Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature

Background: Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure. Methods: A 77-year-old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter. Results: Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications. Conclusion: When anatomical revision of the venous anastomosis is not feasible in a venous-congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.