Introduction
Free flap reconstruction is commonly regarded as a safe surgical intervention [1,2]. Meticulous hemostasis during surgery is crucial for maintaining a clear surgical field and for postoperative management [3]. Despite achieving perfect hemostasis, postoperative bleeding can occur, postoperative bleeding may still occur due to factors such as the dislodgement of clips or ties, or elevations in blood pressure during the recovery from general anesthesia [4].
In the majority of instances, minor postoperative bleeding is effectively managed through close observation and compression. However, persistent bleeding can pose a significant threat to both flap viability and patient survival, necessitating extensive blood transfusions [5].
The literature contains limited reports on the utilization of coil embolization for managing bleeding in the context of free flap surgery. This paper aims to present a case where coil embolization was effectively employed to not only preserve flap viability but also ensure the maintenance of critical patient vitals following postoperative hemorrhage.
Case report
This study was approved by the Institutional Review Board (IRB) of Chungnam National University Hospital (CNUH IRB 2024-04-027). Written informed consent was obtained from the patient for the publication of this report including all clinical images.
A 77-year-old female patient with a history of recurrent myxofibrosarcoma on the left thigh underwent wide excision and muscle-sparing latissimus dorsi (LD) free flap reconstruction. The orthopedic surgeons performed the wide excision, which included the removal of skin, subcutaneous tissue, and parts of the vastus medialis, intermedius, lateralis, and sartorius muscles. Following this, the plastic surgeons conducted the muscle-sparing LD free flap procedure. End-to-end anastomosis was successfully performed on the descending branch of the lateral circumflex femoral artery (LCFA). The surgery proceeded without significant complications, and postoperative flap circulation was satisfactory.
Four hours after surgery, the patient’s hemoglobin (Hb) was noted to be 8.8, with moderate oozing from the wound, necessitating compression and the transfusion of one pack of packed red cells (PRC). The bleeding was likely caused by a clip dislodging postoperatively, following clipping performed during the tumor excision surgery. On the morning of postoperative day (POD) 1, despite continuous transfusions maintaining Hb levels to some extent, severe oozing and flap swelling necessitated a hematoma evacuation and exploration under local anesthesia. However, the deep surgical site and the patient’s significant discomfort prevented the identification of a clear bleeding point, leading to the decision to proceed with compression and observation.
Transitioning from POD 1 to 2, the oozing remained at a similar level to the previous day, with no significant changes in vital signs. Observation continued, but a laboratory test in the early hours revealed a critical drop in Hb to 3.7 g/dL, leading to an emergency embolization alongside the transfusion of three packs of PRC. Given the patient’s unstable hemodynamic state and continuous bleeding, coupled with the significant risk of failing to locate the bleeding point, embolization was selected as a safer and more effective method to control the hemorrhage, rather than attempting multiple explorations under general anesthesia. Angiography identified the bleeding point at the proximal segment of the descending branch of the LCFA. Prepared for the potential loss of the flap, an embolization was performed using five Nester Embolization Coils (Cook Medical, Bloomington, IN, USA) at the site above the active bleeding point (Figs. 1, 2). While preserving the blood flow to the flap as much as possible, coil embolization was performed on the proximal segment of the LCFA and the branch artery with bleeding. In the post-procedural phase, apprehensions were raised regarding potential flap necrosis. However, these concerns were mitigated as hemostasis was achieved at the bleeding sites, and the vascular supply to the flap was preserved. As a result, the perfusion to the flap was notably enhanced (Fig. 3).
Discussion
A significant challenge in this case was the occurrence of bleeding near the flap pedicle. This proximity made selective control of the bleeding through coiling particularly difficult. Prior to the procedure, extensive discussions were held with interventional radiologists to devise a strategy that would both preserve the flap and control the bleeding point. It was acknowledged and communicated to the patient that although maximum efforts would be directed towards saving the flap, there remained a possibility that redoing the free flap might be necessary.
Fortunately, postoperative outcomes differed positively from the expectations based on computed tomography and angiography images. The procedure successfully managed to stop the bleeding while maintaining blood flow to the flap. Following the reestablishment of systemic hemodynamic stability, there was a dramatic improvement in the perfusion of the flap.
The successful application of selective embolization in this case can be attributed to the bleeding point being relatively distant from the anastomosis and a considerable distance from the bifurcation site. If the stump had been too short, it would have necessitated occluding the entire proximal segment to block the bleeding point, potentially leading to flap ischemia. Therefore, when discussing embolization with an interventional radiologist, it is crucial to thoroughly analyze the vascular anatomy. It is particularly important to attempt selective embolization as distally as possible to minimize the risk of compromising the flap’s blood supply. This strategy promotes both effective hemorrhage control and the preservation of tissue viability.
Transcatheter arterial microcoil embolization is recognized as a safe and effective procedure for the curative treatment of gastrointestinal bleeding, extrahepatic pseudoaneurysms of the hepatic arteries, coronary artery perforation, and arterial injuries of the lower limbs.
To our knowledge, this case appears to be the first instance of using coil embolization to control postoperative bleeding following free flap surgery. In the existing literature, the application of coil embolization in free flap procedures is mainly documented in the context of preoperative feeding vessel embolization to minimize perioperative bleeding [6], or for addressing postoperative complications such as pseudoaneurysms or arteriovenous fistulas that occur more than a month after the surgery [7-10].
Based on the findings in our paper, it has been demonstrated that in cases of free flap surgery, when bleeding occurs in areas other than the anastomosis site, it is possible to control bleeding and preserve the flap through selective embolization. While it is not always feasible to save the flap and control bleeding in every case, this approach seems to be a viable option as a last resort.
This case report, while providing novel insights into the use of coil embolization in free flap surgery, does have its limitations. Firstly, the findings are based on a single case, which limits the generalizability of the results. The unique anatomical and physiological characteristics of the patient may have contributed to the successful outcome, which may not be replicable in all patients. Additionally, the long-term effects and potential complications of using coil embolization in this context are not fully understood and require further observation. As shown in the Fig. 3, the flap was well-preserved on the 30th day after surgery. However, since the coil is located at the anastomosis proximal portion, the possibility of future embolization or occlusion cannot be ruled out. Continuous observation of the flap is necessary to monitor for these risks. Future research should focus on conducting larger, more comprehensive studies to evaluate the generalizability and long-term outcomes of coil embolization in free flap surgery.
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