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Mechanical failure of a Fogarty catheter in a microsurgical procedure: A case report
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 966e968
CASE REPORT
Mechanical failure of a Fogarty catheter in a microsurgical procedure: A case report D. Rizis, J. Bibeau Poirier, A. Nikolis, J.-P. Brutus, C. Cordoba * Service of Plastic and Reconstructive Surgery, Hoˆpital Notre-Dame, Centre Hospitalier de l’Universite´ de Montre´al (CHUM), Montreal, Quebec, Canada Received 15 October 2010; accepted 19 October 2010
KEYWORDS Fogarty catheter; Mechanical failure; Microsurgical free-flap salvage; Thrombectomy; Microsurgery
Summary Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Since its development in 1963 by Dr Thomas J. Fogarty, the Fogarty catheter has gained widespread acceptance as a valuable addition to the armamentarium of the vascular surgeon. While its primary role is aimed at treating lowerlimb vascular insufficiency, the Fogarty catheter can also be used in the salvage of thrombosed free flaps. Its use is not without risk; complications may arise through trauma to the vessels or by mechanical failure of the catheter itself. This article focusses on the problems that may potentially arise
* Corresponding author. Centre Hospitalier de l’Universite ´ de Montre ´al (CHUM), 1560 Sherbrooke Street East, Montreal, Quebec H2L 4M1, Canada. Tel.: þ1 (514) 890 8000x23757; fax: þ1 (514) 412 7575. E-mail address: [email protected] (C. Cordoba).
with the use of Fogarty catheters in free-flap salvage. Herein, we discuss a case where the Fogarty catheter balloon was completely separated from the rest of the catheter during a thrombectomy for microsurgical flap salvage.
Case report A 71-year-old man presenting with a floor-of-mouth tumour was treated by surgical excision and immediate reconstruction using a radial forearm free flap. Microsurgical anastomoses were performed between the cephalic and external jugular veins as well as an end-to-end arterial anastomosis between the radial and the facial arteries. At 40 h post-intervention, venous congestion of the flap was diagnosed, and emergent exploration was undertaken at the level of the anastomoses with subsequent extraction of
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.10.012
A case report
967
a 4-cm thrombus at the venous anastomosis. There was no improvement in venous outflow. Consequently, a #3 Fogarty catheter was passed several times through the cephalic vein with evacuation of smaller organised clots. The catheter returned, during a final passage with minimal resistance, without its balloon or metallic coil (Figures 1 and 2). Although traction applied to the coil was unsuccessful in retrieving the device, a second Fogarty catheter was successfully used to retrieve the missing balloon and coil (Figure 2). The arterial anastomosis was found to be permeable; however, venous return had not improved post-thrombectomy. Thrombolysis was therefore performed via intra-arterial irrigation of 6 mg of recombinant tissue plasminogen activator (rTPA) in an attempt to lyse potential proximally located clots. Venous outflow failed to improve once again. The free flap was therefore removed and replaced by a pedicled sternocleidomastoid muscular flap and split-thickness skin graft.
Figure 2 Fogarty catheter with the missing balloon and coil retrieved. The lower normal Fogarty catheter was used to retrieve the broken upper one.
Discussion Microvascular free-tissue transfer has proved to be a reliable technique for the reconstruction of complex wounds, with a reported failure rate of less than 5%. Free-flap failure is considered an early complication, occurring within the first 4e5 postoperative days. Several causes of flap compromise have been identified, and include external compression from haematoma, pedicle kinking and thrombosis. Free-flap compromise will often necessitate emergent operative exploration. Successful salvage rates following exploration have been reported in the literature as ranging between 19% and 100%, with rapid identification of flap compromise and emergent exploration being the most important factors influencing outcome.1e3 The Fogarty catheter consists of a vinyl body, 40e80 cm in length, with an inflatable balloon near its tip. Although its main use is for vascular clot extraction, the catheter’s role has evolved through the years, and it is now used as a complementary tool in the treatment of endobronchial foreign bodies and gallstones.4 As the field of microsurgery developed, so did the role of the Fogarty catheter. It may be employed for thrombectomy of an affected pedicle during flap exploration. The efficacy of catheter thrombectomy in restoring vascular blood flow in the setting of
Figure 1
a total thrombosis of a pedicle vessel has been reported by Wheatley and Meltzer, who salvaged seven free flaps using Fogarty #2 and #3 catheters.5 Other approaches have been described using catheter-directed thrombolysis with agents such as heparin, streptokinase, urokinase and rTPA. In addition, the catheter has also been used as a tool for the late salvage of compromised flaps.6,7 Complication rates associated with Fogarty catheter use range between 1% and 6%, and may be classified into two types: those caused by trauma to vessels and those related to mechanical failure of the catheter itself. The most frequent vessel traumas include vessel wall perforation by the tip of the catheter, vessel wall rupture due to balloon inflation, intima disruption or tearing and arteriovenous fistula formation.8,9 Although rare, complications associated with malfunction or rupture of the catheter have been reported, with balloon rupture being the most common. In spite of there being no reported cases in the literature, distal air emboli remain theoretically possible.8e10 In and of itself, balloon rupture is benign unless fragmentation and distal embolisation compromising blood flow occur, thereby contributing to the development of thrombi through turbulence and stasis.9
a-b. Catheter returned without its balloon nor its metallic coil.
968 Complete separation of the balloon from the rest of the catheter has been reported in the setting of vascular surgery but, to our knowledge, not in the case of free-flap salvage.8 The use of a second Fogarty catheter should be the primary therapeutic choice in an attempt to free and retrieve the entrapped balloon prior to proceeding with an arteriotomy or venotomy. The separation of the catheter tip is often associated with the mishandling of the material either by forcing its passage or by applying excessive traction. The instrument may also be weakened by repeated back and forth motions.9 Several recommendations, such as familiarity with the catheter prior to its usage, avoidance of aggressive withdrawals and deflation of the balloon followed by withdrawal of the catheter in the presence of significance resistance, can be made to decrease the likelihood of this complication. One must be aware of this possible complication when using a Fogarty catheter for free-flap salvage and also how to promptly manage this situation.
Conflict of interest statement No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
D. Rizis et al.
References 1. Hidalgo DA, Jones CS. The role of emergent exploration in freetissue transfers: a review of 150 consecutive cases. Plast Reconstr Surg 1990;86:492e8. 2. Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996;98:1230e3. 3. Yii NW, Evans GRD, Miller MJ, et al. Thrombolytic therapy: what is its role in free flap salvage? Ann Plast Surg 2001;46:601e4. 4. Fogarty TJ, Cranley JJ, Kranse RJ, et al. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 1963;116:241e4. 5. Wheatley MJ, Meltzer TR. The role of vascular pedicle thrombectomy in the management of compromised free tissue transfers. Ann Plast Surg 1996;36:360e4. 6. Tse R, Ross D, Gan BS. Late salvage of a free TRAM flap. Br J Plast Surg 2003;56:59e62. 7. Trussler AP, Watson JP, Crisera CA. Late free-flap salvage with catheter-directed thrombolysis. Microsurgery 2008;28:217e22. 8. Schweitzer DL, Aguam AS, Wilder JR. Complications encountered during arterial embolectomy with the Fogarty balloon catheter. Vasc Surg 1976;10:144e56. 9. Foster JH, Carter JW, Graham CP, et al. Arterial injuries secondary to the use of the Fogarty catheter. Ann Surg 1970; 171:971e8. 10. Dainko EA. Complications of the use of the Fogarty balloon catheter. Arch Surg 1972;105:79e82.
CASE REPORT
Mechanical failure of a Fogarty catheter in a microsurgical procedure: A case report D. Rizis, J. Bibeau Poirier, A. Nikolis, J.-P. Brutus, C. Cordoba * Service of Plastic and Reconstructive Surgery, Hoˆpital Notre-Dame, Centre Hospitalier de l’Universite´ de Montre´al (CHUM), Montreal, Quebec, Canada Received 15 October 2010; accepted 19 October 2010
KEYWORDS Fogarty catheter; Mechanical failure; Microsurgical free-flap salvage; Thrombectomy; Microsurgery
Summary Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Since its development in 1963 by Dr Thomas J. Fogarty, the Fogarty catheter has gained widespread acceptance as a valuable addition to the armamentarium of the vascular surgeon. While its primary role is aimed at treating lowerlimb vascular insufficiency, the Fogarty catheter can also be used in the salvage of thrombosed free flaps. Its use is not without risk; complications may arise through trauma to the vessels or by mechanical failure of the catheter itself. This article focusses on the problems that may potentially arise
* Corresponding author. Centre Hospitalier de l’Universite ´ de Montre ´al (CHUM), 1560 Sherbrooke Street East, Montreal, Quebec H2L 4M1, Canada. Tel.: þ1 (514) 890 8000x23757; fax: þ1 (514) 412 7575. E-mail address: [email protected] (C. Cordoba).
with the use of Fogarty catheters in free-flap salvage. Herein, we discuss a case where the Fogarty catheter balloon was completely separated from the rest of the catheter during a thrombectomy for microsurgical flap salvage.
Case report A 71-year-old man presenting with a floor-of-mouth tumour was treated by surgical excision and immediate reconstruction using a radial forearm free flap. Microsurgical anastomoses were performed between the cephalic and external jugular veins as well as an end-to-end arterial anastomosis between the radial and the facial arteries. At 40 h post-intervention, venous congestion of the flap was diagnosed, and emergent exploration was undertaken at the level of the anastomoses with subsequent extraction of
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.10.012
A case report
967
a 4-cm thrombus at the venous anastomosis. There was no improvement in venous outflow. Consequently, a #3 Fogarty catheter was passed several times through the cephalic vein with evacuation of smaller organised clots. The catheter returned, during a final passage with minimal resistance, without its balloon or metallic coil (Figures 1 and 2). Although traction applied to the coil was unsuccessful in retrieving the device, a second Fogarty catheter was successfully used to retrieve the missing balloon and coil (Figure 2). The arterial anastomosis was found to be permeable; however, venous return had not improved post-thrombectomy. Thrombolysis was therefore performed via intra-arterial irrigation of 6 mg of recombinant tissue plasminogen activator (rTPA) in an attempt to lyse potential proximally located clots. Venous outflow failed to improve once again. The free flap was therefore removed and replaced by a pedicled sternocleidomastoid muscular flap and split-thickness skin graft.
Figure 2 Fogarty catheter with the missing balloon and coil retrieved. The lower normal Fogarty catheter was used to retrieve the broken upper one.
Discussion Microvascular free-tissue transfer has proved to be a reliable technique for the reconstruction of complex wounds, with a reported failure rate of less than 5%. Free-flap failure is considered an early complication, occurring within the first 4e5 postoperative days. Several causes of flap compromise have been identified, and include external compression from haematoma, pedicle kinking and thrombosis. Free-flap compromise will often necessitate emergent operative exploration. Successful salvage rates following exploration have been reported in the literature as ranging between 19% and 100%, with rapid identification of flap compromise and emergent exploration being the most important factors influencing outcome.1e3 The Fogarty catheter consists of a vinyl body, 40e80 cm in length, with an inflatable balloon near its tip. Although its main use is for vascular clot extraction, the catheter’s role has evolved through the years, and it is now used as a complementary tool in the treatment of endobronchial foreign bodies and gallstones.4 As the field of microsurgery developed, so did the role of the Fogarty catheter. It may be employed for thrombectomy of an affected pedicle during flap exploration. The efficacy of catheter thrombectomy in restoring vascular blood flow in the setting of
Figure 1
a total thrombosis of a pedicle vessel has been reported by Wheatley and Meltzer, who salvaged seven free flaps using Fogarty #2 and #3 catheters.5 Other approaches have been described using catheter-directed thrombolysis with agents such as heparin, streptokinase, urokinase and rTPA. In addition, the catheter has also been used as a tool for the late salvage of compromised flaps.6,7 Complication rates associated with Fogarty catheter use range between 1% and 6%, and may be classified into two types: those caused by trauma to vessels and those related to mechanical failure of the catheter itself. The most frequent vessel traumas include vessel wall perforation by the tip of the catheter, vessel wall rupture due to balloon inflation, intima disruption or tearing and arteriovenous fistula formation.8,9 Although rare, complications associated with malfunction or rupture of the catheter have been reported, with balloon rupture being the most common. In spite of there being no reported cases in the literature, distal air emboli remain theoretically possible.8e10 In and of itself, balloon rupture is benign unless fragmentation and distal embolisation compromising blood flow occur, thereby contributing to the development of thrombi through turbulence and stasis.9
a-b. Catheter returned without its balloon nor its metallic coil.
968 Complete separation of the balloon from the rest of the catheter has been reported in the setting of vascular surgery but, to our knowledge, not in the case of free-flap salvage.8 The use of a second Fogarty catheter should be the primary therapeutic choice in an attempt to free and retrieve the entrapped balloon prior to proceeding with an arteriotomy or venotomy. The separation of the catheter tip is often associated with the mishandling of the material either by forcing its passage or by applying excessive traction. The instrument may also be weakened by repeated back and forth motions.9 Several recommendations, such as familiarity with the catheter prior to its usage, avoidance of aggressive withdrawals and deflation of the balloon followed by withdrawal of the catheter in the presence of significance resistance, can be made to decrease the likelihood of this complication. One must be aware of this possible complication when using a Fogarty catheter for free-flap salvage and also how to promptly manage this situation.
Conflict of interest statement No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
D. Rizis et al.
References 1. Hidalgo DA, Jones CS. The role of emergent exploration in freetissue transfers: a review of 150 consecutive cases. Plast Reconstr Surg 1990;86:492e8. 2. Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996;98:1230e3. 3. Yii NW, Evans GRD, Miller MJ, et al. Thrombolytic therapy: what is its role in free flap salvage? Ann Plast Surg 2001;46:601e4. 4. Fogarty TJ, Cranley JJ, Kranse RJ, et al. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 1963;116:241e4. 5. Wheatley MJ, Meltzer TR. The role of vascular pedicle thrombectomy in the management of compromised free tissue transfers. Ann Plast Surg 1996;36:360e4. 6. Tse R, Ross D, Gan BS. Late salvage of a free TRAM flap. Br J Plast Surg 2003;56:59e62. 7. Trussler AP, Watson JP, Crisera CA. Late free-flap salvage with catheter-directed thrombolysis. Microsurgery 2008;28:217e22. 8. Schweitzer DL, Aguam AS, Wilder JR. Complications encountered during arterial embolectomy with the Fogarty balloon catheter. Vasc Surg 1976;10:144e56. 9. Foster JH, Carter JW, Graham CP, et al. Arterial injuries secondary to the use of the Fogarty catheter. Ann Surg 1970; 171:971e8. 10. Dainko EA. Complications of the use of the Fogarty balloon catheter. Arch Surg 1972;105:79e82.