Thrombotic Occlusion of a Microvascular Anastomosis in a Resistance to Activated Protein C (APC) Patient with Incomplete Wound Healing after High Doses of Ascorbic Acid (Vitamin C)

Martijn P. J. Loonen, Bob De Frene, Bob Casaer

Department of Plastic, Reconstructive and Aesthetic Surgery at the Sint-Jan Hospital, Bruges, Belgium.

DOI: 10.4236/mps.2012.23015                

Abstract

A 45-year-old woman underwent a delayed breast reconstruction with a free Deep Inferior Epigastric Perforator Flap (DIEP flap) with total flap failure on the fourth postoperative day. Hematological investigation to exclude thrombofilia revealed a resistance to activated protein C (APC) with a factor V Leiden heterozygous mutation. The postoperative course was further complicated by delayed wound healing probably due to ascorbic acid (Vitamin C) related cytotoxic activity to fibroblasts. The surgeon must be aware of the use of preoperative nutritional supplement administration among patients. Future cost-effectiveness analyses should be made to warrant preoperative thrombophilia screening to prevent free flap failures.

Keywords

Thrombotic Occlusion; Vitamin C; Activated Protein C

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	D. L. Chengelis, P. J. Bendick, J. L. Glover, O. W. Brown and T. J. Ranval, “Progression of Superficial Venous Thrombosis to Deep Vein Thrombosis,” Journal of Vascular Surgery, Vol. 24, No. 5, 1996, pp. 745-749. doi:10.1016/S0741-5214(96)70007-1
[2]	E. Olsson and P. H?ijer, “Activated Protein C Resistance Due to Factor V Leiden, Elevated Coagulation Factor VIII and Postoperative Deep Vein Thrombosis in Late Breast Reconstruction with a Free TRAM Flap: A Report of Two Cases,” British Journal of Plastic Surgery, Vol. 58, No. 5, 2005, pp. 720-723. doi:10.1016/j.bjps.2004.12.024
[3]	I. C. Warnecke, F. Kretschmer, S. Brüner, O. Frerichs and H. Fansa, “Hereditary Thrombophilia in Free Microvascular Flaps—A Case Report,” Handchirurgie Mikrochirurgie Plastische Chirurgie, Vol. 39, No. 3, 2007, pp. 220-224. doi:10.1055/s-2007-965139
[4]	N. A. Mikirova, T. E. Ichim and N. Riordan, “Anti-Angiogenic Effect of High Doses of Ascorbic Acid,” Journal of Translational Medicine, Vol. 6, 2008, pp. 50-65. doi:10.1186/1479-5876-6-50
[5]	Q. Chen, M. G. Espey, A. Y. Sun, J. H. Lee, M. C. Krishna, E. Shacter, P. L. Choyke, C. Pooput, K. L. Kirk, G. R. Buettner and M. Levine, “Ascorbate in Pharmacologic Concentrations Selectively Generates Ascorbate Radical and Hydrogen Peroxide in Extracellular Fluid in Vivo,” Proceedings of the National Academy of Sciences, Vol. 104, No. 21, 2007, pp. 8749-8754. doi:10.1073/pnas.0702854104
[6]	B. Peterkofsky and W. Prather, “Cytotoxicity of Ascorbate and Other Reducing Agents towards Cultured Fibroblasts as a Result of Hydrogen Peroxide Formation,” Journal of Cellular Physiology, Vol. 90, No. 1, 1977, pp. 61-70. doi:10.1002/jcp.1040900109
[7]	H. D. Jampel, “Ascorbic Acid Is Cytotoxic to Dividing Human Tenon’s Capsule Fibroblasts. A Possible Contributing Factor in Glaucoma Filtration Surgery Success,” Archives of Ophthalmology, Vol. 108, No. 9, 1990, pp. 1323-1325. doi:10.1001/archopht.1990.01070110139038