Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction—An Ultrasonographic Study

Abstract

Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Eighteen patients with a mean age and body mass index of 52.7 years (range, 29-76 years) and 31.3 kg/m (range, 21.9-43.4 kg/m) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (< 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference ( = 0.0007) and area (< 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV ( = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

Implementing Our Microsurgical Breast Reconstruction Enhanced Recovery after Surgery Pathway: Consensus Obstacles and Recommendations

“…14 Because of these factors and others such as difficulty ambulating in the postoperative period and potentially decreased venous return from the lower extremities due to tightened abdominal fascial closure, our free flap breast reconstruction patients are carefully considered for extended low molecular weight heparin treatment following discharge. 15,16 Current recommendations for high risk patients suggests pharmacologic anticoagulation to continue at least 7 days. 5,17,18 Self-administration can be easily taught to the patient before discharge.…”

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…Second, the harvest of the abdominal DIEP flap may increase intraabdominal pressure upon closure and reduce venous return. [9][10][11][12] Many patients undergoing DIEP flap procedures have prior or concomitant breast cancer, which can induce a systemic hypercoagulable state and hormonal breast cancer therapies such as tamoxifen may further increase the risk of VTE. 13,14 Overall, as VTE events are associated with serious complications including increased mortality, bleeding risk, and increased health care costs due to prolonged hospitalization and readmission; [15][16][17] there is a critical need to accurately characterize VTE incidence and risk-stratify patients undergoing DIEP procedures.…”