Current concepts in salvage procedures for failing microvascular flaps: is there a superior technique? Insights from a systematic review of the literature
Troeltzsch M, Troeltzsch M, Probst FA, Ristow O, Ehrenfeld M, Otto S (2016) · International Journal of Oral and Maxillofacial Surgery · n=330
Study Profile
- Design
- systematic review of 39 studies (330 microvascular free flap salvage cases) published between 1990 and 2015, with predefined inclusion/exclusion criteria and pooled descriptive analysis of salvage techniques; 11 leech-therapy studies (73 flaps) included (LMU Munich, University Goettingen, University Heidelberg)
- Sample size (n)
- 330
- Intervention
- Comparative assessment across four primary salvage techniques: (1) Fogarty catheter thrombectomy (6 studies, 68 flaps), (2) intraoperative thrombolytic drugs (16 studies, 184 flaps), (3) placement of an arteriovenous fistula (5 case reports, 5 flaps), and (4) postoperative medicinal leech therapy (11 studies, 73 flaps)
- Comparator
- Cross-technique comparison of pooled salvage success rates from heterogeneous studies; only 5 studies provided comparative control-group data
- Primary endpoint
- Flap salvage success rate across published techniques; identification of methodological strengths and limitations in flap salvage literature
- Primary result
- Pooled flap salvage success rates were broadly comparable across all four techniques with no single approach demonstrating clear superiority over the others; total reported sample limited to 330 flaps across 39 studies; only 5 of 39 included studies had control groups; level of evidence was uniformly low; the authors concluded that no superior salvage technique was identifiable from the existing evidence base
- Follow-up duration
- follow-up varied by included study (most reported acute postoperative flap status only)
- PMID
- 27450660
Key Findings
- Largest pooled flap salvage systematic review at time of publication (39 studies, 330 flaps, 1990-2015)
- Leech therapy was 1 of 4 main salvage techniques and contributed 11 studies / 73 flaps to the dataset
- No salvage technique demonstrated clear superiority — emphasizes that leech therapy is a reasonable, evidence-supported option among several
- Only 5 of 39 studies had control groups, exposing the methodological weakness of the salvage literature
- Provides the strongest published basis for treating individual salvage technique selection as case-specific rather than algorithm-driven
Limitations
- Pooled descriptive analysis only — no quantitative meta-analysis due to study heterogeneity
- Underlying studies overwhelmingly low-quality with small samples and missing control groups
- Publication and reporting bias likely (successful salvage cases over-represented)
- Inclusion period ends in 2015 — does not capture more recent leech-therapy literature (Lehnhardt 2021, Merlino 2020)
- Outcome adjudication varied widely across included studies
Clinical Implications
Troeltzsch 2016 is the definitive evidence-quality assessment of the flap-salvage literature through 2015 and concludes that the current published evidence cannot identify a superior salvage technique. For US clinicians, the review reinforces that medicinal leech therapy is one of the four established salvage options (alongside Fogarty thrombectomy, intraoperative thrombolytics, and arteriovenous fistula placement) and that local institutional expertise, patient-specific factors, and technique availability should drive case-by-case decisions. The review is also commonly cited to justify continued use of leech therapy as a legitimate K040187 technique pending higher-quality comparative trials.
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