Free tissue transfer in patients with cold agglutinin disease (CAD) is a procedure that lacks sufficient publications. Despite the risk of performing this procedure in patients with CAD due to possible underlying hematological complications, successful free tissue transfer is possible, according to an article published in Microsurgery.

Microvascular free tissue transfer is a meticulous process requiring adequate hematological functioning. Patients with CAD tend to have microvascular hematological complications like occlusion, directly impacting the outcome of free tissue transfer. 

The authors presented the case of a 61-year-old male patient with CAD with a gunshot wound to his lower face who underwent a successful free tissue transfer.

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The patient had Waldenström macroglobulinemia and secondary CAD. His CAD manifested with chronic hemolysis, which was compensated, and symptomatic acrocyanosis. After soft tissue closure following debridement and rigid plate fixation of the mandible, the lower lip was substantially lost with plate exposure. 

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Two days later, reconstruction of the lower lip using a microvascular technique was performed. The authors consulted the hematology department before the procedure. No preoperative therapy was necessary because there were no clinical or paraclinical signs of acute worsening of hemolysis or symptomatic hyperviscosity. 

The patient was monitored closely and kept warm via warmed fluids, a heated theater, and a warming blanket. “In order to reduce the risk of microvascular occlusion in the limb and the flap, the radial forearm flap was harvested without tourniquet control,” the authors said. 

The authors used special techniques to avoid agglutination and, hence, thrombosis. Before the disconnection of the flap from the systemic circulation, the neck vessels were prepared for anastomosis. Then, the flap stayed in a warm swab soaked with saline. The remainder of the procedure was completed. The patient did not have any postoperative complications, and the complete flap survived.

The authors discussed previous studies on other types of surgery in patients with CAD, such as coronary artery bypass surgery and abdominal surgeries, which used several warming techniques to improve the chances of successful outcomes. Overall, adding warming techniques proved successful in free tissue transfer in this case report.

“This report gives guidance in the management of microvascular free tissue transfer in CAD,” the authors concluded. “It is highly relevant in microsurgery as antibody activation can lead to hemolysis, microvascular occlusion and thrombosis, and ultimate flap failure.”


Beecher SM, Quigley A, Gurney M, Hussey AJ, McInerney NM. Microvascular free tissue transfer in the setting of cold agglutinin diseaseMicrosurgery. Published online May 25, 2022. doi:10.1002/micr.30923