Feasibility of Microvascular Head and Neck Reconstruction in the Setting of Calcified Arteriosclerosis of the Vascular Pedicle

Lee, Matthew; Blackwell, Keith E.; Kim, Brandon; Nabili, Vishad

doi:10.1001/2013.jamafacial.208

Cited by 17 publications

(22 citation statements)

References 17 publications

(26 reference statements)

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“…in patients with underlying comorbidities. 5,8,10,[15][16][17][18] Recently, we published our experience with 43 consecutive free flaps performed for non-traumatic lower extremity reconstruction in patients who were preoperatively screened for thrombophilia. 5 Routine laboratory testing identified traits among 61% of our population, whereas only 16% screened positive for risk factors based on history alone.…”

mentioning

confidence: 99%

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

DeFazio

Economides

Anghel

et al. 2018

J reconstr Microsurg

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Background No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols. Methods Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods. Results Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure. Conclusion Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.

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confidence: 99%

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

DeFazio

Economides

Anghel

et al. 2018

J reconstr Microsurg

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“…Some authors advocate the selection of a recipient site less commonly affected by atherosclerotic disease and the appropriate adjustment of the surgical technique to minimize potential disruption of atherosclerotic plaques during the execution of the anastomosis. [43][44][45] This study has some limitations that should be recognized. Despite the significant data observed in terms of degenerative changes, the number of specimens is limited for definitive conclusions.…”

Section: Discussionmentioning

confidence: 93%

“…43,44 Chiefly, the incidence of arteriosclerosis affecting the donor or recipient vessels has been identified as increasing the complication rate of free flap reconstruction. 43 In fact, there is an increased risk of separation of the tunica intima from the tunica media with the passing of anastomosis sutures and may subsequently contribute to thrombosis and flap failure. [43][44][45] In addition, vessels affected by atherosclerotic changes frequently develop vascular calcifications leading to a loss of vessel elasticity and compliance and has been associated with an increased risk of atheroma plaque instability and thrombus formation.…”

Section: Discussionmentioning

confidence: 99%

“…43 In fact, there is an increased risk of separation of the tunica intima from the tunica media with the passing of anastomosis sutures and may subsequently contribute to thrombosis and flap failure. [43][44][45] In addition, vessels affected by atherosclerotic changes frequently develop vascular calcifications leading to a loss of vessel elasticity and compliance and has been associated with an increased risk of atheroma plaque instability and thrombus formation. 43,46 In our sample, fibrous medial layer thickening, medial elastosis, and medial calcification were the main degenerative changes observed.…”

Section: Discussionmentioning

confidence: 99%

“…[43][44][45] In addition, vessels affected by atherosclerotic changes frequently develop vascular calcifications leading to a loss of vessel elasticity and compliance and has been associated with an increased risk of atheroma plaque instability and thrombus formation. 43,46 In our sample, fibrous medial layer thickening, medial elastosis, and medial calcification were the main degenerative changes observed. Although no major degenerative changes (grade IV) were observed, we believe that for those with a severe atherosclerosis, appropriate adjustments should be made to the treatment plan preoperatively and intraoperatively.…”

Section: Discussionmentioning

confidence: 99%

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Internal mammary perforator vessels as recipient site for microsurgical breast reconstruction: A comparative histomorphometric analysis and incidence of degenerative vascular changes

et al. 2013

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Controversies in free tissue transfer for head and neck cancer: A review of the literature

et al. 2019

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Background Microvascular free tissue transfer provides superior functional outcomes when reconstructing head and neck cancer defects. Careful patient selection and surgical planning is necessary to ensure success, as many preoperative, intraoperative, and postoperative patient and technical factors may affect outcome. Aims To provide a concise, yet thorough, review of the current literature regarding free flap patient selection and management for the patient with head and neck. Materials and Methods PubMed and Cochrane databases were queried for publications pertaining to free tissue transfer management and outcomes. Results Malnutrition and tobacco use are modifiable patient factors that negatively impact surgical outcomes. The use of postoperative antiplatelet medications and perioperative antibiotics for greater than 24 hours have not been shown to improve outcomes, although the use of clindamycin alone has been shown to have a higher risk of flap failure. Liberal blood transfusion should be avoided due to higher risk of wound infection and medical complications. Discussion There is a wide range of beliefs regarding proper management of patients undergoing free tissue transfer. While there is some data to support these practices, much of the data is conflicting and common practices are often continued out of habit or dogma. Conclusion Free flap reconstruction remains a highly successful surgery overall despite as many different approaches to patient care as there are free flap surgeons. Close patient monitoring remains a cornerstone of surgical success.

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Feasibility of Microvascular Head and Neck Reconstruction in the Setting of Calcified Arteriosclerosis of the Vascular Pedicle

Cited by 17 publications

References 17 publications

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

Internal mammary perforator vessels as recipient site for microsurgical breast reconstruction: A comparative histomorphometric analysis and incidence of degenerative vascular changes

Controversies in free tissue transfer for head and neck cancer: A review of the literature

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