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Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure.
- Source :
-
Journal of reconstructive microsurgery [J Reconstr Microsurg] 2019 May; Vol. 35 (4), pp. 270-286. Date of Electronic Publication: 2018 Oct 16. - Publication Year :
- 2019
-
Abstract
- Background: No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols.<br />Methods: Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods.<br />Results: Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified ( n = 27) or risk-stratified ( n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure.<br />Conclusion: Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.<br />Competing Interests: None declared.<br /> (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)
- Subjects :
- Adult
Aged
Clinical Protocols
Female
Graft Survival
Humans
Lower Extremity surgery
Male
Middle Aged
Perioperative Care
Postoperative Complications physiopathology
Retrospective Studies
Thrombophilia complications
Thrombophilia physiopathology
Treatment Outcome
Venous Thromboembolism physiopathology
Young Adult
Anticoagulants therapeutic use
Free Tissue Flaps blood supply
Lower Extremity physiopathology
Postoperative Complications prevention & control
Thrombophilia drug therapy
Venous Thromboembolism prevention & control
Subjects
Details
- Language :
- English
- ISSN :
- 1098-8947
- Volume :
- 35
- Issue :
- 4
- Database :
- MEDLINE
- Journal :
- Journal of reconstructive microsurgery
- Publication Type :
- Academic Journal
- Accession number :
- 30326523
- Full Text :
- https://doi.org/10.1055/s-0038-1675145