Comparison of Ischemic Preconditioning and Systemic Piracetam for Prevention of Ischemia-Reperfusion Injury in Musculocutaneous Flaps

Abstract

Background Ischemia-reperfusion injury plays an important role in flap failure. Ischemic preconditioning technique is the only proven method for preventing ischemia-reperfusion injury, but it is not used widely in daily practice because of difficulties such as prolonging the operation time, need for surgical experience, and increasing the risk of complications. This study has been performed with the assumption that piracetam may be a simple and inexpensive alternative to the preconditioning technique due to its antioxidant, antiaggregant, rheological, anti-inflammatory, antiapoptotic, cytoprotective, and immune modulating effects. Methods Thirty-two rats were divided into four groups and latissimus dorsi musculocutaneous flaps were raised. No extra procedure was applied, and no treatment was given to the control group. Four hours of ischemia was created by clamping the thoracodorsal pedicle in the second group. The animals in the third group were treated with 10 minutes of ischemia and reperfusion periods as a preconditioning procedure before the 4 hours of ischemia. Animals in the fourth group received systemic piracetam 30 minutes before and 6 days after reperfusion. Nitric oxide and myeloperoxidase levels in serum and tissue, acute inflammatory cell response, and vascular proliferation in tissue were examined at the postoperative 24th hour and 10th day. Results Myeloperoxidase activity in both preconditioning and piracetam groups, was significantly lower than the ischemia-reperfusion group. Acute inflammatory cell response was similarly decreased in both preconditioning and piracetam groups compared with ischemia-reperfusion group. Tissue measurements of nitric oxide were also significantly higher in both preconditioning and piracetam groups than in the ischemia-reperfusion group. However, vascular proliferation increased in the preconditioning group, while it did not show any significant change in the piracetam group. Conclusion This study shows that systemic piracetam treatment provides protection against ischemia-reperfusion injury in musculocutaneous flaps and can offer a simple and inexpensive alternative to the preconditioning technique.

An Innovative and Economical Device for Ischemic Preconditioning of the Forehead Flap Prior to Pedicle Division: A Comparative Study

“…preconditioning accelerated the neovascularization and reduced the damage of ischemia-reperfusion injury by increasing the vascular proliferation and nitric oxide content, lowering the myeloperoxidase activity, acute inflammatory cell response, and edema formation. 11,12 In our study, the duration of each preconditioning process was between 30 and 60 minutes rather than long-term ischemia. Therefore, the ischemia-reperfusion injury was avoided and the intermittent ischemic preconditioning facilitated the revascularization and shortened the time to pedicle division.…”

“…10 Ischemic preconditioning is another mechanism to reduce flap necrosis by forming a locally hypoxic microenvironment for angiogenesis. 11,12 Animal studies have showed that ischemic preconditioning leads to an increase in capillary perfusion, a decrease in leukocyte-mediated reperfusion injury, an increase in critical ischemic time tolerated by affected tissue, and a reduction in vasospasm. [13][14][15] Only a tiny number of ischemic preconditioning methods have been clinically transformed from bench to bedside.…”

Cannabidiol Improves Random-Pattern Skin Flap Survival in Rats: Involvement of Cannabinoid Type-2 Receptors

“…However, these techniques require multiple surgeries and manipulation of the tissue which is time consuming and might lead to further complications, exerting economic and disease-related burden to the patients and healthcare systems. 36,37 Pharmacologic approaches have garnered much attention in recent years to tackle this issue which could be more efficient in terms of time, complications, and economic burden. Some studies examined the simultaneous effect of IPC and pharmacological investigations.…”

“…However, they did not find significantly different outcomes than the IPC group. 37 Some recent studies also attempted to repurpose the use of agents that are already administered in the clinical setting to improve random-pattern SFS. For instance, Cheng et al, Lin et al, and Kailiang et al investigated protective effects of tirofiban (a widely used antiplatelet medication), bezafibrate, and muscone (one of the most well-known Chinese traditional medicines) in the McFarlane random-pattern skin flap model, respectively.…”