A MASSIVE ARTERIAL THROMBOSIS OF A FREE
ANTEROLATERAL THIGH FLAP IN A PATIENT WITH
M. SALGARELLO, M.D.,
D. CERVELLI, M.D., and L. BARONE-ADESI, M.D.
The antiphospholipid syndrome is a pathological condition characterized by recurrent thrombotic manifestations in venous and/or arterial
vascular systems and by peculiar laboratory ﬁndings as anticardiolipin antibodies and/or positive lupus anticoagulant. We present a case
of massive pedicle thrombosis of a free anterolateral thigh perforator ﬂap used for tongue reconstruction following hemiglossectomy in a
patient with antiphospholipid syndrome, which compelled us to an immediate second reconstruction choice with a radial forearm free ﬂap.
This case is an example of how this syndrome, especially if unknown before surgery, can inﬂuence the outcome of microsurgical transfer
2008 Wiley-Liss, Inc. Microsurgery 28:447–451, 2008.
hrombophilia sums up a large number of hemostatic
disorders, which can cause thrombosis, and may be trig-
gered by many factors. Major surgery, as microsurgical
transfer of ﬂaps, may activate hereditary or acquired
thrombophilic disorders leading to overt thrombotic
Driven by this evidence, recent studies have addressed
hypercoagulability states as an important risk factor for
thrombosis in microsurgical settings.
In this context, antiphospholipid syndrome (APS) is
nowadays considered one of the main causes of recurrent
thrombotic manifestations in venous and/or arterial vascu-
lar systems, making evident how this syndrome might
endanger free ﬂap surgery and cause postoperative mor-
bidity and even mortality.
In this report, we present a patient who underwent
hemiglossectomy due to cancer, and reconstruction with
an anterolateral thigh (ALT) perforator ﬂap. During sur-
gery the artery of the pedicle showed irreversible throm-
bosis, which compelled us to harvest a second ﬂap,
namely a radial forearm free (RFF) ﬂap. Postoperative
laboratory ﬁndings allowed us to promptly diagnose APS.
A 51-year-old woman with an ulcerating lesion of 1
cm in diameter of the left half of the tongue (see Fig. 1),
revealed at histological exam as a scarcely differentiated
squamous cell carcinoma (pT4a pN0 pMx), was referred
to us to undergo immediate reconstruction after left hemi-
glossectomy and lymph node dissection.
Her medical history was uneventful for previous
thrombosis, abortions (she never had been pregnant), or
other diseases and she referred nothing about current dis-
orders; routine preoperative tests conﬁrmed her apparent
A preoperative Color-Doppler Sonography (CDS) had
revealed two good caliber perforating vessels of the ante-
rior surface of the right thigh: the superior one had the
arterial diameter of 0.8 mm, with a ﬂow velocity of 15
cm/second, and the vein diameter of 0.7 mm; the inferior
one had the arterial diameter of 0.9 mm, with a ﬂow ve-
locity of 13 cm/second, and the vein diameter of 1 mm.
The tumor was resected by the maxillo-facial team
and resulted in a defect of the left half of the tongue and
of the homolateral buccal ﬂoor. Then, an ALT perforator
ﬂap (9 cm 3 6 cm) was raised on the two perforators
shown by the CDS (see Fig. 2), with a total length of the
pedicle (descending branch of the lateral femoral circum-
ﬂex artery) of 12 cm.
The microsurgical anastomoses started after ﬂap shap-
ing. The recipient vessels were the superior thyroid artery
and a vein of the thyroid-lingual-facial trunk. The total
ischemia time (ﬂap shaping time plus anastomoses time)
was about 1 hour and 30 min.
Once removed the vascular clamps at the end of the
anastomosis, we noted that the artery of the pedicle, dis-
tally to the anastomosis, remained empty with no blood
ﬂow inside it. The vessel showed a massive arterial
thrombosis. We tried to dissolve it with several irriga-
tions of heparinate solution (25,000 U.I. in 250 cc of sa-
line), and then with urokinase solution unsuccessfully.
Since a long tract of the artery of the pedicle
appeared clearly thrombosed, we decided not to perform
the arterial anastomosis again but to harvest a second
ﬂap, namely a RFF ﬂap. We performed the anastomoses
of the radial artery and cephalic vein to the same recipi-
ent vessels used for the ﬁrst ﬂap, as the arterial inﬂow
and venous outﬂow appeared adequate after removing the
Department of Plastic and Reconstructive Surgery, Catholic University of
Sacred Heart, Rome, Italy
*Correspondence to: Marzia Salgarello, M.D., Via della Pineta Sacchetti 484,
00168 Rome, Italy. E-mail: email@example.com
Received 16 November 2007; Accepted 24 March 2008
Published online 11 July 2008 in Wiley InterScience (www.interscience.wiley.
com). DOI 10.1002/micr.20518
2008 Wiley-Liss, Inc.