Role of Postoperative Anticoagulation in Predicting Digit Replantation and Revascularization Failure

Abstract

Purpose The use of intravenous heparin after digit replantation or revascularization (DRR) varies greatly. The insufficient evidence presents a lack of clinical equipoise needed for a randomized trial; as such, a matched propensity score analysis was performed to evaluate the role of postoperative anticoagulation after DRR. The purpose of this study was to determine if the use of postoperative therapeutic anticoagulation reduced the risk of digit failure. Methods A retrospective cohort of patients who underwent DRR from 2005 to 2016 was identified. A propensity score was calculated based on age, smoking, injury mechanism, procedure type, vein graft, and number of digits injured. Patients were matched 1:2 by propensity score to create 2 groups with similar risks of receiving anticoagulation postoperatively. Generalized estimating equation logistic model was used to determine differences in digit failure between groups. Results Digit replantation or revascularization was performed on 282 patients (92% male; median age, 43 years). Postoperative anticoagulation was administered in 69 (24%) patients, with continuous IV heparin in 34 patients and intravenous heparin with dextran in 35 patients. Digit failure occurred in 88 patients overall, representing 38% of patients receiving anticoagulation and 29% of those not. Major complications were higher among the anticoagulated patients (13% vs 3.3%). After propensity score matching, use of anticoagulation was not associated with digit failure (odds ratio, 0.79; 95% confidence interval, 0.47–1.32). Conclusions Among DRR patients with similar predisposing characteristics for postoperative therapeutic heparin or dextran, the use of therapeutic anticoagulation does not have a protective effect against digit failure. Studies are needed to define the role of postoperative IV anticoagulation in DRR and to justify the risk of its administration.

Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study

“…Therapeutic intravenous anticoagulation administered postoperatively was not shown to be predictive of failure in our cohort in a previously published study (Retrouvey et al, 2019). In the current study, leeching was an important predictor of both early and late failure, implicating venous congestion as a common cause of failure.…”

“…The use of prophylactic and therapeutic anticoagulation was applied on a case-by-case basis when one or more of these parameters was abnormal rather than applying a standard institutional protocol. This is because the benefits of its routine use have not been shown to outweigh the risks (Retrouvey et al., 2019). Leeching or therapeutic anticoagulation in the form of heparin, dextran or heparin with dextran were applied selectively in patients showing evidence of vascular insufficiency.…”

Propensity Scoring in Plastic Surgery Research: An Analysis and Best Practice Guide

“…Therefore, we used this collection of predictors to generate a propensity score for each patient. As another example, Retrouvey et al, in their retrospective study on postoperative anticoagulation in digit replantation and revascularization outcomes, 14 recognized that certain variables may have influenced both the use of anticoagulation and the success of replantation and revascularization. Thus, they generated propensity scores that reflected patients’ probability of having received anticoagulation; predictors used to generate the scores included age, smoking status, digit injury mechanism, number of injured digits, procedure type, and use of a vein graft.…”

50+ years of replantation surgery experience: are we progressing or regressing?

“…A 2019 randomized and single-blinded study found no significant difference between the three groups: (1) no heparin; (2) low dose heparin (10,000 IU/day); and (3) high dose heparin (starting at 15,000 IU/day and adjusted to achieve activated partial thromboplastin time of 1.5-2.5 times the patient's baseline) [37] . Studies with various therapeutic evidence levels have supported these conclusions [38,39] . In addition to dose, one study found increased survival with progressive weaning of heparin rather than abruptly discontinuing it [40] .…”