Free Tissue Transfer in the Hypercoagulable Patient

Abstract

Risk, IV.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

“…Patients with renal disease seem to be more prone to complications (75,76). Very little has been published on the history of DVT and postoperative complications, but one study showed an increased risk for thrombosis in free flap surgery in hypercoagulative patients and a very low salvage rate of the affected flaps (77). No reports seem to exist on the effect of concurrent rheumatic or neurologic disease and outcome after breast reconstruction.…”

Evidence to Support Controversy in Microsurgery

“…[83][84][85][86][87][88][89][90][91][92][93] In a recent article by Wang et al examining 58 free flaps in patients with a variety of procoagulant states including factor V Leiden mutation, protein C deficiency, hyperhomocysteinemia, antiphospholipid antibody syndrome, prothrombin gene mutation, factor VIII elevation, anticardiolipin antibody syndrome, and essential thrombocytosis, a 20 percent rate of thrombosis and a 0 percent rate of salvage in flaps that had clotted postoperatively was reported (Level IV Evidence). 94 A retrospective series of 2260 free flaps concluded that elevated platelet count (>300,000/μl) and thrombophilia were risk factors for failure of a take-back, suggesting that platelet-derived blood coagulation pathways are important contributors to the flap failure pathologic condition (Level III Evidence). 95 Screening free flap patients preoperatively for a procoagulant condition is vital, including a history of deep venous thrombosis or pulmonary embolism, history of multiple miscarriages, and a family history of blood clots.…”

“…Patients with risk factors for a hypercoagulable condition should be seen by a hematologist before surgery for recommendations regarding a preoperative and postoperative anticoagulation regimen. 94 101 End-to-end versus end-to-side anastomosis has also been a subject of debate historically. For upper and lower extremity reconstruction, endto-side anastomosis is sometimes necessary to preserve distal blood supply.…”

Microsurgery and the Hypercoagulable State

“…33 Surgeons' practice patterns for prevention of microvascular clotting target coagulation, platelet activation, or both. [33][34][35] Askari et al provide an extensive review of pharmacologic manipulation of the clotting cascade as it relates to microvascular thrombosis, and we direct readers to their well-written article for additional information. 20…”

“…34 The authors concluded that the presence of a hypercoagulable state adversely impacts microsurgery outcomes. However, a closer analysis of the data suggests that the nature of the hypercoagulable state was a critical determinant of outcome.…”