Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction

Abstract Objective Microvascular free-tissue transfer is essential for functional reconstruction in head and neck cancer surgery. The risk of free flap failure depends on venous thrombosis rather than arterial thrombosis, and any type of failure caused by venous thrombosis is often diagnosed late. In this study, we studied the flap survival rate achieved by this technique depending on the recipient vein. Further, the risk factor was analyzed for venous thrombosis with regard to preservation of recipient vein during neck dissection. Methods This study is a retrospective review of 102 consecutive free flaps performed by a single head and neck surgical team from 2000 to 2006 at the Department of Otolaryngology, Head and Neck Surgery at Kagoshima University Hospital. The recipient vessels such as the external jugular (EJ) vein and internal jugular (IJ) system were carefully preserved during neck dissection. All patients received 80 μg of prostaglandin E1 (Alprostadil) for 5 days after surgery. Results The overall success rate was 94.1%. All the six cases of unsuccessful free flap transfer were caused by venous thrombosis. Microvascular free flaps anastomosed to the EJ vein failed at a significantly higher rate (13.3%) than those anastomosed to the IJ system (2.8%) ( p < 0.05). On studying the failed cases after IJ system anastomosis, we found that all complications were caused by internal jugular vein thrombosis (IJVT) and not by microvascular anastomotic thrombosis. In all the three cases of flap failure with IJVT, the dissected IJ vein was patently ballooning because of the remaining connective tissue, including the adventitia around the IJ vein in the supraclavicular lesion. Conclusions Although the IJ system is the ideal recipient vessel when compared with EJ vein, there is another risk of flap failure due to IJVT. To improve the survival rate, IJVT should be prevented by a careful manipulation of IJ system during neck dissection to avoid ballooning of the IJ vein in head and neck cancer surgery.