Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Abstract

Background: Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment. Methods: Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma. Results: Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001). Conclusions: Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

The radiated breast and autologous reconstruction: benefits and alternatives

“…Bifurcation points may differ depending on laterality, and vessel crosssectional area decreases in the superior-inferior direction as the vessel travels along the sternal body. Furthermore, prior work has demonstrated the minimum necessary vessel caliber for certain flap sizes [50] . For this reason, it may be necessary to extend the dissection of the recipient vessels more superiorly along the chest wall to expose larger mammary vessel recipients for anastomoses.…”

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.

“…Use of multiple antithrombotic agents has been associated with increased risk of haematoma/ bleeding. 26 Regarding dosage of anticoagulation, evidence from prospective clinical trials suggests that fixed-dose heparin was deemed insufficient for reaching the level of anticoagulation required for VTE prophylaxis after microsurgical procedures. 27 Weight-based heparin infusions at 10 units kg À1 h À1 provided a detectable level of anticoagulation for some patients following microsurgical procedures, but most required dose adjustment to ensure adequate VTE prophylaxis.…”

“…A randomised clinical trial is currently underway, comparing Apixaban vs. Enoxaparin following microsurgical breast reconstruction [NCT04504318]. Use of multiple antithrombotic agents has been associated with increased risk of haematoma/bleeding 26 …”

A Survey of Microvascular Technique Preferences Among American Head Neck Society Members

“…Studies consistently identify an increased risk in bleeding after use of anticoagulants with no associated improvement in rates of free flap failure. 34,35 On the other hand, despite the preferred use of antiplatelet therapy among respondents, there is sparse evidence on the positive impact of antiplatelets on free flap outcomes. A study by Lighthall et al, noted no improvement in rates of free flap failure among 380 patients undergoing microvascular reconstruction, whether or not aspirin was provided (p = 0.839).…”