Evaluation of an Extended-duration Chemoprophylaxis Regimen for Venous Thromboembolism after Microsurgical Breast Reconstruction

Abstract

Background: Patients undergoing free flap breast reconstruction are at a high risk for venous thromboembolism based upon Caprini scores. Guidelines for venous thromboembolism prophylaxis recommend high-risk groups receive extended chemoprophylaxis for several weeks after gynecological, orthopedic, and surgical oncology cases. Extended prophylaxis has not been studied in free flap breast reconstruction. The purpose of this study was to compare outcomes of free flap breast reconstruction patients who received extended venous thromboembolism (VTE) prophylaxis with those who received standard inpatient-only prophylaxis. METHODS: Patients undergoing microsurgical breast reconstruction were divided into two groups: standard VTE prophylaxis (Group I) and extended prophylaxis (Group II). Both groups received prophylactic subcutaneous heparin or enoxaparin preoperatively and enoxaparin 40 mg daily postoperatively while inpatient. Group II was discharged with a home regimen of enoxaparin 40 mg daily for an additional 14 days. RESULTS: In total, 103 patients met inclusion criteria (36 patients in Group I, 67 patients in Group II). The incidence of VTE was 1.5% in Group II compared with 2.8% in Group I ( P = 0.6). There was no difference in reoperative hematoma between Group I (n = 0) and Group II (n = 1) ( P = 0.7). Total flap loss was 2.2%. Conclusions: Although this retrospective pilot study did not show statistical significance in VTE between those receiving extended home chemoprophylaxis (1.5% incidence) compared with inpatient-only chemoprophylaxis (2.8%), the risk of bleeding complications was similar. These results indicate that a larger, higher powered study is justified to assess if an extended home chemoprophylaxis protocol should be standard of care post free flap breast reconstruction.

Extended Duration Venous Thromboembolism Chemoprophylaxis Following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation

“…Our study demonstrates that the incidence of bleeding complications, hematomas, and operative hematomas are not different between patients who receive outpatient prophylaxis and those who do not, which is consistent with previous studies supporting the safety of inpatient prophylaxis. 10,26,27,35…”

“…Their study results demonstrated a not significant decrease in VTE (1.5% versus 2.8%; P = 0.6) and no significant difference in reoperative hematoma. 27 The ACCP most recently published guidelines for VTE prevention in 2012 and included guidance for plastic surgery patients. The ACCP strongly suggests no specific chemoprophylaxis in very low-risk patients (Caprini score = 0, as defined by the ACCP) and only mechanical prophylaxis (ie, pneumatic compression devices) is necessary in low-risk patients (Caprini score 1 to 2).…”

“…Their study results demonstrated a not significant decrease in VTE (1.5% versus 2.8%; P = 0.6) and no significant difference in reoperative hematoma. 27…”

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction

“…However, there is a relative paucity of literature investigating the benefits of this therapy in plastic surgery, 5 and at the time of publication of this work, only one pilot study exists concerning microsurgical breast reconstruction (MBR). 22 …”

“…However, there is a relative paucity of literature investigating the benefits of this therapy in plastic surgery, 5 and at the time of publication of this work, only one pilot study exists concerning microsurgical breast reconstruction (MBR). 22 The purpose of this study is to (1) report updated hematoma, DVT, and pulmonary embolism (PE) rates in MBR in the era of strict VTE protocols and increased awareness of the morbidity and mortality of these complications and (2) investigate the benefits and/or potential harms of extended postoperative VTE prophylaxis in patients undergoing MBR, when compared with patients who receive VTE prophylaxis only while hospitalized. This work is intended to guide clinical practice and serve as a foundation for further investigation into this domain.…”