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

Kearns, Marie; Baker, Jill; Myers, Simon; Ghanem, Ali

doi:10.1007/s00238-018-1417-0

Cited by 17 publications

(14 citation statements)

References 45 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…25,26 On the other hand, ASA alone is not recommended for VTE prophylaxis 9 and evidence is generally conflicting with regards to ASA efficacy in preventing microvascular thrombosis. 27 Still, our study shows that many surgeons continue to use ASA as part of their free flap antithrombotic regimen. Indeed, several other authors do support the use of ASA in combination with heparin or enoxaparin for prevention of both free flap thrombosis and VTE.…”

Section: Discussionmentioning

confidence: 80%

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

Venkatesh

Ambani

Arakelians

et al. 2020

J Reconstr Microsurg

View full text Add to dashboard Cite

Background Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States. Methods An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link. Results There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1–190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases. Conclusion The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.

show abstract

Section: Discussionmentioning

confidence: 80%

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

Venkatesh

Ambani

Arakelians

et al. 2020

J Reconstr Microsurg

View full text Add to dashboard Cite

show abstract

“…Its use, however, has declined due to the significant risk of systemic complications including anaphylaxis and pulmonary edema. 46 Khouri et al demonstrated improved vessel patency in a rat vessel crush-avulsion model when an antiplatelet agent was used in combination with heparin compared with either agent alone. Their group additionally found that heparin may be of greater value than an antiplatelet agent alone.…”

Section: Discussionmentioning

confidence: 99%

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

Kotamarti

Shiah

Rezak

et al. 2019

J reconstr Microsurg

View full text Add to dashboard Cite

Background Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management. Methods A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples t-tests. Results Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk. Conclusion Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.

show abstract

“…Unfractionated heparin (UFH) is applied intravenously and inhibits circulating thrombin. Thrombin converts fibrinogen to fibrin, which leads to the formation of cross-linked fibrin, promotes platelet aggregation, and activates blood clotting factors V and VIII [ 9 ]. Low-molecular-weight heparin (LMWH) has an inhibitory effect on activated factor X.…”

Section: Introductionmentioning

confidence: 99%

“…Low-molecular-weight heparin (LMWH) has an inhibitory effect on activated factor X. However, anti-thrombin activity is less intense [ 9 ]. Observations in animal studies showed the ability of LMWH to reduce thrombosis formation in microvascular anastomoses [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

“…Few clinical studies are suggesting an improvement in outcome [ 11 ]. However, the superiority of a therapy regimen is still not evident [ 9 , 11 , 12 ]. The purpose of this study was to distinguish the difference between flap survival and postoperative complications depending on the use of intravenous low-dose UFH and subcutaneous LMWH in patients undergoing free-flap reconstruction in the head and neck area, to provide a recommendation for clinical practice.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin

Sievert

Goncalves

Tamse

et al. 2020

Eur Arch Otorhinolaryngol

View full text Add to dashboard Cite

Purpose Free flap reconstruction is a valuable technique to preserve function in oncological head and neck surgery. Postoperative graft thrombosis is a dreaded risk. This study aims to compare low-dose unfractionated heparin (UFH) and lowmolecular-weight heparin (LMWH) in perioperative thrombosis prophylaxis. Methods This is a retrospective analysis of 266 free flaps performed at our academic center. A comparison was made between 2 patient groups, based on their respective postoperative prophylaxis protocols either with UFH (n = 87) or LMWH (n = 179). Primary endpoints were the frequency of transplant thrombosis and the number of flap failures. Secondary endpoints were the occurrence of peri-and postoperative complications. Results The flap survival rate was 96.6% and 93.3% for the groups UFH and LMWH, respectively (P = 0.280). The rate of postoperative bleeding requiring revision was 4.6% and 6.7% for each group, respectively (P = 0.498). We found a hematoma formation in 4.6% and 3.9% (P = 0.792). Conclusion The free-flap survival rate using low-dose UFH seems to be equivalent to LMWH regimens without compromising the postoperative outcome. Consequently, for risk-adapted thrombosis prophylaxis, either LMWH or UFH can be administrated.

show abstract

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

Cited by 17 publications

References 45 publications

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin

Contact Info

Product

Resources

About