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

Barton, Blair; Riley, Charles A.; Fitzpatrick, John; Hasney, Christian P.; Moore, Brian A.; McCoul, Edward D.

doi:10.1002/lary.26703

Cited by 38 publications

(61 citation statements)

References 57 publications

(109 reference statements)

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“…Anticoagulation is primarily aimed at preventing venous thrombosis at or near the microvascular anastomosis, as compromised venous outflow is a common contributor to free flap failure and may require return to the OR for anastomotic revision. Many surgeons choose an anticoagulation regimen based on anecdotal evidence and personal experience, and studies have found comparable free flap outcomes in a wide variety of regimens . Our study shows the variable use of heparin and Lovenox, though there is relatively widespread adoption of postoperative aspirin (40.3% 81 mg, 48.4% 325 mg) and abandonment of dextran (Fig.…”

Section: Discussionmentioning

confidence: 77%

“…Many modalities of flap monitoring exist, as well as many institutional schema regarding the optimal timing and responsible providers for flap checks . Anesthetic/sedation plans, appropriate postoperative level of care, duration of postoperative antibiotics, and anticoagulation plans have all been studied, yet no consensus exists for these aspects of patient care following MFTT . Furthermore, perioperative care regimens have not been reliably associated with measures of overall free flap success or complication rates .…”

Section: Introductionmentioning

confidence: 99%

“…2,8 Anesthetic/sedation plans, appropriate post-operative level of care, duration of postoperative antibiotics, and anticoagulation plans have all been studied, yet no consensus exists for many aspects of patient care following MFTT. 1,9–12 Further, perioperative care regimens have not been reliably associated with measures of overall free flap success or complication rates. 1,13–15 Thus, current research is being directed toward optimizing perioperative care protocols.…”

Section: Introductionmentioning

confidence: 99%

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Current practices in microvascular reconstruction in otolaryngology–head and neck surgery

et al. 2018

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Section: Discussionmentioning

confidence: 77%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Current practices in microvascular reconstruction in otolaryngology–head and neck surgery

et al. 2018

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“…Chien et al reported that 96% of reconstructive surgeons utilize some form of anticoagulation regimen to manage free tissue transfer patients [24]. Various anticoagulants that are administered include aspirin, heparin, low molecular weight heparin, and dextran [23]. The patient in this report received daily aspirin 325 mg. We suggest that if hemophilic patients have their factor deficiencies adequately replenished, they can be treated the same as a nonhemophilic patient with regard to antiplatelet therapy.…”

Section: Discussionmentioning

confidence: 85%

“…Do not draw through a heparinized IV. If factor IX level < 50%, give 100 units/kg Mononine and then continue 25 units/kg every 12 hours (vii) Discharge the patient with peripheral IV in place so that he can administer factor at home Home schedule: [23]. Chien et al reported that 96% of reconstructive surgeons utilize some form of anticoagulation regimen to manage free tissue transfer patients [24].…”

Section: Discussionmentioning

confidence: 99%

Vascularized Free Tissue Transfer in a Patient with Hemophilia B: Case Report and Literature Review

Qaisi

Kierce

Murphy

2019

Case Reports in Surgery

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Hemophilia is a blood disorder characterized by impairment of the coagulation cascade leading to an increased bleeding risk (Kauffman, 2014). As such, surgical management of these patients can become difficult and well-defined surgical guidelines are not yet in place (Assoumane et al., 2017). Close monitoring of perioperative factor levels may be even more crucial for those undergoing microvascular free tissue transfer. This is because either a hypercoagulable or hypocoagulable bleeding state has the potential to further increase the risk of vascular compromise to the flap. We report a successful case of mandibular reconstruction using a free fibular flap in a patient with severe hemophilia B and the protocols we used, as well as a review of the literature of similar cases. In the literature, we identified 6 cases of microvascular free tissue transfer in patients with hemophilia; two of these cases had complications which were both related to excess bleeding. It is crucial that these cases be managed in a multidisciplinary fashion in close consultation with a hematologist. The role of venothromboembolism (VTE) prophylaxis in the hemophilic patient undergoing free tissue transfer is discussed.

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Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

Saadoun

Bengür

Moroni

et al. 2022

JAMA Otolaryngol Head Neck Surg

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ImportanceVenous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&amp;N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile.ObjectiveTo assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID.Design, Setting, and ParticipantsThis was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&amp;N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022.Main Outcomes and MeasuresOutcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes.ResultsAmong the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI &gt;30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701).Conclusions and RelevanceThis cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&amp;N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

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

Cited by 38 publications

References 57 publications

Current practices in microvascular reconstruction in otolaryngology–head and neck surgery

Current practices in microvascular reconstruction in otolaryngology–head and neck surgery

Vascularized Free Tissue Transfer in a Patient with Hemophilia B: Case Report and Literature Review

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

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