Effects of Perioperative Venous Thromboembolism on Outcomes in Soft Tissue Reconstruction of Traumatic Lower Extremity Injuries

Abstract

Background Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a significant perioperative complication. However, the outcomes of lower extremity salvage in the setting of perioperative VTE are not well reported. Methods A retrospective review of lower extremity trauma patients requiring soft tissue reconstruction between July 2007 and December 2015 at an urban trauma center was performed. Patients with clinically apparent VTE during inpatient stay were identified. Outcomes compared included success of limb salvage, flap survival, and flap complications. Comorbidities, injury characteristics and perioperative data were also compared between patients with and without VTE. Results One hundred ninety patients with lower extremity injuries underwent local and free flap procedures, with 12 (6.3%) patients developing clinically apparent VTE during hospitalization. Nine VTEs (75.0%) were diagnosed prior to soft tissue reconstruction, and 3 (25.0%) VTEs were diagnosed postreconstruction. The limb salvage rate in patients with VTE was 100%. There were no flap losses in patients with VTE, and the overall flap complication rate was similar between VTE and non-VTE groups (P = 0.26). However, there was an increased risk of postoperative hematoma in patients undergoing free flap transfer with diagnosed VTE compared with patients receiving free flaps without VTE (40.0% vs 2.6%, P = 0.02). Additionally, 1 patient died as a result of pulmonary embolism, and another patient experienced an ischemic stroke from a paradoxical embolism. Conclusions These results suggest that successful limb salvage and flap survival may be achieved in the setting of perioperative VTE, although anticoagulation prophylaxis and treatment are critical in this population due to significant morbidity and mortality associated with VTE.

The Great Saphenous Vein—An Underrated Recipient Vein in Free Flap Plasty for Lower Extremity Reconstruction: A Retrospective Monocenter Study

“…In clinical practice, however, there is only a limited selection of suitable venous connection vessels in the lower extremity, so that such selective demands cannot always be met. 9,11 Reasons for the loss of function of the venous vessels can be the consequences of traumatic/infectious processes, acute (e.g., thrombophlebitis and deep vein thrombosis), and chronic venous diseases (e.g., varicosis and chronic venous insufficiency). 15 Lorenzo et al also evaluated the impact of the type of venous anastomosis on the flap outcome of microsurgical lower extremity reconstruction.…”

“…The main focus in the literature so far has been the investigation of the arterial recipient vessels. 8 11 In this study, we took a closer look at venous recipient vessels, especially the saphenous vein as part of the superficial venous system. The majority of published articles avoid the use of the superficial system, as they are usually predamaged by trauma or infectious processes due to their exposed location and suffer from the so-called posttraumatic vessel disease.…”

“…Janhofer et al describe an additional venous duplex assessment to find any venous pathologies since venous thrombosis is considered to be a frequent source of flap failure. 11 12 It is believed that, especially, the superficial venous system suffers from “posttraumatic vessel disease” because they are more exposed and should therefore not be primarily used. 13 This condition has been first mentioned by Acland which describes the usual injured and fibrotic state of the vessels in the trauma zone.…”

Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery

“…The only difference in outcomes between the VTE and non-VTE groups was significantly increased recipient site hematoma (OR: 25) specifically in the free flap patients (40.0% vs. 2.6%, p = 0.02). 68 In these patients careful preoperative and intraoperative decisions must be taken. For example, in the latter study, intraoperatively the recipient veins were carefully evaluated first for signs of obstructive thrombosis such as flow absence or backflow.…”

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts.

“…After loop construction, the patient was heparinized to a PTT of 75% of therapeutic, started on aspirin 81 mg daily and continued until the free flap transfer was accomplished. 13,14 Decision of free flap tissue transfer (FFT) was performed at the discretion of the plastic surgeon. Mobilization of the rectus abdominis, latissimus dorsi and anterior lateral thigh graft with transfer are described elsewhere.…”