Successful Salvage of Venous Thromboembolism Manifested as Free Flap Venous Insufficiency and Pulmonary Embolism in a Patient Receiving Microvascular Free Flap Reconstruction after Oral Cancer Resection: A Case Report and Review of the Literature

Case Report

Austin Crit Care Case Rep. 2022; 6(1): 1038.

Successful Salvage of Venous Thromboembolism Manifested as Free Flap Venous Insufficiency and Pulmonary Embolism in a Patient Receiving Microvascular Free Flap Reconstruction after Oral Cancer Resection: A Case Report and Review of the Literature

Shih-Hao M1 and Szu-Hsien W2,3*

¹Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C

²Division of Plastic and Reconstructive Surgery, Department of Surgery, National Yang Ming Chiao Tung University and Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C

³Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan, R.O.C

*Corresponding author: Wu Szu-Hsien, Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan, R.O.C

Received: March 02, 2022; Accepted: March 22, 2022; Published: March 29, 2022

Abstract

Venous insufficiency is a severe complication of microvascular free tissue transfers, which may ultimately cause free flap failure. In this report, we describe a case of microvascular free flap reconstruction after oral cancer resection, complicated with venous thromboembolism manifested as venous insufficiency of the flap and pulmonary embolism (PE). Antithrombin III deficiency related heparin resistance was found during the course of treatment. With flap reexploration, veno-venous extracorporeal membrane oxygenation (V-V ECMO) and systemic anticoagulation therapy with a direct oral anticoagulant (DOAC), the flap was successfully salvaged and the patient recovered well.

Keywords: Venous thromboembolism; Free flap venous insufficiency; Pulmonary embolism; Microvascular free tissue transfer; Extracorporeal membrane oxygenation (ECMO); Direct oral anticoagulant (DOAC)

Case Presentation

A 59-year-old Asian man was admitted to the Division of the Oral and Maxillofacial Surgery of the Taipei Veterans General Hospital for a scheduled operation of right buccal squamous cell carcinoma and left retromolar trigon squamous cell carcinoma. He had class 1 obesity (Body Mass Index: 30.78kg/m²) and the history of a benign neoplasm of left buccal status post excision and reconstruction with a split-thickness skin graft seven years before this admission. He was a heavy smoker who had smoked half a pack of cigarettes every day for more than 20 years. He also chewed betel nuts and drank alcohol. No other medical history was noted. The pre-operative evaluation was acceptable. The American Society of Anaesthesiologists (ASA) physical status was level 2. Oral maxillofacial surgeons performed wide excision of the tumor, radical neck dissection, and tracheostomy for the patient, and then plastic surgeons harvested a free fibular flap from his left leg for reconstruction. The reconstruction was completed with one artery (the peroneal artery to the left superior thyroid artery) and one vein (a comitant vein to a branch of the left internal jugular vein) anastomosis. The whole operation had lasted for around 12 hours and was completed smoothly. The patient was then transferred to an intensive care unit for monitoring.

However, hypoxemia had been found since post-operative day (POD) 1. The chest film showed no pneumothorax, atelectasis, pulmonary infiltrate, or pleural effusion. There was only a small amount of sputum. We increased the setting of FiO2 and PEEP in order to keep oxygenation. On POD 3, flap swelling with a skin color change to purplish was noted (Figure 1). Under the impression of venous insufficiency of the flap, we re-explored the flap immediately at bedside and found engorgement in the recipient vein with venous thrombosis. We repositioned the vein and started anticoagulation therapy with enoxaparin (Clexane®) 2000 IU Q12H. The venous congestion of the flap was resolved; however, hypoxemia deteriorated so much that we had to increase the setting of FiO2 to 75% to maintain the SpO2. The D-dimer level was 1.153ug/ml at that time. Computed tomography pulmonary angiography (CTPA) was arranged for suspected pulmonary embolism (PE) on POD 3. The CTPA showed filling defects in the right main pulmonary artery to the inferior branch of the right pulmonary artery (Figure 2), and PE was diagnosed. A high dose of enoxaparin (Clexane®) 6000 IU Q12H was prescribed. Unfortunately, hypoxemia was still profound even under the anticoagulation therapy. Thus, we consulted a cardiovascular surgeon for veno-venous extracorporeal membrane oxygenation (V-V ECMO). Femoral-femoral V-V ECMO was set up on POD 5, and the continuous heparin infusion was used for thromboembolism prophylaxis. However, we found that the therapeutic level of heparin (aPTT > 55 seconds) could not be reached even under a high dose of heparin (30000 U/24 hours, 14U/kg/hr, aPTT: maximum to 32.8 seconds). In the survey of heparin resistance, antithrombin III deficiency was found (antithrombin III: 55.2%, reference range: 83~128%). Due to heparin resistance, we shifted the heparin pump to Rivaroxaban 15mg BID on POD 9. Under the treatment of a direct oral anticoagulant (DOAC), his respiratory condition showed gradual improvement. The patient successfully weaned from VV-ECMO on POD 13 and a ventilator on POD 14.

Citation:Shih-Hao M and Szu-Hsien W. Successful Salvage of Venous Thromboembolism Manifested as Free Flap Venous Insufficiency and Pulmonary Embolism in a Patient Receiving Microvascular Free Flap Reconstruction after Oral Cancer Resection: A Case Report and Review of the Literature. Austin Crit Care Case Rep. 2022; 6(1): 1038.