Papaverine Shortage: Verapamil-Nitroglycerin Solution as a Substitute

Objective: Papaverine is a topical agent commonly used during microvascular surgery to inhibit undesired vasoconstriction. There is a national shortage of papaverine due to ceased production by the only manufacturer within the United States. Establishment of an alternative vasodilator is critically important. This study aims to assess the experience of a solution of verapamil and nitroglycerin (VG solution), a potentially suitable alternative pharmacologic vasodilator. Study Design: Retrospective chart review Methods: 188 consecutive free flaps were performed for head and neck defect reconstruction between February 11, 2013 and February 28, 2015. The topical vasodilator of VG solution was used during these cases. Charts were reviewed for patient and flap characteristics, intraoperative patient and flap complications, and postoperative complications. Results: Flaps performed (n=188) included fibula, radial forearm, subscapular system, anterolateral thigh, and rectus abdominis. There were no vascular thromboses or free flap failures, and one patient with hematoma formation. Specific to topical application of the VG solution, there were no intraoperative cardiac events or abnormalities secondary to application of the solution, including obvious endothelial damage or irreversible arterial vasospasm. No vessels demonstrated intraoperative vasospasm after VG solution application. Conclusion: Use of a VG solution for pharmacological vasodilation during microvascular free tissue transfer did not result in any adverse events and an acceptable vasodilation was witnessed, yielding a potentially acceptable papaverine substitute.