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J Reconstr Microsurg 2019; 35(04): 270-286
DOI: 10.1055/s-0038-1675145
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

Michael V. DeFazio
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
James M. Economides
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Ersilia L. Anghel
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Eshetu A. Tefera
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Karen K. Evans
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
› Author Affiliations
Further Information

Publication History

24 April 2018

30 August 2018

Publication Date:
16 October 2018 (online)

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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.

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.

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.

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.

Keywords

anticoagulation - free tissue transfer - hypercoagulability - microsurgery - thrombophilia
 

  • References

  • 1 Cohn DM, Roshani S, Middeldorp S. Thrombophilia and venous thromboembolism: implications for testing. Semin Thromb Hemost 2007; 33 (06) 573-581
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Mateo J, Oliver A, Borrell M, Sala N, Fontcuberta J. Laboratory evaluation and clinical characteristics of 2,132 consecutive unselected patients with venous thromboembolism--results of the Spanish Multicentric Study on Thrombophilia (EMET-Study). Thromb Haemost 1997; 77 (03) 444-451
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Olsson E, Svartling N, Asko-Seljavaara S, Lassila R. Activation of coagulation and fibrinolysis during reconstructive microsurgery in patients with cancer. Microsurgery 2001; 21 (05) 208-213
    CrossrefPubMedGoogle Scholar
  • 4 Thorson CM, Van Haren RM, Ryan ML. , et al. Pre-existing hypercoagulability in patients undergoing potentially curative cancer resection. Surgery 2014; 155 (01) 134-144
    CrossrefPubMedGoogle Scholar
  • 5 DeFazio MV, Hung RW, Han KD, Bunting HA, Evans KK. Lower extremity flap salvage in thrombophilic patients: managing expectations in the setting of microvascular thrombosis. J Reconstr Microsurg 2016; 32 (06) 431-444
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 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
  • 7 Friedman T, O'Brien Coon D, Michaels V J. , et al. Hereditary coagulopathies: practical diagnosis and management for the plastic surgeon. Plast Reconstr Surg 2010; 125 (05) 1544-1552
    CrossrefPubMedGoogle Scholar
  • 8 Srikanthan K, Viswanathan N, Yuen JC. Free-flap failure in thrombophilia: case report and systematic review of the literature. Ann Plast Surg 2013; 71 (06) 675-681
    CrossrefPubMedGoogle Scholar
  • 9 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
  • 10 Davison SP, Kessler CM, Al-Attar A. Microvascular free flap failure caused by unrecognized hypercoagulability. Plast Reconstr Surg 2009; 124 (02) 490-495
    CrossrefPubMedGoogle Scholar
  • 11 Nicoletti G, Gamba G, Scevola S, Faga A. The congenital deficit of protein S as a new prognostic factor in microsurgery. Plast Reconstr Surg 2005; 116 (06) 1837-1838
    CrossrefPubMedGoogle Scholar
  • 12 Shaw RJ, Rogers SN. Venous microvascular anastomotic failure due to prothrombin gene mutation. Plast Reconstr Surg 2005; 115 (05) 1451-1452
    CrossrefPubMedGoogle Scholar
  • 13 Ayala C, Blackwell KE. Protein C deficiency in microvascular head and neck reconstruction. Laryngoscope 1999; 109 (2, Pt 1): 259-265
    CrossrefPubMedGoogle Scholar
  • 14 Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist's perspective. Plast Reconstr Surg 2015; 136 (04) 545e-552e
    CrossrefPubMedGoogle Scholar
  • 15 Davis MR, Shell IV DH, Marques M, Long JN. Free flap failure secondary to dual thrombophilia. Microsurgery 2009; 29 (01) 62-65
    CrossrefPubMedGoogle Scholar
  • 16 Meinardi JR, Middeldorp S, de Kam PJ. , et al. Risk of venous thromboembolism in carriers of factor V Leiden with a concomitant inherited thrombophilic defect: a retrospective analysis. Blood Coagul Fibrinolysis 2001; 12 (08) 713-720
    CrossrefPubMedGoogle Scholar
  • 17 Cigna E, Lo Torto F, Parisi P, Felli A, Ribuffo D. Management of microanastomosis in patients affected by vessel diseases. Eur Rev Med Pharmacol Sci 2014; 18 (22) 3399-3405
    PubMedGoogle Scholar
  • 18 Lee MK, Blackwell KE, Kim B, Nabili V. Feasibility of microvascular head and neck reconstruction in the setting of calcified arteriosclerosis of the vascular pedicle. JAMA Facial Plast Surg 2013; 15 (02) 135-140
    CrossrefPubMedGoogle Scholar
  • 19 Senchenkov A, Lemaine V, Tran NV. Management of perioperative microvascular thrombotic complications - The use of multiagent anticoagulation algorithm in 395 consecutive free flaps. J Plast Reconstr Aesthet Surg 2015; 68 (09) 1293-1303
    CrossrefPubMedGoogle Scholar
  • 20 Nikolis A, Tahiri Y, St-Supery V. , et al. Intravenous heparin use in digital replantation and revascularization: The Quebec Provincial Replantation program experience. Microsurgery 2011; 31 (06) 421-427
    CrossrefPubMedGoogle Scholar
  • 21 Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009; 31 (01) 45-51
    CrossrefPubMedGoogle Scholar
  • 22 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (03) 579-589
    CrossrefPubMedGoogle Scholar
  • 23 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
  • 24 Li X, Cooley BC. Effect of anticoagulation and inhibition of platelet aggregation on arterial versus venous microvascular thrombosis. Ann Plast Surg 1995; 35 (02) 165-169 , discussion 169–170
    CrossrefPubMedGoogle Scholar
  • 25 Shi G, Meister D, Daley RA, Cooley BC. Thrombodynamics of microvascular repairs: effects of antithrombotic therapy on platelets and fibrin. J Hand Surg Am 2013; 38 (09) 1784-1789
    CrossrefPubMedGoogle Scholar
  • 26 Cooley BC, Ruas EJ, Wilgis EF. Scanning electron microscopy of crush/avulsion arterial trauma: effect of heparin and aspirin administration. Microsurgery 1987; 8 (01) 11-16
    CrossrefPubMedGoogle Scholar
  • 27 Cho EH, Ligh C, Hodulik KL, Hollenbeck ST. Role of platelet inhibition in microvascular surgery. J Reconstr Microsurg 2014; 30 (09) 589-598
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 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
  • 29 Chien W, Varvares MA, Hadlock T, Cheney M, Deschler DG. Effects of aspirin and low-dose heparin in head and neck reconstruction using microvascular free flaps. Laryngoscope 2005; 115 (06) 973-976
    CrossrefPubMedGoogle Scholar
  • 30 Chen CM, Ashjian P, Disa JJ, Cordeiro PG, Pusic AL, Mehrara BJ. Is the use of intraoperative heparin safe?. Plast Reconstr Surg 2008; 121 (03) 49e-53e
    CrossrefPubMedGoogle Scholar
  • 31 Peter FW, Franken RJ, Wang WZ. , et al. Effect of low dose aspirin on thrombus formation at arterial and venous microanastomoses and on the tissue microcirculation. Plast Reconstr Surg 1997; 99 (04) 1112-1121
    CrossrefPubMedGoogle Scholar
  • 32 Ritter EF, Cronan JC, Rudner AM, Serafin D, Klitzman B. Improved microsurgical anastomotic patency with low molecular weight heparin. J Reconstr Microsurg 1998; 14 (05) 331-336
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 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
  • 34 Chang EI, Zhang H, Liu J, Yu P, Skoracki RJ, Hanasono MM. Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction. Head Neck 2016; 38 (Suppl. 01) E771-E775
    CrossrefPubMedGoogle Scholar
  • 35 Lighthall JG, Cain R, Ghanem TA, Wax MK. Effect of postoperative aspirin on outcomes in microvascular free tissue transfer surgery. Otolaryngol Head Neck Surg 2013; 148 (01) 40-46
    CrossrefPubMedGoogle Scholar
  • 36 Lee KT, Mun GH. The efficacy of postoperative antithrombotics in free flap surgery: a systematic review and meta-analysis. Plast Reconstr Surg 2015; 135 (04) 1124-1139
    CrossrefPubMedGoogle Scholar
  • 37 Nelson JA, Chung CU, Bauder AR, Wu LC. Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: a novel anticoagulation protocol. J Plast Reconstr Aesthet Surg 2017; 70 (03) 307-312
    CrossrefPubMedGoogle Scholar
  • 38 Serletti JM, Deuber MA, Guidera PM. , et al. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage. Plast Reconstr Surg 1995; 96 (05) 1136-1144
    CrossrefPubMedGoogle Scholar
  • 39 Lee YK, Park KY, Koo YT. , et al. Analysis of multiple risk factors affecting the result of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes mellitus. J Plast Reconstr Aesthet Surg 2014; 67 (05) 624-628
    CrossrefPubMedGoogle Scholar
  • 40 Miyamoto S, Okazaki M, Takushima A, Shiraishi T, Omori M, Harii K. Versatility of a posterior-wall-first anastomotic technique using a short-thread double-needle microsuture for atherosclerotic arterial anastomosis. Microsurgery 2008; 28 (07) 505-508
    CrossrefPubMedGoogle Scholar
  • 41 Chen HC, Coskunfirat OK, Ozkan O. , et al. Guidelines for the optimization of microsurgery in atherosclerotic patients. Microsurgery 2006; 26 (05) 356-362
    CrossrefPubMedGoogle Scholar
  • 42 Wax MK. The role of the implantable Doppler probe in free flap surgery. Laryngoscope 2014; 124 (Suppl. 01) S1-S12
    PubMedGoogle Scholar
  • 43 O'Neill AC, Haykal S, Bagher S, Zhong T, Hofer S. Predictors and consequences of intraoperative microvascular problems in autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1349-1355
    CrossrefPubMedGoogle Scholar
  • 44 Fosnot J, Jandali S, Low DW, Kovach III SJ, Wu LC, Serletti JM. Closer to an understanding of fate: the role of vascular complications in free flap breast reconstruction. Plast Reconstr Surg 2011; 128 (04) 835-843
    CrossrefPubMedGoogle Scholar
  • 45 Chao AH, Coriddi M. The impact of intraoperative microvascular compromise on outcomes in microsurgical breast reconstruction. J Reconstr Microsurg 2015; 31 (07) 493-499
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 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
  • 47 Höijer P, Olsson E. Elevated coagulation factor VIII, postoperative thrombosis and flap failure in late breast reconstruction with a free TRAM flap: a case report. J Plast Reconstr Aesthet Surg 2006; 59 (01) 102-104
    CrossrefPubMedGoogle Scholar
  • 48 Labow BI, Greene AK, Upton J. Homocystinuria: an unrecognized cause of microvascular failure. Plast Reconstr Surg 2007; 120 (01) 6e-12e
    CrossrefPubMedGoogle Scholar
  • 49 Uppal RS, Stillaert FB, Hamdi M. Antiphospholipid syndrome--a rare cause of free flap thrombosis in perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2008; 61 (03) 347-348
    PubMedGoogle Scholar
  • 50 Salgarello M, Cervelli D, Barone-Adesi L. A massive arterial thrombosis of a free anterolateral thigh flap in a patient with antiphospholipid syndrome. Microsurgery 2008; 28 (06) 447-451
    CrossrefPubMedGoogle Scholar
  • 51 Pugh CM, Dennis II RH, Massac EA. Evaluation of intraoperative anticoagulants in microvascular free-flap surgery. J Natl Med Assoc 1996; 88 (10) 655-657
    PubMedGoogle Scholar