Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Objective: Our primary objective was to compare outcomes of adjunct local bivalirudin injection (bival) vs leeches for venous congestion of head and neck reconstructive flaps. A secondary objective was to compare safety and outcomes of adjunct bival to standard surgical exploration alone. The primary outcome measure was free flap viability.
Study Design: Retrospective cohort study
Setting: Single tertiary academic center
Methods: A retrospective chart review of patients who underwent treatment for venous congestion of head and neck reconstructive flaps from Oct 1, 2004 to Oct 1, 2024 was undertaken. Individuals were treated with exploration surgery alone, or the addition of adjuncts including leeches and bival.
Results: There were 94 patients with venous congestion of head and neck reconstructive flaps. Bival was utilized as primary treatment in 2 patients and adjunctly to surgical exploration in 10 patients. Leeches were used as primary treatment 11 times and adjunctly to surgical exploration 23 times. When comparing adjunct bival to adjunct leech therapy there was no significant difference in demographics, resection subsite, flap type, anastomosis vessels, vein coupler size, duration of adjunct treatment, or admission length. We categorized exploratory surgery findings as hematoma compression, clot in the vein, kinking/malposition, or microscopic perfusion concerns, and found no difference between the two adjuncts. There was no statistical difference in flap viability after the two adjuncts, 60% of flaps after bival were viable compared to 50% after leeches, 10% were partially viable after bival vs 27.3% with leeches, and 30% were non-viable after bival vs. 22.7% after leeches (Cramer’s V (CV)=.195, p=0.545). This remained true when including the patients treated primarily with bival or leeches without exploratory surgery. Patients treated with leech therapy required significantly greater blood transfusions (5.2 vs 0.8 units, p=0.007) and ICU admissions, for all indications, (95% vs 20%, p<0.001). One patient died from anemia and hypotension related complications during leech therapy, and another required surgical exploration to find a leech that migrated to the oropharynx. When comparing adjunct bivalirudin with surgical exploration to surgical exploration alone (n=48), there were no differences in outcomes including flap viability, ICU admission, number of blood transfusions, or length of admission. When flap viability was dichotomized into viable/non-viable, there were no differences between adjunct bival and leech therapy, or between adjunct bival and surgical exploration alone. We did find an association of greater flap viability with patients being white, heparin drip use, and hematoma compression on exploratory surgery. After adjustment in a logistic regression model, none of those factors nor the adjunct use of bival and leeches were associated with flap viability.
Conclusion: The efficacy of adjunct bivalirudin for venous congestion of head and neck reconstructive flaps remains difficult to assess, but in selected cases the high rate of flap viability is promising. Its safety, ease of use, and decreased resource use, offers distinct advantages over adjunct leech therapy.