Are antithrombotic agents necessary for head and neck microvascular surgery?

Zhou, W.; Zhang, W.-B.; Yu, Yanxin; Wang, Y.; Mao, Chi; Guo, Chuanbin; Yu, Guang‐Yan; Peng, Xin

doi:10.1016/j.ijom.2018.10.022

Cited by 13 publications

(32 citation statements)

References 23 publications

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“…Zhou et al, for example, concluded with such a regime that postoperative antithrombotic agents neither provide a significant improvement in the free flap success rate nor decrease the risk of thrombosis. 8 Khouri et al, who investigated different concentrations of tissue factor pathway inhibitor or heparin, could also see no differences for intraoperative revision of anastomosis, postoperative thrombosis, or flap failure. 9 Swartz et al saw, in his retrospective study and analysis including 759 patients, no improvement of free radial forearm flap survival or lower complication rate by anticoagulation drugs.…”

Section: Discussionmentioning

confidence: 98%

The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients

Rothweiler

Metzger

Zieger

et al. 2021

Plastic and Reconstructive Surgery - Global Open

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Summary: Microvascular anastomosis has become a standard surgical technique for reconstruction because of increasing possibilities, indications, and clinical success regarding the survival of the flaps. However, the main dreaded complications exist in thrombosis. Leaving surgical complications aside, systemic problems like disorder of the coagulation-fibrinolysis system are a significant cause of graft loss usually being unrecognized. Reports exist describing a hypercoagulable state with clotting activation and inhibition of fibrinolysis after trauma and delayed surgery considering the secondary homeostasis. In this clinical case, a patient had a large soft tissue defect at the temporal side of the head after severe trauma. After some days of primary stabilization, reconstruction using a free microvascular latissimus dorsi flap was performed. Multiple revisions of the arterial and venous branches had to be performed intraoperatively due to insufficient flap perfusion. After 24 hours, definitive flap loss occurred due to multiple thrombosis in the arterial and venous branches. Postoperative comprehensive coagulation analysis revealed a distinct activation of primary hemostasis with massively increased von Willebrand factor parameters and factor VIII activity as well as acetylsalicylic acid resistance contributing to thrombotic occlusion. In severely injured patients, comprehensive preoperative determination of the coagulation status (especially those of the primary hemostasis) is indispensable before performing free flap reconstruction surgeries to reduce the risk of microvascular flap loss.

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Section: Discussionmentioning

confidence: 98%

The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients

Rothweiler

Metzger

Zieger

et al. 2021

Plastic and Reconstructive Surgery - Global Open

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“…Previous studies have not shown an increased risk of bleeding when dextran has been compared with other antithrombotic agents or no antithrombotic treatment. 6 , 7 …”

Section: Discussionmentioning

confidence: 99%

“…Dextran was omitted from the standard treatment at our department in 2011 since there was evolving evidence showing no beneficial effect with dextran used in head and neck free flaps, but rather an increased risk for systemic complications. 13 Over the last decade, most centers have abandoned the use of dextran because several studies have confirmed that it does not decrease the risk for thrombosis and flap failure 7 , 14 – 16 …”

Section: Discussionmentioning

confidence: 99%

“…Zhou et al recently showed an increased risk of bleeding in the group of head and neck patients randomized to postoperative LMWH compared with those receiving dextran and ASA or no antithrombotic agent. 7 On the other hand, even when triple VTE prophylaxis with LMWH, sequential compressive devices, and early ambulation was used in microsurgical breast reconstruction, 3.4% of the patients had a subclinically detected DVT. 17 Emphasizing the importance of chemoprophylaxis to prevent systemic VTE, the American Association of Plastic Surgeons recommend that chemoprophylaxis should be considered in patients with a Caprini score greater than eight.…”

Section: Discussionmentioning

confidence: 99%

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Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Jakobsson

Kamali

Nord

et al. 2021

Plastic and Reconstructive Surgery - Global Open

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Background: Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment. Methods: Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma. Results: Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001). Conclusions: Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

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“…A drawback is a lack of information about medical complications and the absence of a control group. Zhou et al conducted a randomized, prospective trial, determining no significant difference in flap failure (P = 0.615) between patients with aspirin and dextran, patients with LMWH, and those who did not receive any antithrombotic medication at all [27]. However, it was remarkable that patients with LMWH significantly more often developed hematomas in need of revision (P = 0.032).…”

Section: Discussionmentioning

confidence: 99%

Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin

Sievert

Goncalves

Tamse

et al. 2020

Eur Arch Otorhinolaryngol

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Purpose Free flap reconstruction is a valuable technique to preserve function in oncological head and neck surgery. Postoperative graft thrombosis is a dreaded risk. This study aims to compare low-dose unfractionated heparin (UFH) and lowmolecular-weight heparin (LMWH) in perioperative thrombosis prophylaxis. Methods This is a retrospective analysis of 266 free flaps performed at our academic center. A comparison was made between 2 patient groups, based on their respective postoperative prophylaxis protocols either with UFH (n = 87) or LMWH (n = 179). Primary endpoints were the frequency of transplant thrombosis and the number of flap failures. Secondary endpoints were the occurrence of peri-and postoperative complications. Results The flap survival rate was 96.6% and 93.3% for the groups UFH and LMWH, respectively (P = 0.280). The rate of postoperative bleeding requiring revision was 4.6% and 6.7% for each group, respectively (P = 0.498). We found a hematoma formation in 4.6% and 3.9% (P = 0.792). Conclusion The free-flap survival rate using low-dose UFH seems to be equivalent to LMWH regimens without compromising the postoperative outcome. Consequently, for risk-adapted thrombosis prophylaxis, either LMWH or UFH can be administrated.

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Are antithrombotic agents necessary for head and neck microvascular surgery?

Cited by 13 publications

References 23 publications

The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients

The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin

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