- 期刊
The Perils of Unrecognized Subclavian Artery Stenosis and Free Flap Failure in Head and Neck Reconstruction
術前未察覺的鎖骨下動脈狹窄造成顯微皮瓣手術失敗－病例報告
摘要
Background: Recipient vessels selection is often the key to the success of a free flap. However, proximal obstruction of the selected recipient vessels is rarely investigated during routine preoperative planning. Aim and Objectives: We describe a case where a major proximal vessel obstruction was not noted preoperatively, leading to intraoperative complication and ultimate flap loss. We intend to highlight this peril which may catch out other reconstructive surgeons. Materials and Methods: A 55-year old male who had a previous left parotidectomy along with a left neck dissection and postoperatively radiotherapy developed osteoradionecrosis(ORN) of his left mandible. He underwent a segmental mandibulectomy and wide excision of the necrotic soft tissue around followed by a fibula osteoseptocutaneous flap reconstruction. The contralateral neck vessels were used as a recipient site in consideration of the previous neck dissection and radiotherapy. An event of arterial insufficiency was noted subsequently which necessitated the re-exploration of the flap and a discrepancy of the systolic blood pressure between bilateral upper limbs was noted at this time. Results: The flap failed after two attempts of flap salvage due to uncorrectable arterial insufficiency. The CTA(Computed tomography angiography) revealed severe right subclavian artery stenosis. The necrotic fibula osteoseptocutaneous flap was removed and the wound was subsequently reconstructed successfully with a pedicled Pectoralis Major Flap from the left side chest which not affected by subclavian stenosis. Conclusion: Major discrepancy of systolic blood pressure between bilateral upper limbs may indicate a proximal obstruction of the recipient vessel which may lead to free flap failure. In light of this major discrepancy, preoperative CTA (Computed tomography angiography) or MRA (magnetic resonance angiography) should be performed to rule out its presence so that a reconstruction plan including recipient vessel selection can be properly established.
並列摘要
背 景：適當的供應血管選擇是顯微皮瓣手術成功的關鍵。然而供應血管近心端的阻塞或狹窄是我們術前評估時常常會忽略的部分。目的及目標：我們報告一個案例，因為術前未發覺供應血管之近心端大血管阻塞，造成併發症以及最終手術宣告失敗。我們希望藉由這個案例，提醒顯微重建外科醫師要更加注意這個容易忽略的陷阱。材料及方法：一個55 歲男性因左側腮腺癌術後電療，造成左邊下顎骨放射性骨壞死。他接受了左半邊下顎骨全切除及壞死軟組織的清創，及自由腓骨皮瓣的立即性重建。因為過去之電療及手術史，我們選擇右側血管供應皮瓣之血流。術後皮瓣發生動脈血流不足的問題，同時在加護病房我們也觀測到病人雙手血壓差異非常大。結 果：經過兩次搶救，還是無法避免皮瓣壞死。電腦斷層血管攝影檢查發現病人之右鎖骨下動脈嚴重狹窄。最後壞死的皮瓣經過清創之後，傷口用左側胸大肌皮瓣進行覆蓋，病人傷口癒合良好。結 論：雙側手臂血壓顯著差異通常代表上肢大血管的狹窄或阻塞。為了避免因此而造成的自由皮瓣手術失敗，若是術前發現雙側手臂顯著的血壓差異，術前的電腦斷層血管攝影或核磁共振血管攝影是必須的，可以幫助我們評估並找到適當的供應血管。