Incidence of heparin-induced thrombocytopenia in lower-extremity free flap reconstruction correlates with the overall surgical population

Stimac, Gregory; Walters, Elliot T.; Elmarsafi, Tammer; Attinger, Christopher E.; Evans, Karen K.

doi:10.1016/j.bjps.2018.05.034

Cited by 7 publications

(18 citation statements)

References 31 publications

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“…Re‐exploration surgeries can only remove thrombosis and cannot alter the hypercoagulation status caused by HITT. Therefore, patients who underwent microsurgical tissue transfer with HITT had repetitive thrombosis and multiple re‐exploration surgeries 18–27,39 . In our study, 25.7% (8/31) of the patients in the HITT group required two re‐exploration surgeries, and 6.5% (2/31) of the patients required three re‐exploration surgeries.…”

Section: Discussionmentioning

confidence: 62%

“…However, two of the four parameters of the 4Ts score are calculated based on thrombotic events 14,41,48 ; thus, the 4Ts score is only available to identify high‐risk patients after thrombotic events occur 14,41,48 . Using the 4Ts score to identify the high risk of HITT patients who underwent microsurgical tissue transfer was not as sensitive as cardiac surgery because it only shows high scores after pedicle vessel thrombosis or flap failure 14,18–20,48 . The clinical presentation of HITT is a spectrum 15,28 .…”

Section: Discussionmentioning

confidence: 99%

“…The unique characteristics, including small vessel diameter, incision of pedicle vessel endothelium, and exclusive single pedicle artery and vein perfusion, make the free flap vulnerable in HITT episodes 39 . Early identification of HITT with high sensitivity is crucial in the microsurgery field 18–20,26 . When the flap was congested with the developing HITT in previous studies, the 4Ts score is typically low because the platelet count decreased less than 30% (the cutoff value to have a point in 4Ts score) (Table 1).…”

Section: Discussionmentioning

confidence: 99%

“…This vicious circle results in platelet consumption and leads to thrombocytopenia‐and bleeding, which can be life‐threatening‐such as disseminated intravascular coagulation 13,15,17 . The hypercoagulation status and thrombosis formation in HITT also cause severe complications in the microsurgical field 18–27 …”

Section: Introductionmentioning

confidence: 99%

“…13,15,17 The hypercoagulation status and thrombosis formation in HITT also cause severe complications in the microsurgical field. [18][19][20][21][22][23][24][25][26][27] Given that the pathophysiology of HITT correlated with primary lymphedema, patients with primary lymphedema have a high risk of HITT if heparin therapy is administered for microsurgery. 4,6,13,28,29 However, there is limited literature that discusses the correlation between these two diseases.…”

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confidence: 99%

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Heparin‐induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations

Hsu

Lin

Cheng

2022

Journal of Surgical Oncology

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BackgroundHeparin‐induced thrombocytopenia and thrombosis (HITT) may result in microsurgical flap failure. This study investigated the outcomes of HITT in primary lymphedema patients who underwent vascularized lymph node transplantations (VLNT).MethodsBetween 2012 and 2019, primary lymphedema patients who underwent VLNTs were retrospectively included. The 4Ts score was used to categorize patients into HITT (scores of 5–7) and non‐HITT (score < 5) groups. Outcome evaluations included the re‐exploration rate, success rate, circumferential differences, cellulitis episodes, and Lymphedema Specific Quality of Life Questionnaire (LYMQoL) scores.ResultsTwenty‐six and 15 patients with 31 and 16 VLNTs were included in the HITT and non‐HITT groups, respectively. The HITT group had significantly greater first, second and third re‐exploration rates of 38.7% (12/31), 25.7% (8/31), and 6.5% (2/31) than the non‐HITT group (6.3%, 0%, and 0%, all p < 0.01), respectively. The platelet counts significantly decreased by 21.0% in the HITT group compared with the non‐HITT group (14%) on postoperative Day one (p < 0.01) with a cutoff value of 17% and AUC = 0.88.ConclusionsHITT may cause a high re‐exploration rate of VLNTs in primary lymphedema patients. The 17% reduction in platelets on postoperative day one was an early sign for detecting HITT.

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Section: Discussionmentioning

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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Heparin‐induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations

Hsu

Lin

Cheng

2022

Journal of Surgical Oncology

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Distal facial vein catheterization for prevention and management of thrombosis in vascularized lymph node transfers

Mallarino-Restrepo

Lin

Cheng

2022

Journal of Surgical Oncology

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Background: This study investigated the outcomes of the distal facial vein catheterization (DFVC) to manage venous thrombosis in vascularized submental lymph nodes (VSLN) flap transplantations. Methods: Between March 2017 and December 2020, patients who underwent VSLN flaps were divided into Group I: combined delayed primary retention sutures (DPRS) with DFVC, and Group II: DPRS alone. Primary outcomes were early (within 72 h) and late venous thrombosis. Secondary outcomes included other nonvascular complications and mechanical factors of the thrombosis.Results: A total of 105 patients who underwent 106 VSLN flaps, including 37 and 69 flaps in Groups I and II, respectively, were included. There were no statistically significant differences in age, body mass index, Taiwan lymphoscintigraphy staging, and surgical factors between the two groups (all p > 0.05). Early venous thrombosis requiring re-exploration developed in one (2.7%) and three (4.3%) flaps in Groups I and II, respectively (p = 0.20). One flap (2.7%) and eight (11.5%) flaps developed late venous thrombosis in Groups I and II, respectively (p < 0.01). There was no statistically significant difference in total complication rates between both groups (p = 0.9). Conclusion: VSLN flap transplantation had a significantly higher risk of late venous thrombosis. DFVC significantly decreased the late venous thrombosis. K E Y W O R D S free tissue transfer, lymphedema, venous thrombosis, VLNT 1 | INTRODUCTION Extremity lymphedema is a chronic and progressive disease that can immensely hamper a patient's functionality and quality of life.

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Heparin‐induced thrombocytopenia in lower extremity free tissue transfers

et al. 2023

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BackgroundHeparin‐induced thrombocytopenia (HIT) an immunologically mediated reaction to heparin products, can lead to severe thrombocytopenia and potentially life‐threatening thrombotic events. In microsurgery, a missed or delayed diagnosis of HIT can cause complications requiring revision operations, flap loss, or limb loss. Surgeons must remain vigilant for this uncommon yet potentially devastating condition and keep abreast of management strategies.MethodsCPT and ICD‐10 codes in electronic medical records were used to collect demographic information, clinical courses, and outcomes for patients with a HIT diagnosis who underwent lower extremity free tissue transfer in one institution.ResultsThe authors' institution performed 415 lower extremity free flaps in 411 patients during the 10‐year study period. Flap salvage rate was 71% for compromised lower extremity flaps without HIT, and 25% in those with HIT. Four patients (four flaps) met study inclusion criteria during the study period. Three of the four flaps failed and were later debrided; one was rescued after a takeback for anastomosis revision. Two patients successfully underwent a delayed second free flap procedure after recovery, and one was salvaged with a pedicled muscle flap.ConclusionsSurgeons should monitor for HIT by establishing coagulation panel and platelet count baselines and trending these values in the early post‐operative period for patients treated with heparin products. The 4T score can be used to screen for HIT with high clinical suspicion. Arterial thrombosis or poor flap perfusion despite sound microvascular technique could suggest HIT. Surgical and medical management including strict heparin avoidance can prevent adverse events for these patients.

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Incidence of heparin-induced thrombocytopenia in lower-extremity free flap reconstruction correlates with the overall surgical population

Cited by 7 publications

References 31 publications

Heparin‐induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations

Heparin‐induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations

Distal facial vein catheterization for prevention and management of thrombosis in vascularized lymph node transfers

Heparin‐induced thrombocytopenia in lower extremity free tissue transfers

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