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Handchir Mikrochir Plast Chir 2025; 57(02): 92-101
DOI: 10.1055/a-2535-2467
Consensus Statement

Perioperative Diagnostik und Management von Hyperkoagulabilität und Thrombophilie in der Mikrochirurgie – Konsensus-Bericht der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM)

Perioperative Assessment and Management of Hypercoagulability and Thrombophilia in Microsurgery: Consensus Report of the German-Speaking Society for Reconstructive Microsurgery (GSRM)
Benjamin Thomas 
1   Klinik für Hand, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
,
Thorsten Steinfeldt
2   Abteilung für Anästhesie, Intensivmedizin und Schmerztherapie, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
,
Ulrich Seyfert
3   Hämostaseologie und Transfusionsmedizin, Institut für Blut Forschung, Saarbrücken, Germany
,
Kai Megerle
4   Zentrum für Handchirurgie, Mikrochirurgie und plastische Chirurgie, Schön Klinik München Harlaching, München, Germany
,
Rolf-Dieter Bader
5   Abteilung für Mund-, Kiefer- und Gesichtschirurgie, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany
,
Christine Radtke
6   Plastic, Reconstructive and Aesthetic Surgery, Medizinische Universitat Wien, Wien, Austria
,
Christoph Hirche 
7   Klinik für Plastische Chirurgie, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
,
Amir K. Bigdeli 
8   Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Klinikum Kassel GmbH, Kassel, Germany
,
Ulrich Kneser
1   Klinik für Hand, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
,
Emre Gazyakan
1   Klinik für Hand, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen am Rhein, Germany
,
Jurij Kiefer   ‡
9   Plastic Surgery, Orlando Health, Orlando, United States
,
Björn Behr   ‡
10   Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, KEM Evang. Kliniken Essen-Mitte gGmbH, Essen, Germany
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Zusammenfassung

Der regelrechte Blutfluss durch mikrochirurgisch anastomosierte Gefäße ist für den Therapieerfolg der rekonstruktiven Mikrochirurgie post operationem entscheidend. Im Gegensatz zu inzwischen in weiten Teilen ausgereiften und standardisierten Anastomosentechniken steht die erfolgsentscheidende Partnerdisziplin der evidenzbasierten mikrochirurgischen Hämostaseologie und Hämorheologie allerdings noch am Anfang. Prospektive klinische Studien und daraus ableitbare evidenzbasierte Empfehlungen fehlen. Lediglich standortspezifische Erfahrungswerte bilden heutzutage die Grundlage des perioperativen Managements in der Mikrochirurgie. Gemeinsames Ziel dieser mannigfaltigen Bemühungen sind die präoperative Identifikation erhöhter Gerinnungsneigungen (Hyperkoagulabilität) oder Gerinnungsaktivitäten (Thrombophilie) und die Formulierung korrespondierender Antikoagulationsregime. Im Zuge der 43. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM) im November 2022 in Frankfurt wurden Grundlagen der Gerinnung und Physiologie von Experten der Mikrochirurgie, Hämostaseologie und Anästhesie diskutiert, sowie zusammen mit einem Literaturüberblick Konsensusempfehlungen für das perioperative Management von Hyperkoagulopathien erarbeitet. Im Anschluss wurden im Gremium Vorgehensweisen evaluiert, Entscheidungskriterien erfragt und schließlich ein Empfehlungskonsens der DAM bzgl. eines perioperativen Algorithmus erarbeitet, der in diesem Positionspapier festgehalten ist.

Abstract

Uninterrupted blood flow through microsurgically anastomosed vessels is crucial for the postoperative success of reconstructive microsurgery. Contrary to the highly standardized anastomosis techniques, the pivotal partner discipline of evidence-based microsurgical haemostaseology and haemorrheology is still in its infancy. Prospective clinical studies yielding evidence-based recommendations are notably lacking. Currently, perioperative management in microsurgery is based solely on site-specific empirical experience. The collective aim of these diverse efforts is the preoperative identification of increased coagulation (hypercoagulability) or clotting activities (thrombophilia) and the development of relevant anticoagulation strategies. During the 43rd Annual Meeting of the German-Speaking Working Group for Microsurgery (DAM) in November 2022 in Frankfurt, experts in microsurgery, haemostaseology, and anaesthesia deliberated on the fundamentals of coagulation and physiology. Also, alongside a literature review, consensus recommendations for the perioperative management of hypercoagulopathies were established. Subsequently, methodologies were assessed within the panel, criteria for decision-making were gathered, and, ultimately, a consensus recommendation by DAM regarding a perioperative algorithm was devised, which is detailed in this position paper.

Schlüsselwörter

freie Lappenplastiken<Mikrochirurgie - Anästhesie<Sonstige Aspekte - Arterien<Körperregion und Anatomie - Patientensicherheit

Keywords

free flaps - anaesthesia - arteries - patient safety

‡ Geteilte Letztautorenschaft


Zusätzliches Material



Publikationsverlauf

Eingereicht: 01. Dezember 2024

Angenommen: 26. Januar 2025

Artikel online veröffentlicht:
03. April 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Khouri RK. Free flap surgery. The second decade. Clin Plast Surg 1992; 19: 757-761
    CrossrefPubMedSuche in Google Scholar
  • 2 Carney MJ, Weissler JM, Tecce MG. et al. 5000 Free Flaps and Counting. Plast Reconstr Surg 2018; 141: 855-863
    CrossrefPubMedSuche in Google Scholar
  • 3 Schmidt VJ, Hirsch T, Osinga R. et al. The interdisciplinary Microsurgeon – Results of the Consensus Workshop of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Handchirurgie Mikrochirurgie Plast Chir 2019; 51: 295-301
    Thieme ConnectPubMedSuche in Google Scholar
  • 4 Pratt GF, Rozen WM, Chubb D. et al. Modern adjuncts and technologies in microsurgery: An historical and evidence-based review. Microsurgery 2010; 30: 657-666
    CrossrefPubMedSuche in Google Scholar
  • 5 Park JE, Chang DW. Advances and Innovations in Microsurgery. Plast Reconstr Surg 2016; 138: 915e-924e
    CrossrefPubMedSuche in Google Scholar
  • 6 Zhang Y, Gazyakan E, Bigdeli AK. et al. Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety. Microsurgery 2019; 39: 463-475
    CrossrefPubMedSuche in Google Scholar
  • 7 Xiong L, Gazyakan E, Kremer T. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36: 511-524
    CrossrefPubMedSuche in Google Scholar
  • 8 Heidekrueger PI, Moellhoff N, Horch RE. et al. Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany – A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions. J Clin Med 2021; 10: 1016
    CrossrefPubMedSuche in Google Scholar
  • 9 Culliford AT, Spector J, Blank A. et al. The Fate of Lower Extremities With Failed Free Flaps. Ann Plast Surg 2007; 59: 18-22
    CrossrefPubMedSuche in Google Scholar
  • 10 Grant DW, Mlodinow A, Ver Halen JP. et al. Catastrophic Outcomes in Free Tissue Transfer: A Six-Year Review of the NSQIP Database. Plast Surg Int 2014; 2014: 1-10
    CrossrefPubMedSuche in Google Scholar
  • 11 Matros E, Albornoz CR, Razdan SN. et al. Cost-Effectiveness Analysis of Implants versus Autologous Perforator Flaps Using the BREAST-Q. Plast Reconstr Surg 2015; 135: 937-946
    CrossrefPubMedSuche in Google Scholar
  • 12 Lindell JS, Blaschke BL, Only AJ. et al. The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model. J Reconstr Microsurg Open 2021; 06: e28-e34
    Thieme ConnectPubMedSuche in Google Scholar
  • 13 Harashina T. Analysis of 200 free flaps. Br J Plast Surg 1988; 41: 33-36
    CrossrefPubMedSuche in Google Scholar
  • 14 Johnson PC, Barker JH. Thrombosis and antithrombotic therapy in microvascular surgery. Clin Plast Surg 1992; 19: 799-807
    CrossrefPubMedSuche in Google Scholar
  • 15 Baumeister S, Follmar KE, Zenn MR. et al. Strategy for Reoperative Free Flaps after Failure of a First Flap. Plast Reconstr Surg 2008; 122: 962-971
    CrossrefPubMedSuche in Google Scholar
  • 16 Davison SP, Kessler CM, Al-Attar A. Microvascular Free Flap Failure Caused by Unrecognized Hypercoagulability. Plast Reconstr Surg 2009; 124: 490-495
    CrossrefPubMedSuche in Google Scholar
  • 17 Hill JB, Patel A, Del Corral GA. et al. Preoperative Anemia Predicts Thrombosis and Free Flap Failure in Microvascular Reconstruction. Ann Plast Surg 2012; 69: 364-367
    CrossrefPubMedSuche in Google Scholar
  • 18 Park S, Han SH, Lee TJ. Algorithm for Recipient Vessel Selection in Free Tissue Transfer to the Lower Extremity. Plast Reconstr Surg 1999; 103: 1937-1948
    CrossrefPubMedSuche in Google Scholar
  • 19 Duymaz A, Karabekmez FE, Vrtiska TJ. et al. Free Tissue Transfer for Lower Extremity Reconstruction: A Study of the Role of Computed Angiography in the Planning of Free Tissue Transfer in the Posttraumatic Setting. Plast Reconstr Surg 2009; 124: 523-529
    CrossrefPubMedSuche in Google Scholar
  • 20 Schmitz M, Riss R, Kneser U. et al. Perioperatives Gerinnungsmanagement in der Mikrochirurgie – Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erla. Handchirurgie · Mikrochirurgie Plast Chir 2011; 43: 376-383
    Thieme ConnectPubMedSuche in Google Scholar
  • 21 Jokuszies A, Radtke C, Herold C. et al. A survey of anticoagulation practice among German speaking microsurgeons – Perioperative management of anticoagulant therapy in free flap surgery. GMS Ger Plast Reconstr Aesthet Surg 2012; 2: 1-7
    CrossrefPubMedSuche in Google Scholar
  • 22 Kremer T, Bauer M, Zahn P. et al. Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. Handchirurgie · Mikrochirurgie · Plast Chir 2016; 48: 205-211
    Thieme ConnectPubMedSuche in Google Scholar
  • 23 Davie EW, Ratnoff OD. Waterfall Sequence for Intrinsic Blood Clotting. Science (80- ) 1964; 145: 1310-1312
    CrossrefPubMedSuche in Google Scholar
  • 24 Monroe DM, Hoffman M. What Does It Take to Make the Perfect Clot?. Arterioscler Thromb Vasc Biol 2006; 26: 41-48
    CrossrefPubMedSuche in Google Scholar
  • 25 Madlener K, Pötzsch B. Hämostasesystem. In: Hämostaseologie. 2nd ed. Heidelberg: Springer Berlin; 2010: 8-12
    Suche in Google Scholar
  • 26 Rosendaal F. Venous thrombosis: a multicausal disease. Lancet. 1999; 353: 1167-1173
    CrossrefPubMedSuche in Google Scholar
  • 27 Previtali E, Bucciarelli P, Passamonti SM. et al. Risk factors for venous and arterial thrombosis. Blood Transfus 2011; 9: 120-138
    CrossrefPubMedSuche in Google Scholar
  • 28 Luxembourg B, Krause M. Lindhoff-Last E. Basiswissen Gerinnungslabor. Dtsch Arztebl 2007; 104
    PubMedSuche in Google Scholar
  • 29 Metze M, Platz M, Pfrepper C. et al. Gerinnungsdiagnostik im klinischen Alltag – Teil 1. Die Inn Medizin 2022; 63: 619-630
    CrossrefPubMedSuche in Google Scholar
  • 30 Wang TY, Serletti JM, Cuker A. et al. Free Tissue Transfer in the Hypercoagulable Patient. Plast Reconstr Surg 2012; 129: 443-453
    CrossrefPubMedSuche in Google Scholar
  • 31 Sezgin B, Ayhan S, Tuncer S. et al. Hypercoagulability in microvascular breast reconstruction: An algorithmic approach for an underestimated situation. J Reconstr Microsurg 2012; 28: 515-519
    Thieme ConnectPubMedSuche in Google Scholar
  • 32 Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the Hypercoagulable State: A Hematologist’s Perspective. Plast Reconstr Surg 2015; 136: 545e-552e
    CrossrefPubMedSuche in Google Scholar
  • 33 Nelson JA, Chung CU, Bauder AR. et al. Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: A novel anticoagulation protocol. J Plast Reconstr Aesthetic Surg 2017; 70: 307-312
    CrossrefPubMedSuche in Google Scholar
  • 34 DeFazio M, Economides J, Anghel E. et al. Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure. J Reconstr Microsurg 2018; 1
    Thieme ConnectPubMedSuche in Google Scholar
  • 35 Kotamarti VS, Shiah E, Rezak KM. et al. Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review. J Reconstr Microsurg 2020; 36: 204-212
    Thieme ConnectPubMedSuche in Google Scholar
  • 36 Liu FC, Miller TJ, Wan DC. et al. The Impact of Coagulopathy on Clinical Outcomes following Microsurgical Breast Reconstruction. Plast Reconstr Surg 2021; 148: 14e-18e
    CrossrefPubMedSuche in Google Scholar
  • 37 Speck NE, Hellstern P, Farhadi J. Microsurgical Breast Reconstruction in Patients with Disorders of Hemostasis: Perioperative Risks and Management. Plast Reconstr Surg 2022; 150: 95S-104S
    CrossrefPubMedSuche in Google Scholar
  • 38 Falkner F, Thomas B, Aman M. et al. The prognostic role of extended preoperative hypercoagulability work-up in high-risk microsurgical free flaps: a single-center retrospective case series of patients with heterozygotic factor V Leiden thrombophilia. BMC Surg 2022; 22: 190
    CrossrefPubMedSuche in Google Scholar
  • 39 Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ. et al. Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective. Aesthetic Plast Surg 2015; 39: 902-909
    CrossrefPubMedSuche in Google Scholar
  • 40 Rosado P, Cheng H-T, Wu C-M. et al. Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta-analysis. Eisele DW, ed. Head Neck. 2015. 37. 615-618
    CrossrefSuche in Google Scholar
  • 41 Lee KT, Mun GH. Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus Abdominis Myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: A systematic review and. Ann Plast Surg 2016; 76: 576-584
    CrossrefPubMedSuche in Google Scholar
  • 42 Shin JY, Roh SG, Lee NH. et al. Is obesity a predisposing factor for free flap failure and complications? Comparison between breast and nonbreast reconstruction. Med (United States) 2016; 95: 1-11
    CrossrefPubMedSuche in Google Scholar
  • 43 Caputo MP, Shabani S, Mhaskar R. et al. Diabetes mellitus in major head and neck cancer surgery: Systematic review and meta-analysis. Head Neck 2020; 42: 3031-3040
    CrossrefPubMedSuche in Google Scholar
  • 44 Liu Q, Aggarwal A, Wu M. et al. Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthetic Surg 2022; 75: 1793-1804
    CrossrefPubMedSuche in Google Scholar
  • 45 Khouri RK, Shaw WW. Reconstruction of the Lower Extremity with Microvascular Free Flaps. J Trauma Inj Infect Crit Care 1989; 29: 1086-1094
    CrossrefPubMedSuche in Google Scholar
  • 46 Cho EH, Bauder AR, Centkowski S. et al. Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis. Plast Reconstr Surg 2017; 139: 220-230
    CrossrefPubMedSuche in Google Scholar
  • 47 Parikh RP, Odom EB, Yu L. et al. Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis. Breast Cancer Res Treat 2017; 163: 1-10
    CrossrefPubMedSuche in Google Scholar
  • 48 Bunch CM, Moore EE, Moore HB. et al. Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation. Front Surg. 2022. 9.
    CrossrefSuche in Google Scholar
  • 49 Prantl L, Moellhoff N, Fritschen UV. et al. Impact of smoking status in free deep inferior epigastric artery perforator flap breast reconstruction: A multicenter study. J Reconstr Microsurg 2020; 36: 694-702
    Thieme ConnectPubMedSuche in Google Scholar
  • 50 Fan KL, Patel KM, Mardini S. et al. Evidence to support controversy in microsurgery. Plast Reconstr Surg 2015; 135: 595e-608e
    CrossrefPubMedSuche in Google Scholar
  • 51 Üstün GG, Aksu AE, Uzun H. et al. The systematic review and meta-analysis of free flap safety in the elderly patients. Microsurgery 2017; 37: 442-450
    CrossrefPubMedSuche in Google Scholar
  • 52 Torabi R, Stalder MW, Tessler O. et al. Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction. Plast Reconstr Surg 2018; 142: 840e-846e
    CrossrefPubMedSuche in Google Scholar
  • 53 Moellhoff N, Broer PN, Heidekrueger PI. et al. Impact of Intraoperative Hypothermia on Microsurgical Free Flap Reconstructions. J Reconstr Microsurg 2021; 37: 174-180
    Thieme ConnectPubMedSuche in Google Scholar
  • 54 Tapia B, Garrido E, Cebrian JL. et al. Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications. Cancers (Basel) 2021; 13: 1545
    CrossrefPubMedSuche in Google Scholar
  • 55 Goh CSL, Ng MJM, Song DH. et al. Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2019; 35: 529-540
    Thieme ConnectPubMedSuche in Google Scholar
  • 56 Noori O, Pereira JL, Stamou D. et al. Vasopressors improve outcomes in autologous free tissue transfer: A systematic review and meta-analysis. J Plast Reconstr Aesthetic Surg 2022; 81: 151-163
    CrossrefPubMedSuche in Google Scholar
  • 57 Kim MJ, Woo K-J, Park BY. et al. Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion. J Reconstr Microsurg 2018; 34: 610-615
    Thieme ConnectPubMedSuche in Google Scholar
  • 58 Rinkinen J, Halvorson E. Topical Vasodilators in Microsurgery: What Is the Evidence?. J Reconstr Microsurg 2016; 33: 001-007
    Thieme ConnectPubMedSuche in Google Scholar
  • 59 Turin S, Walton R, Dumanian G. et al. Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery. J Reconstr Microsurg 2018; 34: 242-249
    Thieme ConnectPubMedSuche in Google Scholar