(0607) Arterial Anastomotic Avulsions in Head and Neck Free Flap Reconstruction

Introduction: This report details a rare case of arterial anastomotic avulsion (AAA) in a patient undergoing fibular free flap reconstruction, who had a rapidly expanding neck hematoma on POD-3, despite no signs of arterial insufficiency from the flap, suggesting an alternative blood pathway. With most vascular events involving venous complications or arterial thromboses, and limited reporting of AAA in head and neck, we conducted a comprehensive review of the literature.

Methods: The PubMed database was used to conduct a search using the following key terms: free flap, vascular pedicle avulsion, arterial failure, vascular compromise, and anastomotic avulsion. Exclusions comprised cases with non-arterial avulsions, thrombosis-related vascular failure, and avulsions occurring beyond 30 days post-surgery. Statistical trends were analyzed examining the timing of AAA occurrence, free flap types, and management strategies.

Results: After applying these criteria, we identified a total of 11 reports. Most cases involved reconstruction performed by Plastic Surgeons outside of the head and neck. Statistical analysis of the identified cases revealed noteworthy trends. AAA occurred at a mean of 9.56 days postoperatively, with a median timeframe of 10 days (SD = 5.46). Various free flap types were reported, with the fibula being the most common (38%). Most cases involved breast reconstruction (44%). Management strategies varied, including a conservative approach (19%), revision of microsurgical anastomosis (25%), and vein grafting (6%). All other approaches involved ligation. Importantly, flap viability was maintained in most cases (88%).

Conclusions: Managing arterial anastomotic failures in microvascular reconstruction is challenging due to compromised vessel wall integrity, bleeding risks, and challenges in achieving acceptable arterial geometry. This case highlights the necessity of considering AAA as a potential diagnosis and being prepared to weigh the risks and benefits of early anastomotic revision, even in the absence of clinical signs of compromised blood flow.