Predictive risk factors of free flap thrombosis in breast reconstruction surgery

Abstract

Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage.

Predictors of Reoperations in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…Higher complication rates in this subgroup however are in line with other publications from the centers where SIEA flaps are not performed regularly 33–35 and may be attributed to vessel caliber and flap thrombosis.…”

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

“…For example, Nakamizo et al reported that previous surgery and infection were the strongest risk factors for flap failure . Other fields outside of the head and neck literature have identified risk factors associated with flap failure such as peripheral vascular disease and thrombocythemia . Additionally, differences may exist when free flap reconstruction is performed within various subsites.…”

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…Although clinical studies do not completely agree on clearly defined risk factors for flap thrombosis and failure, [19][20][21][22][23][24] the influence of these variables in conjunction with tamoxifen therapy is not well studied and should be considered when assessing tamoxifen as a risk factor. In our study, the percentage of patients with preoperative radiation was significantly higher in the tamoxifen cohort, similar to prior studies, 7,8 as the majority of these patients underwent delayed reconstruction.…”

“…Large reviews provide conflicting conclusions on preoperative radiation therapy as an independent risk factor for flap thrombosis. 20,21,25 Radiation, however, is known to result in intimal and smooth muscle damage in vessels as well as cause perivascular fibrosis that can affect venous anastomosis patency. 26,27 Although the higher rate of preoperative radiation did not increase the incidence of arterial or venous thrombosis in the tamoxifen group, radiation damage to the recipient vasculature may have contributed to the difficulty in flap salvage and the higher rate of flap failure secondary to thrombosis in the tamoxifen cohort.…”