Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score–Matched Analysis

Abstract

Objective: Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. Methods: A retrospective review of thrombocytotic patients who underwent LE FTT between 2011-2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score-matched for comorbidity burden and postoperative risk-stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage and ambulatory status. Results: Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n=51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p=0.949, p=0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p=0.020, p=0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n=43) and 79.2% (n=42), respectively, with no differences between cohorts. Conclusion: Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts, but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.