Known preoperative deep venous thrombosis and/or pulmonary embolus: to flap or not to flap the severely injured extremity?

Background: Warfare-related extremity injury associated with pelvic and long-bone fractures, massive soft-tissue injuries, and high Injury Severity Scores predispose patients to venous thromboembolic events, including deep vein thrombosis and/or pulmonary embolism. The success of flap reconstruction in this setting has not been well described.
Methods: A retrospective review of war-related extremity injuries requiring flap coverage from 2003 to 2012 was completed, and the incidence of venous thromboembolic events determined. Outcomes compared included flap and limb salvage success rates and complications, such as partial/total flap failure, hematomas, and failed limb salvage.
Results: A total of 173 combat extremity injury flap procedures were performed during the period reviewed, with 50 of these flaps (28.9 percent of all cases) identified as having a venous thromboembolic event during the course of care. Preoperative or perioperative events affected 45 flap procedures (26 percent). In the 41 patients with a preoperative event diagnosis, 21 had deep vein thrombosis (51 percent), 17 had a pulmonary embolism (42 percent), and three had both (7 percent). The complication rate in these cases was 29 percent (most commonly flap or donor-site hematoma). While the total complication rate was similar between the event and nonevent groups (29 versus 20 percent; p = 0.141), the hematoma rate was significantly different (20 versus 5 percent; p = 0.009).
Conclusions: Venous thromboembolic events were detected in a high number of the authors' combat-injured patients requiring extremity flap coverage. Despite preoperative events and risks of therapeutic anticoagulation, flap transfers were performed with high success rates and comparable nonhemorrhage complication rates between flap cohorts.
Clinical Question/level of Evidence: Therapeutic, III.