Management of Delayed Vascular Occlusion in Free Flap Breast Reconstruction: A Systematic Review of Literature and Case Report

INTRODUCTION Free flap surgery is a reliable and safe procedure for breast reconstruction. The survival of free flaps depends on their vascular pedicle initially, but neovascularization can sustain their blood supply after a while. Management of late pedicle occlusion in free flap breast reconstruction and potential implications of late pedicle occlusion on the transferred tissue are controversial. METHODS AND MATERIALS We systematically reviewed current literature focusing on articles that reported on late pedicle occlusion in free flaps for breast reconstruction. We aimed to analyze incidences of late pedicle occlusion, the existing evidence for the most appropriate management strategy for late pedicle occlusion, and its implications on overall outcomes. In support of the review, we present a clinical case of a salvage of a deep inferior epigastric artery perforator flap following late arterial thrombosis 12 days postoperatively. RESULTS The literature is limited to a few case reports on pedicle occlusion in free flap breast reconstruction and a few heterogeneous retrospective reviews reporting on late pedicle occlusion in general. Despite the heterogeneity of articles and approaches to salvage flaps with late pedicle occlusion, we found no convincing evidence that surgery is the best choice to salvage flaps in breast reconstruction that appear to have late pedicle occlusion. Our case demonstrates that a conservative approach may be justified more than initially deemed necessary. CONCLUSIONS Late pedicle occlusion is a rare but serious event in free flap breast reconstruction. Surgery does not seem to be the most appropriate approach in every case. Decisions should be based on clinical dynamics and imaging findings such as indocyanine-green angiography. A carefully carried out conservative approach may lead to flap salvage.