Management of perioperative microvascular thrombotic complications – The use of multiagent anticoagulation algorithm in 395 consecutive free flaps

Senchenkov, Alex; Lemaine, Valérie; Tran, Nho V.

doi:10.1016/j.bjps.2015.05.011

Cited by 55 publications

(74 citation statements)

References 46 publications

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“…Dextran can result in anaphylaxis, pulmonary and cerebral edema, and platelet dysfunction . Clinicians must weigh the risks and benefits of each therapy, and may benefit from using a perioperative anticoagulation and free flap salvage algorithm …”

Section: Discussionmentioning

confidence: 99%

“…36,37 Clinicians must weigh the risks and benefits of each therapy, and may benefit from using a perioperative anticoagulation and free flap salvage algorithm. 38 Inconsistency of anticoagulation protocols was identified within certain studies. Lighthall et al determined which anticoagulation medication would be administered based on comorbid conditions or patients who were found to have anastomotic concerns intraoperatively.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

et al. 2017

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There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

et al. 2017

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“…A review of the microsurgical literature reveals a paucity of data to support the role of antithrombotic therapy, beyond routine VTE prophylaxis, after free tissue transfer (FTT). 19 Current recommendations for anticoagulation in thrombophilia are based primarily on surgeon preference and/or anecdotal experience, with some authors advocating for low-dose versus therapeutic heparin infusion or multimodal therapy in the setting of high-risk patients and/or prior flap loss. 14,19,20 Nonetheless, the infrequent nature of free flap failure and generalized concern over the increased bleeding risk have precluded the establishment of well-designed studies to guide recommendations regarding thromboprophylaxis in patients with hypercoagulability.…”

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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“…Senchenkov et al describe preoperative screening for a hypercoagulable history and recommend a complex regime of aspirin, clopidogrel, dextran, and heparin based on this [20]. They describe excellent free flap success (99.5%) in a retrospective case series of 355 free flaps the majority being for breast reconstruction.…”

Section: Discussionmentioning

confidence: 99%

Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis

Kearns

Baker

Myers³

et al. 2018

Eur J Plast Surg

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BackgroundDespite significant improvements in survival rates, free flap failures still occur even in experienced hands and are most commonly due to arterial or venous thrombosis. In the absence of an evidence-based guideline on the prevention of thrombosis, we reviewed the literature to assess the evidence base for commonly used interventions aimed at its prevention.MethodsA comprehensive literature search was performed using the following keywords “free flap” and microsurgery with “pre-operative screening,” “prevention of thrombosis,” “ketorolac,” “heparin,” “low molecular weight heparin,” “aspirin,” “dextran,” and “statins.”ResultsThirteen clinical studies were included in this review. No high-level evidence is available to support any perioperative or postoperative interventions aimed at reducing the risk of flap thrombosis.ConclusionsHigher level studies are needed to investigate the clinical use of antithrombotic medications in microsurgery; however, given the small failure rates in modern practice, these will need to be large multicenter trials in order to reach sufficient power.Level of Evidence: Level III, risk/prognostic study.

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Management of perioperative microvascular thrombotic complications – The use of multiagent anticoagulation algorithm in 395 consecutive free flaps

Cited by 55 publications

References 46 publications

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

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

Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis

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