agents
flow and therefore venous drainage; acceleration of There is 1 article in the literature that deals with the
neovascularization; reduction of interstitial pressure by role of topical agents on venous congestion of flaps. Tested
drainage of exudates and edema. NPT is relevant in situa- substances include sympatholytics, inhibitors of uric acid
tions where the area to be covered is prone to significant synthesis, prostaglandin inhibitors, and nitroglycerin.
edema, especially in trauma patients with a contused limb Long studied in animals, topical agents were then stud-
that can be site of lymphatic stasis.42,43 Use of NPT for man- ied in humans, but none have been shown to be effective
aging venous congestion in flaps is still rare in the litera- for venous congestion.5,54,55 In contrast, transdermal nitro-
ture. Between June 1997 (first description of NPT) and glycerin at a dose of 10 mg/24 hours appears to improve
February 2017, only 3 studies were found42,44,45 for a total of overall flap survival.56 After reading the literature and in
17 treated flaps with venous congestion. The flap survival association with our practice, we propose in Figure  7 a
rate was 100% in each of the 3 included studies. Goldstein decisional algorithm concerning flap venous congestion.

Fig. 6. Sural neurocutaneous flap to cover a calcaneal fracture. A, Flap design. B, Immediate postoperative.
C, Venocutaneous catheterization was set up in anticipation of possible congestion. The valve was opened
3 times over the next 24 hours to decongest the flap and then the patient ripped out the catheter.

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Fig. 7. Decisional algorithm concerning flap venous congestion.

DISCUSSION high, with a priori fewer problems than hirudotherapy.

Altogether there are 2 broad causes of venous con- However, the lack of scientific evidence pushes us to use
gestion of flaps: extrinsic (mechanical) and intrinsic this method in addition to animal leeches or if they are
(microcirculatory). It is common for surgeons to feel pow- not available.
erless when faced with venous congestion that cannot be NPT may be relevant in situations where the area to
explained by an extrinsic cause. The flap may deteriorate be covered is edematous, especially in traumatology.
progressively in front of our eyes without having a valid Although it has a 100% success rate in the literature, defi-
solution. ciencies in study methodology and sample size make it
When the situation suggests a mechanical cause, it is impossible to conclude whether this method is truly effec-
essential to return to the operating room to identify this tive. We also advise using discontinuous suction mode (3
cause and treat it electively. If no mechanical cause is minutes of suction for 1 minute without aspiration).
found, and depending on operative context, we can con- Venocutaneous catheterization allows better control
sider performing a venous anastomosis with a superficial over drained blood volume but the rate of catheter throm-
vein (venous supercharging) if one vein was preserved bosis is high, and the level of evidence is low, which does
during flap harvesting. We can also try to rotate propel- not allow us to propose this technique as a first-line treat-
ler perforator flaps in the opposite direction or replace a ment. For experienced surgeons, using the same vein for
local flap at the donor site. supercharging is also a good alternative although it adds
Regarding free flaps, any venous congestion requires to the microsurgical time. Hyperbaric oxygen therapy has
an emergency return to the operating room. If a thrombus shown no benefit in the literature on venous congestion of
is found, thrombectomy is performed using Dumont for- flaps. Finally, no study has specifically analyzed the action
ceps or a Fogarty venous thrombectomy catheter, depend- of nitroglycerin or any other topical skin agents on iso-
ing on its accessibility. If venous flow does not return lated venous congestion of flaps.
despite this thrombectomy, the thrombosis has affected At this point, it is clear that there is still room for
the microcirculation of the skin paddle. Thrombolysis is research on mechanical procedures or on local or systemic
the last resort. It is also essential to test the permeability of drug therapies that would allow us to get out of these dif-
recipient vessels and, if necessary, to change them. Venous ficult situations with our reconstructions.
bridging may be necessary. Our review has several limitations. First, as a systematic
If these techniques are not feasible or if venous con- review, we were limited by the available published studies
gestion persists after performing them, supplementary that summarize various surgical techniques (performed by
medical treatment is necessary. It should be pointed out different surgeons), which are highly variable and are not
that medical treatments are less effective in free flaps— standardized. Second, there were missing data for comor-
fasciocutaneous flaps will benefit the most. Indeed, the
bidity, localization, size of the flap, and etiology. Third,
techniques based on venous offloading are not sufficient
published studies do not have a homogenous consecutive
to drain all the excess venous blood in large-volume flaps
series of patients. Finally, it was not possible to extract data
such as muscular or adipose flaps.
to perform a meta-analysis.
Leeches are the only medical treatment for managing
venous congestion with a satisfactory level of evidence.
It can be said that hirudotherapy remains the gold stan- CONCLUSIONS
dard, with success rates of more than 70%. The effective- Risks of venous congestion of flaps must always be
ness of “chemical” leeching reported in the literature is present in a surgeon’s mind, at every stage of flap surgery.

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Boissiere et al. • Flap Venous Congestion and Salvage Techniques

Many methods can be used to avoid this major complica- reconstruction using free flaps: A meta-analysis. Plast Reconstr
tion. Nevertheless, our analysis of the literature shows that Surg. 2016;137:1583–1594.
it is difficult to draw a scientifically valid conclusion about 18. Rinker BD, Stewart DH, Pu LL, et al. Role of recombinant tissue
plasminogen activator in free flap salvage. J Reconstr Microsurg.
their effectiveness. In the end, apart from studies on the
2007;23:69–73.
use of leeches, which have a significant follow-up and large 19. Casey WJ III, Craft RO, Rebecca AM, et al. Intra-arterial tissue
enough patient numbers to support their efficacy, the low- plasminogen activator: An effective adjunct following microsur-
level evidence associated with studies of other methods of gical venous thrombosis. Ann Plast Surg. 2007;59:520–525.
venous congestion management does not allow us to draw 20. Chang EI, Mehrara BJ, Festekjian JH, et al. Vascular complica-
any real conclusions. tions and microvascular free flap salvage: The role of thrombo-
lytic agents. Microsurgery. 2011;31:505–509.
Florian Boissiere, MD
21. Greene AK, Austen WG, May JW. Flap ischemia after pedicled
Plastic and Reconstructive Surgery Unit
tissue transfer to a lateral thigh wound: An example of complica-
CHU Lapeyronie
tion assessment using the end result system of E. A. Codman.
371, Avenue du Doyen Gaston Giraud
Plast Reconstr Surg. 2007;119:1599–1603; discussion 1604-5.
Montpellier, France
22. Chaput B, Herlin C, Grolleau JL, et al. Reply: The stitches could
E-mail: [email protected]
be the main risk for failure in perforator-pedicled flaps. Plast
Reconstr Surg. 2016;138:383e–5e.
REFERENCES 23. Knobloch K, Gohritz A, Busch K, et al. [Hirudo medicinalis-
1. Kubo T, Yano K, Hosokawa K. Management of flaps with com- leech applications in plastic and reconstructive microsurgery–a
promised venous outflow in head and neck microsurgical recon- literature review]. Handchir Mikrochir Plast Chir. 2007;39:103–107.
struction. Microsurgery. 2002;22:391–395. 24. Whitaker IS, Oboumarzouk O, Rozen WM, et al. The efficacy
2. Akan IM, Yildirim S, Gideroğlu K. Salvage of flaps with venous of medicinal leeches in plastic and reconstructive surgery: A
congestion. Ann Plast Surg. 2001;46:456. systematic review of 277 reported clinical cases. Microsurgery.
3. Porshinsky BS, Saha S, Grossman MD, et al. Clinical uses 2012;32:240–250.
of the medicinal leech: A practical review. J Postgrad Med. 25. Herlin C, Bertheuil N, Bekara F, et al. Leech therapy in flap sal-
2011;57:65–71. vage: Systematic review and practical recommendations. Ann
4. Elyassi AR, Terres J, Rowshan HH. Medicinal leech therapy Chir Plast Esthet. 2017;62:e1–e13.
on head and neck patients: A review of literature and pro- 26. Soucacos PN, Beris AE, Malizos KN, et al. Successful treatment
posed protocol. Oral Surg Oral Med Oral Pathol Oral Radiol. of venous congestion in free skin flaps using medical leeches.
2013;116:e167–e172. Microsurgery. 1994;15:496–501.
5. Jones NF, Lin MP, Dickinson BP, et al. Successful salvage of 27. Chepeha DB, Nussenbaum B, Bradford CR, et al. Leech therapy
venous thrombosis of a free flap by creation of a venocutaneous for patients with surgically unsalvageable venous obstruction
fistula. J Reconstr Microsurg. 2011;27:243–250. after revascularized free tissue transfer. Arch Otolaryngol Head
6. Iglesias M, Butrón P. Local subcutaneous heparin as treatment Neck Surg. 2002;128:960–965.
for venous insufficiency in replanted digits. Plast Reconstr Surg. 28. Whitaker IS, Josty IC, Hawkins S, et al. Medicinal leeches and the
1999;103:1719–1724. microsurgeon: A four-year study, clinical series and risk benefit
7. Riot S, Herlin C, Mojallal A, et al. A systematic review and meta- review. Microsurgery. 2011;31:281–287.
analysis of double venous anastomosis in free flaps. Plast Reconstr 29. Nguyen MQ, Crosby MA, Skoracki RJ, et al. Outcomes of flap sal-
Surg. 2015;136:1299–1311. vage with medicinal leech therapy. Microsurgery. 2012;32:351–357.
8. Selber JC, Angel Soto-Miranda M, Liu J, et al. The survival curve: 30. FDA. 2004. Available at: https://www.accessdata.fda.gov/cdrh_
Factors impacting the outcome of free flap take-backs. Plast docs/pdf4/k040187.pdf.
Reconstr Surg. 2012;130:105–113. 31. Barnett GR, Taylor GI, Mutimer KL. The “chemical leech”: Intra-
9. Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural replant subcutaneous heparin as an alternative to venous anasto-
flap: A new modification increasing the reliability of the flap. mosis. Report of three cases. Br J Plast Surg. 1989;42:556–558.
Microsurgery. 2005;25:36–43. 32. Robinson C. Artificial leech technique. Plast Reconstr Surg.
10. Demir A, Acar M, Yldz L, et al. The effect of twisting on perfora- 1998;102:1787–1788.
tor flap viability: An experimental study in rats. Ann Plast Surg. 33. Eskitascioglu T, Coruh A, Ozyazgan I, et al. Salvage of venous
2006;56:186–189. congested flaps by simple methods. Plast Reconstr Surg.
11. Williams CW. Delaying of flaps. A useful adjunct. Br J Plast Surg. 2006;117:344–346.
1973;26:61–65. 34. MacGill KA. The “chemical leech” revisited. Plast Reconstr Surg.
12. Ahmed SK, Hashmi PM. Delayed supramalleolar flap–an innova- 2000;105:2272–2273.
tive technique for enhanced viability. J Ayub Med Coll Abbottabad. 35. Pérez M, Sancho J, Ferrer C, et al. Management of flap venous
2005;17:76–79. congestion: The role of heparin local subcutaneous injection. J
13. Tosun Z, Ozkan A, Karaçor Z, et al. Delaying the reverse sural Plast Reconstr Aesthet Surg. 2014;67:48–55.
flap provides predictable results for complicated wounds in dia- 36. Azzopardi EA, Whitaker IS, Rozen WM, et al. Chemical and
betic foot. Ann Plast Surg. 2005;55:169–173. mechanical alternatives to leech therapy: A systematic review and
14. Codner MA, Bostwick J III, Nahai F, et al. TRAM flap vascular critical appraisal. J Reconstr Microsurg. 2011;27:481–486.
delay for high-risk breast reconstruction. Plast Reconstr Surg. 37. Fahmy HW, Moneim MS. The effect of prolonged blood stasis on
1995;96:1615–1622. a microarterial repair. J Reconstr Microsurg. 1988;4:139–143.
15. Lambert DM, Rigano WC. Delaying the skin for TRAM flaps. 38. Caplin DA, Nathan CR, Couper SG. Salvage of TRAM flaps
Curr Surg. 2000;57:480–483. with compromised venous outflow. Plast Reconstr Surg.
16. Ono S, Ogawa R, Eura S, et al. Perforator-supercharged perfora- 2000;106:400–401.
tor-based propeller flaps. Plast Reconstr Surg. 2012;129:875e–877e. 39. Eker G, Akan IM, Aydoğdu E, et al. Salvage of neurocutaneous
17. Chaput B, Vergez S, Somda S, et al. Comparison of single flaps with venous congestion using intravenous cannula. Plast
and double venous anastomoses in head and neck oncologic Reconstr Surg. 2003;112:1191–1192.

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40. Gürsoy K, Kankaya Y, Uysal A, et al. Dealing with the venous 48. Lozano DD, Stephenson LL, Zamboni WA. Effect of hyper-
congestion of free flaps: Venous catheterization. J Craniofac Surg. baric oxygen and medicinal leeching on survival of axial skin
2008;19:1645–1647. flaps subjected to total venous occlusion. Plast Reconstr Surg.
41. Mozafari N, Ghazisaidi MR, Hosseini SN, et al. Comparisons 1999;104:1029–1032.
of medicinal leech therapy with venous catheterization in the 49. Nemiroff PM, Merwin GE, Brant T, et al. Effects of hyperbaric
treatment of venous congestion of the sural flap. Microsurgery. oxygen and irradiation on experimental skin flaps in rats.
2011;31:36–40. Otolaryngol Head Neck Surg. 1985;93:485–491.
42. Vaienti L, Gazzola R, Benanti E, et al. Failure by congestion of 50. Tan CM, Im MJ, Myers RA, et al. Effects of hyperbaric oxygen
pedicled and free flaps for reconstruction of lower limbs after and hyperbaric air on the survival of island skin flaps. Plast
trauma: The role of negative-pressure wound therapy. J Orthop Reconstr Surg. 1984;73:27–30.
Traumatol. 2013;14:213–217. 51. Kaelin CM, Im MJ, Myers RA, et al. The effects of hyperbaric
43. Goldstein JA, Iorio ML, Brown B, et al. The use of negative pres- oxygen on free flaps in rats. Arch Surg. 1990;125:607–609.
sure wound therapy for random local flaps at the ankle region. J 52. Zamboni WA, Roth AC, Russell RC, et al. The effect of acute
Foot Ankle Surg. 2010;49:513–516. hyperbaric oxygen therapy on axial pattern skin flap survival
44. Qiu SS, Hsu CC, Hanna SA, et al. Negative pressure wound when administered during and after total ischemia. J Reconstr
therapy for the management of flaps with venous congestion. Microsurg. 1989;5:343–7; discussion 349.
Microsurgery. 2016;36:467–473. 53. Vishwanath G. Hyperbaric oxygen therapy in free flap surgery: Is
45. Uygur F, Duman H, Ulkür E, et al. The role of the vacuum- it meaningful? Med J Armed Forces India. 2011;67:253–256.
assisted closure therapy in the salvage of venous congestion of 54. Kerrigan CL, Daniel RK. Pharmacologic treatment of the failing
the free flap: Case report. Int Wound J. 2008;5:50–53. skin flap. Plast Reconstr Surg. 1982;70:541–549.
46. Morgan K, Brantigan CO, Field CJ, et al. Reverse sural artery 55. Nichter LS, Sobieski MW, Edgerton MT. Augmentation of criti-
flap for the reconstruction of chronic lower extremity wounds in cal skin flap survival following ibuprofen therapy. Ann Plast Surg.
high-risk patients. J Foot Ankle Surg. 2006;45:417–423. 1986;16:305–312.
47. Gampper TJ, Zhang F, Mofakhami NF, et al. Beneficial effect of 56. Hwang K. Effects of nitroglycerin ointment on mastectomy flap
hyperbaric oxygen on island flaps subjected to secondary venous necrosis in immediate breast reconstruction: A randomized con-
ischemia. Microsurgery. 2002;22:49–52. trolled trial. Plast Reconstr Surg. 2016;137:747e–748e.

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