Comparing the Outcomes of Different Agents to Treat Vasospasm at Microsurgical Anastomosis during the Papaverine Shortage

Background: Papaverine remains popular for treating intraoperative vasospasm, but the recent shortage has forced surgeons to trial antispasmodic agents unproven in microsurgery but commonly used in other body areas. During this shortage, the authors have used topical lidocaine and nicardipine to break intraoperative vasospasm. This study aims to analyze the outcomes of these medications on flap complications compared with papaverine. Methods: All consecutive free flaps performed for breast reconstruction at a single institution were reviewed. Data collected included patient demographics, comorbidities, complications, and type of antispasmodic agent. Rates of reexploration, complications, and flap salvage were compared between patients receiving antispasmodic agents and matched papaverine controls. Results: Of the 1087 flaps treated with antispasmodic agents, nicardipine was used on 59 flaps and lidocaine was used on 55 flaps. Patients treated with lidocaine had higher body mass indexes (31.0 kg/m² versus 27.4 kg/m²; p = 0.001). Patients treated with nicardipine tended to be older (64.0 versus 48.5; p < 0.01) and have a history of hypertension (22.0 percent versus 10.4 percent; p = 0.08) or preoperative irradiation (32.2 percent versus 13.6 percent; p = 0.016) compared with papaverine controls. No differences in the rates of total or partial flap loss, unplanned return to the operating room, or fat necrosis were observed between any of the groups. However, the nicardipine group demonstrated a higher rate of infection (15.3 percent versus 3.4 percent; p = 0.027). Conclusion: Substituting lidocaine or nicardipine for papaverine to treat vasospasm did not demonstrate an increased rate of flap loss or return to the operating room, making these medications safe and efficacious alternatives to papaverine.