Download PDF
J Reconstr Microsurg 2019; 35(03): 198-208
DOI: 10.1055/s-0038-1670683
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography

Dmitry Zavlin
1   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas, United States
,
Vishwanath Chegireddy
1   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas, United States
,
Kevin T. Jubbal
2   Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
,
Nikhil A. Agrawal
1   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas, United States
,
Aldona J. Spiegel
1   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas, United States
› Author Affiliations Funding No funding was received for the work presented in this manuscript.
Further Information

Publication History

29 December 2017

02 August 2018

Publication Date:
19 September 2018 (online)

    Permissions and Reprints

Abstract

Background Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patient's coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications.

Methods A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points.

Results A total of hundred patients were identified, who underwent 172 abdominal-based free flaps for breast reconstruction. TEG was more dynamic compared with PT or aPTT and demonstrated borderline hypocoagulate values intraoperatively upon unfractionated heparin administration and hypercoagulate values postoperatively. In contrast, PT and aPTT demonstrated a continuously hypocoagulable state. Complications included five thrombotic events and three hematomas. The thrombotic cases had much steeper increases of TEG-G between surgery and postoperative day 2 (p = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery.

Conclusion The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients' changing coagulation status.

Keywords

microsurgery - breast reconstruction - thrombosis - coagulation - anticoagulation - thromboelastography

Ethical Considerations

The work described in this manuscript was approved by our institutional review board (Protocol number Pro00000607 at the Houston Methodist Research Institute). The authors adhered to the Declaration of Helsinki at all times.


Presentation

Parts of this manuscript have been presented at the annual ASPS meeting in Orlando, Florida (October 6–10, 2017) and the annual ASRM meeting in Phoenix, Arizona (January 13–16, 2018).


This study is a retrospective case series with level of evidence IV.


 

  • References

  • 1 Kwok AC, Agarwal JP. An analysis of free flap failure using the ACS NSQIP database. Does flap site and flap type matter?. Microsurgery 2017; 37 (06) 531-538
    CrossrefPubMedGoogle Scholar
  • 2 Kolbenschlag J, Daigeler A, Lauer S. , et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery?. Microsurgery 2014; 34 (04) 253-260
    CrossrefPubMedGoogle Scholar
  • 3 Pannucci CJ, Bailey SH, Dreszer G. , et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg 2011; 212 (01) 105-112
    CrossrefPubMedGoogle Scholar
  • 4 Parker RJ, Eley KA, Von Kier S, Pearson O, Watt-Smith SR. Functional fibrinogen to platelet ratio using thromboelastography as a predictive parameter for thrombotic complications following free tissue transfer surgery: a preliminary study. Microsurgery 2012; 32 (07) 512-519
    CrossrefPubMedGoogle Scholar
  • 5 Gorton HJ, Warren ER, Simpson NA, Lyons GR, Columb MO. Thromboelastography identifies sex-related differences in coagulation. Anesth Analg 2000; 91 (05) 1279-1281
    PubMedGoogle Scholar
  • 6 Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care 2014; 18 (05) 518
    CrossrefPubMedGoogle Scholar
  • 7 Seo MH, Kim SM, Huan F, Myoung H, Lee JH, Lee SK. Analysis of microvascular free flap failure focusing on the microscopic findings of the anastomosed vessels. J Craniofac Surg 2015; 26 (07) 2047-2051
    CrossrefPubMedGoogle Scholar
  • 8 Grant DW, Mlodinow A, Ver Halen JP, Kim JY. Catastrophic outcomes in free tissue transfer: a six-year review of the nsqip database. Plast Surg Int 2014; 2014: 704206
    PubMedGoogle Scholar
  • 9 Seruya M, Venturi ML, Iorio ML, Davison SP. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Plast Reconstr Surg 2008; 122 (06) 1701-1708
    CrossrefPubMedGoogle Scholar
  • 10 Miszkiewicz K, Perreault I, Landes G. , et al. Venous thromboembolism in plastic surgery: incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg 2009; 62 (05) 580-588
    CrossrefPubMedGoogle Scholar
  • 11 Askari M, Fisher C, Weniger FG, Bidic S, Lee WP. Anticoagulation therapy in microsurgery: a review. J Hand Surg Am 2006; 31 (05) 836-846
    CrossrefPubMedGoogle Scholar
  • 12 Fan KL, Patel KM, Mardini S, Attinger C, Levin LS, Evans KK. Evidence to support controversy in microsurgery. Plast Reconstr Surg 2015; 135 (03) 595e-608e
    CrossrefPubMedGoogle Scholar
  • 13 Mitchell DA, Gorton H. Thromboelastographic study of the effect of manipulation of central veins on coagulability of venous blood. Br J Oral Maxillofac Surg 2005; 43 (03) 215-218
    CrossrefPubMedGoogle Scholar
  • 14 Van Boerum DH. Using TEG in the ED, OR, and ICU. Available at: https://intermountainphysician.org/intermountaincme/Documents/01_Van%20Boerum_TEG.pdf . Accessed February 23, 2017
    PubMedGoogle Scholar
  • 15 Kroll SS, Miller MJ, Reece GP. , et al. Anticoagulants and hematomas in free flap surgery. Plast Reconstr Surg 1995; 96 (03) 643-647
    CrossrefPubMedGoogle Scholar
  • 16 Conrad MH, Adams Jr WP. Pharmacologic optimization of microsurgery in the new millennium. Plast Reconstr Surg 2001; 108 (07) 2088-2096 , quiz 2097
    CrossrefPubMedGoogle Scholar
  • 17 Jokuszies A, Herold C, Niederbichler AD, Vogt PM. Anticoagulative strategies in reconstructive surgery--clinical significance and applicability. Ger Med Sci 2012; 10: Doc01
    PubMedGoogle Scholar
  • 18 da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG®): practical considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc Emerg Med 2013; 21: 29-29
    CrossrefPubMedGoogle Scholar
  • 19 Deppe AC, Weber C, Zimmermann J. , et al. Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients. J Surg Res 2016; 203 (02) 424-433
    CrossrefPubMedGoogle Scholar
  • 20 Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev 2012; 26 (01) 1-13
    CrossrefPubMedGoogle Scholar
  • 21 Hans GA, Besser MW. The place of viscoelastic testing in clinical practice. Br J Haematol 2016; 173 (01) 37-48
    CrossrefPubMedGoogle Scholar
  • 22 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 23 Handschin AE, Guggenheim M, Calcagni M, Künzi W, Giovanoli P. Factor V Leiden mutation and thrombotic occlusion of microsurgical anastomosis after free TRAM flap. Clin Appl Thromb Hemost 2010; 16 (02) 199-203
    CrossrefPubMedGoogle Scholar
  • 24 Wang TY, Serletti JM, Cuker A. , et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 2012; 129 (02) 443-453
    CrossrefPubMedGoogle Scholar
  • 25 Herrera FA, Lee CK, Kryger G. , et al. Microsurgery in the hypercoagulable patient: review of the literature. J Reconstr Microsurg 2012; 28 (05) 305-312
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Sugiyama N, Takao S, Suzuki E, Kimata Y. Risk factors of thrombosis in a single method of microsurgical head and neck reconstruction: a multi-institutional study of 773 reconstructions with a free jejunal graft after total pharyngolaryngoesophagectomy for hypopharyngeal cancer. Head Neck 2016; 38 (11) 1688-1694
    CrossrefPubMedGoogle Scholar
  • 27 Masoomi H, Clark EG, Paydar KZ. , et al. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery 2014; 34 (08) 589-594
    CrossrefPubMedGoogle Scholar
  • 28 Rao S, Stolle EC, Sher S, Lin CW, Momen B, Nahabedian MY. A multiple logistic regression analysis of complications following microsurgical breast reconstruction. Gland Surg 2014; 3 (04) 226-231
    PubMedGoogle Scholar
  • 29 Gill PS, Hunt JP, Guerra AB. , et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 30 Bounameaux H, Marbet GA, Lämmle B, Eichlisberger R, Duckert F. Monitoring of heparin treatment. Comparison of thrombin time, activated partial thromboplastin time, and plasma heparin concentration, and analysis of the behavior of antithrombin III. Am J Clin Pathol 1980; 74 (01) 68-73
    CrossrefPubMedGoogle Scholar
  • 31 Prado A, Andrades P, Danilla S, Parada F. Perioperative thromboelastography analysis during suction-assisted lipectomy: a prospective cohort study. J Plast Reconstr Aesthet Surg 2009; 62 (11) 1453-1458
    CrossrefPubMedGoogle Scholar
  • 32 Seth AK, Hirsch EM, Kim JY. , et al. Hematoma after mastectomy with immediate reconstruction: an analysis of risk factors in 883 patients. Ann Plast Surg 2013; 71 (01) 20-23
    CrossrefPubMedGoogle Scholar
  • 33 Bates SM, Jaeschke R, Stevens SM. , et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141 (2,Suppl): e351S-418S
    CrossrefPubMedGoogle Scholar
  • 34 Falck-Ytter Y, Francis CW, Johanson NA. , et al. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141 (2,Suppl): e278S-e325S
    CrossrefPubMedGoogle Scholar
  • 35 Kearon C. Duration of venous thromboembolism prophylaxis after surgery. Chest 2003; 124 (6, Suppl): 386S-392S
    CrossrefPubMedGoogle Scholar
  • 36 Conroy FJ, Thornton DJ, Mather DP, Srinivasan J, Hart NB. Thromboembolic prophylaxis in plastic surgery a 12-year follow up in the U.K. J Plast Reconstr Aesthet Surg 2006; 59 (05) 510-514
    CrossrefPubMedGoogle Scholar
  • 37 Ashjian P, Chen CM, Pusic A, Disa JJ, Cordeiro PG, Mehrara BJ. The effect of postoperative anticoagulation on microvascular thrombosis. Ann Plast Surg 2007; 59 (01) 36-39 , discussion 39–40
    CrossrefPubMedGoogle Scholar
  • 38 Froemel D, Fitzsimons SJ, Frank J, Sauerbier M, Meurer A, Barker JH. A review of thrombosis and antithrombotic therapy in microvascular surgery. Eur Surg Res 2013; 50 (01) 32-43
    CrossrefPubMedGoogle Scholar
  • 39 Pan XL, Chen GX, Shao HW, Han CM, Zhang LP, Zhi LZ. Effect of heparin on prevention of flap loss in microsurgical free flap transfer: a meta-analysis. PLoS One 2014; 9 (04) e95111
    CrossrefPubMedGoogle Scholar
  • 40 Hudson DA, Engelbrecht G, Duminy FJ. Another method to prevent venous thrombosis in microsurgery: an in situ venous catheter. Plast Reconstr Surg 2000; 105 (03) 999-1003
    CrossrefPubMedGoogle Scholar
  • 41 Lecoq JP, Senard M, Hartstein GM, Lamy M, Heymans O. Thromboprophylaxis in microsurgery. Acta Chir Belg 2006; 106 (02) 158-164
    PubMedGoogle Scholar
  • 42 Pršić A, Kiwanuka E, Caterson SA, Caterson EJ. Anticoagulants and statins as pharmacological agents in free flap surgery: current rationale. Eplasty 2015; 15: e51
    PubMedGoogle Scholar
  • 43 Afshari A, Wikkelsø A, Brok J, Møller AM, Wetterslev J. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011; (03) CD007871
    PubMedGoogle Scholar
  • 44 Avidan MS, Alcock EL, Da Fonseca J. , et al. Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery. Br J Anaesth 2004; 92 (02) 178-186
    CrossrefPubMedGoogle Scholar
  • 45 Madsen DE, Ingerslev J, Sidelmann JJ, Thorn JJ, Gram J. Intraoperative blood loss during orthognathic surgery is predicted by thromboelastography. J Oral Maxillofac Surg 2012; 70 (10) e547-e552
    CrossrefPubMedGoogle Scholar
  • 46 Nuttall GA, Oliver WC, Santrach PJ. , et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001; 94 (05) 773-781 , discussion 5A–6A
    CrossrefPubMedGoogle Scholar
  • 47 Royston D, von Kier S. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 2001; 86 (04) 575-578
    CrossrefPubMedGoogle Scholar
  • 48 Spiess BD, Gillies BS, Chandler W, Verrier E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth 1995; 9 (02) 168-173
    CrossrefPubMedGoogle Scholar
  • 49 Wang SC, Shieh JF, Chang KY. , et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc 2010; 42 (07) 2590-2593
    CrossrefPubMedGoogle Scholar