Intraoperative findings that were common to these failed anastomoses were as follows:1. The arterial anastomosis does not flash when the clamp is removed; it requires manipulation.2. The arterial anastomosis goes down quickly (within 1 hour), before the rest of the procedure is completed.3. The vessels, particularly the recipient flap vessels, are flaccid.4. Topical agents such as papaverine and lidocaine do not appear to resolve the perfusion problem.5. Heparin may make it worse.6. Administration of intravascular thrombolytic agents (Activase; Genentech, Inc., South San Francisco, Calif.) provides instant bright red bleeding from every cut surface, but thrombus quickly reaccumulates at the anastomotic site.
First, the operative defect should be temporized using dressing changes until more definitive reconstruction can be safely performed.Second, immediate perioperative anticoagulation needs to be initiated, as the hypercoagulable state places the patient at high risk for postoperative venous thromboembolism/deep venous thrombosis.Third, plans for long-term anticoagulation, if any, need to be coordinated with the hematology service. Some hypercoagulable patients (those with lupus or malignancy) might need protracted anticoagulation, whereas other patients simply require counseling on anticoagulation strategies during future scenarios associated with high risk of venous thromboembolism, such as operations, long plane flights, pregnancy, and other conditions that might unmask their predisposition to hypercoagulability.