Experience with pharmacologic leeching with bivalirudin for adjunct treatment of venous congestion of head and neck reconstructive flaps.

OBJECTIVES: The goal of this study was to review the feasibility of local bivalirudin injection for adjunct treatment of venous congestion of head and neck reconstructive flaps. METHODS: A retrospective chart review of patients who underwent bivalirudin treatment for venous congestion of head and neck reconstructive flaps in a single institution from September 1, 2012 to September 1, 2015 was undertaken. Individuals were treated with variable number of intradermal injections directly into the flap followed by a small skin incision to allow extended passive bleeding. The main outcome measure was improvement of flap congestion. RESULTS: Ten patients with free flap reconstruction (4 anterolateral thigh flaps, 2 pectoralis major flaps, 2 fibula osseocutaneous flaps, 1 supraclavicular flap, and 1 radial forearm free flap) of various head and neck defects underwent treatment with bivalirudin. Bivalirudin injections were utilized as adjunct therapy in 6 patients. Two individuals underwent alternate therapy for venous congestion immediately following injection and therefore the efficacy could not be assessed. Of the 8 remaining flaps, 4 developed partial necrosis, and 1 developed complete necrosis requiring additional reconstruction. Two individuals required blood transfusions during bivalirudin treatment. CONCLUSIONS: Bivalirudin is a safe and feasible adjunct therapy for treatment of flap congestion. It may serve as a useful alternative to traditional leech therapy, as bivalirudin negates the need for antibiotic prophylaxis, eliminates the psychological aversion associated with leech therapy, and avoids the potential for leech migration. Further work to determine the efficacy of bivalirudin to standard leech therapy is warranted.

Antimicrobial prophylaxis during Hirudo medicinalis therapy: a multicenter study.

BACKGROUND: Medicinal leeches (Hirudo medicinalis) are indicated for salvage of tissue flaps, grafts, or replants when venous congestion threatens tissue viability. The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial agents in patients who received medicinal leech therapy. MATERIALS AND METHODS: A multicenter retrospective cohort study of all adult patients between January 1, 2010, and February 28, 2013, who received medicinal leech therapy was conducted. RESULTS: Antimicrobial prophylaxis was documented in 54 (91.5%) of the included patients, ciprofloxacin, trimethoprim-sulfamethoxazole, piperacillin-tazobactam, and ceftriaxone in 33 (61.1%), 18 (33.3%), 2 (3.7%), and 2 (3.7%) patients, respectively. Surgical site infection (SSI) was found in seven (11.9%) patients, all of whom received antimicrobial prophylaxis. Aeromonas spp. was isolated in four infections, and all isolates were resistant to the chosen prophylactic agent. The SSI incidence was similar between antimicrobial prophylaxis agents. CONCLUSION: Trimethoprim-sulfamethoxazole and ciprofloxacin appear equally effective at preventing leech-associated infections.