Microvascular Surgery: Vasopressors

There has long been concern with the use of vasopressors in microvascular or free-flap surgery due to the presumed risk of vasospasm and eventual flap compromise. This led to the avoidance of vasopressors in favor of fluid administration, sometimes resulting in fluid overload and subsequent complications. Recent studies have questioned the risk of vasopressor administration in microvascular surgery.

A meta-analysis by Knackstedt et al. in 2019 examined vasopressor usage and risk of complications in microvascular surgery for all recipient sites. They analyzed four prospective and six retrospective studies with a total of 6321 patients and 7526 flaps. They found that flaps that received vasopressors had a statistically lower rate of take-backs and flap failure.

Another meta-analysis by Goh et al. in 2019 evaluated free flap outcomes in patients who had received vasopressors and compared them to patients who had not received vasopressors. They looked at 14 studies representing 8,653 cases. Meta-analysis showed that vasopressors were associated with less flap failure overall and resulted in less pedicle thrombosis in head and neck surgery. They concluded that the benefit of increased perfusion of vasopressors likely outweighed the risk for flap failure and the negative effects of excessive fluid administration.