Ischemic preconditioning (IP) of a flap is defined as a brief period of ischemia ("preclamping") followed by tissue reperfusion that increases the tolerance of the flap for a subsequent longer ischemic period. Several studies have showed the effectiveness of classic local IP by preclamping the flap pedicle.
There are two temporally and mechanically different types of IP: acute preconditioning, which is induced by preclamping the flap pedicle briefly before flap ischemia, and late preconditioning, which is induced by a preclamping procedure 24 to 48 hours before flap ischemia. However, neither type of IP is commonly used clinically, most likely because they are invasive, substantially increase surgical time, or even require a second surgery.
We have shown in different experimental models that acute IP, enhancement of flap survival, and improved microvascular reperfusion can be achieved not only by preclamping the flap pedicle, but also by inducing an ischemia-reperfusion event in a body area distant from the flap before elevation. This new, acute "remote ischemia preconditioning" procedure can be applied noninvasively by applying a tourniquet shortly before flap ischemia. The effectiveness of acute remote IP has been confirmed by other authors in large animal models.
The use of a tourniquet to induce limb ischemia before flap ischemia could provide a new, alternative, noninvasive remote IP protocol, although late remote IP might be effective only in muscle flaps. However, the possible future clinical application for late IP is elective flap surgery, whereas acute remote IP could even be used to create emergency flaps.
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