Prolonged Venous Thromboembolism Prophylaxis May Not Be Necessary for DIEP Flap Breast Reconstruction: A Tertiary Center's 10-Year Experience

Abstract

Background Based on the 2005 Caprini Risk Assessment Model for venous thromboembolism, the American Society of Plastic Surgeons prevention guidelines would result in prolonged chemoprophylaxis (1 week or more) for the majority of patients undergoing deep inferior epigastric perforator flap breast reconstruction. We aim to assess the necessity of prolonged prophylaxis by describing our institutional experience in thromboembolism prevention and evaluating the incidence of symptomatic VTE in our patient cohort. Methods Women who underwent DIEP flap reconstruction from August 2011 to March 2020 at a tertiary care center were included. Charts were retrospectively reviewed for patient characteristics, VTE prophylaxis regimens, and development of deep vein thrombosis and pulmonary embolism within 60 days of surgery. Caprini scores were calculated for all patients. Results Out of the 249 patients included in the study, 245 patients received chemoprophylaxis only during hospitalization, while four patients additionally received anticoagulant for at least 2 weeks after discharge for prophylactic or therapeutic indications. The cohort's average Caprini score was 6.0, with 72.7% of scores between 3 and 6 and 26.5% at 7 or higher. One patient (0.4%), who scored a 7 and received prophylaxis only while hospitalized, developed deep vein thrombosis. There were no cases of pulmonary embolism. There was no significant difference in VTE rate between patients who received chemoprophylaxis consistent with ASPS guidelines and those who did not (p = 1.000). Conclusion Despite our limited chemoprophylaxis use in DIEP flap patients, our VTE incidence is low. This current work suggests that the blanket application of prolonged prophylaxis is not warranted, and it further serves as impetus to re-evaluate the 2005 Caprini RAM in this patient population.

Prior COVID-19 Infection Predisposes to Worse Outcomes After Autologous Breast Reconstruction

“…Therefore, appropriate perioperative and postoperative coagulopathy prophylaxis is imperative for patients undergoing autologous breast reconstruction. Whereas the American Society of Plastic Surgeons has released guidelines on chemoprophylaxis for the prevention of postoperative venous thromboembolic events, there has been a great deal of research into risk stratifying patients for thromboembolic events and determining optimal prophylactic regimens 25–29 . The Caprini score was created in 1991 and has served as a helpful tool for assessing thromboembolic risk in surgical patients.…”

“…Whereas the American Society of Plastic Surgeons has released guidelines on chemoprophylaxis for the prevention of postoperative venous thromboembolic events, there has been a great deal of research into risk stratifying patients for thromboembolic events and determining optimal prophylactic regimens. [25][26][27][28][29] The Caprini score was created in 1991 and has served as a helpful tool for assessing thromboembolic risk in surgical patients. It has since been validated across many surgical subspecialties, including plastic and reconstructive surgery.…”

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…Current guidelines by the ACCP state that for patients at high risk for VTE following hip and knee replacement, prophylaxis should be extended by an additional three weeks. [28][29][30] Furthermore, a review by Huo and Muntz found that the risk of VTE extends past high-risk patients' hospitalizations; extended VTE prophylaxis between 28 and 45 days aids in reducing the risk of late VTE events. 31 Surgeon preferences for anticoagulation of choice, ranging from subcutaneous heparin, enoxaparin, to other agents, varied widely.…”

Survey of Surgeon-reported Postoperative Protocols for Deep Inferior Epigastric Perforator Flap in Breast Reconstruction

“…Notably, VTE rates did not significantly differ between guideline-consistent and nonconsistent chemoprophylaxis. 17 Conversely, Modarressi et al found in a similar study that over 90 PODs, four patients (2.1%) had pulmonary embolism, and two patients (1%) developed deep venous thrombosis, yielding an overall VTE incidence of 3.1%. Interestingly, most patients (92.2%) had high-risk Caprini scores (>5), and all VTE cases were within this group.…”

“…ASPS recommends VTE prophylaxis for Caprini scores above 3, with prolonged prophylaxis (4 weeks) for scores exceeding 7. 17 Given this recommendation, it would be expected that most, if not all, ASPS surgeons would use the Caprini score to determine VTE prophylaxis for their patients. However, surprising findings indicate a majority of surgeons discontinue prophylaxis upon the patient's discharge from the hospital.…”