CASE REPORT Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin Dariush Nikkhah 1 & Ben Green 2 & Stamatis Sapountzis 2 & Onur Gilleard 3 & Amanpreet Sidhu 2 & Adam Blackburn 2 Received: 2 August 2015 /Accepted: 26 October 2015 /Published online: 14 November 2015 # Springer-Verlag Berlin Heidelberg 2015 Abstract The authors present the salvage of an anterolateral (ALT) thigh flap, which was congested secondary to venous thrombosis for a period of more than 12 h. This case report details the technical steps that were employed and the evidence base behind them. Level of Evidence : Level V, therapeutic study. Keywords Flap salvage . ALT flap . Recombinant tissue plasminogen activator . Heparin Introduction Free tissue transfer is now commonplace in many plastic sur- gery units worldwide in both elective and trauma settings. In experienced microsurgical units, acceptable flap failure rates are <2 % for elective reconstructions and up to 5 % [1] following trauma. Higher failure rates are more common in trauma cases where recipient vessels for microsurgery can be damaged due to the zone of injury [2, 3]. It is well known that venous thrombosis as a cause of flap compromise is far more common than arterial thrombosis [1]. This risk is reduced by sound microsurgical technique, avoiding tension on the flap pedicle and utilising vessels of a good calibre out of the zone of injury [2]. In order to reduce the chances of flap failure early detection and surgical re-exploration is warranted [1]. Early detection is best achieved by regular flap observations using clinical examination. However, in some rare events, the ‘free flap in difficulty’ can be detected late due to very gradual changes in clinical appearance and also human error. We present such a case where we salvaged a free fasciocutaneous flap used in a case of lower limb trauma. Though the use of Alteplase (Genentech, San Francisco, USA) in free flap salvage is not new, there is no standardised recipe for how best to use it. Here, we present the recipe we used to help the reader in challenging scenarios such as this. Alteplase is recombinantly manufactured tissue plasmino- gen activator (rtPA). When using Alteplase to salvage a free flap, there are two important variables to consider. The first is its concentration and the second is its dwell time. For systemic use, therapeutic levels in the blood circulation are in the region of 0.004 mg/ml (20 mg in 5 L circulating volume). When used for unblocking catheters it is recommended to use 2 mg and allow this to work for at least 30 min before seeing whether it is unblocked. As the catheter is in the systemic circulation a repeat dose is not recommended for 2 h. When salvaging flaps we dilute the 1 mg/ml solution with 4 ml of normal saline to make 5 ml with a concentration of 0.2 mg/ml. This is infused at a rate of 1 ml (0.2 mg)/min and alternated with heparin with a strength of 100 u/ml (5000 units heparin in 50 ml N Saline) also infused at 1 ml (100)u/min. Case report A 36-year-old farmer was referred to our unit after tibial nail fixation of a Gustilo 3b Injury. The trauma had been secondary to a crush injury from a bale of hay falling on his lower limb. The distal third of his leg had an open wound with bone * Dariush Nikkhah dariushnikkhah@hotmail.com 1 Department of Plastic & Reconstructive Surgery, Royal Free Hospital, London, UK 2 Department of Plastic & Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, UK 3 Department of Plastic & Reconstructive surgery, Royal London Hospital, London, UK Eur J Plast Surg (2016) 39:221–224 DOI 10.1007/s00238-015-1169-z