Role of Platelet Inhibition in Microvascular Surgery

Abstract

Thrombosis remains a significant complication of microvascular free tissue transfer. Recent discoveries in the field of vascular biology have led to a greater understanding of thrombogenesis and the pivotal role that platelets play in the formation of a clot. However, current antithrombotic strategies in the clinical practice of free tissue transfer have not typically focused on platelet inhibition. Decades of cardiovascular clinical trials have delineated the essential role of platelet inhibitor therapy in patients with acute coronary syndromes and those undergoing percutaneous coronary interventions. Understanding the current treatment guidelines for antiplatelet therapy across the spectrum of patients with coronary heart disease may provide insights into their use in the prevention and treatment of thrombosis in microvascular surgery. In this review, we examine the current antiplatelet agents in clinical use and discuss the potential role of platelet inhibition in free flap surgery, particularly in the setting of repeated microvascular thrombosis.

Thrombocytosis is associated with complications after microvascular surgery: An NSQIP data analysis

“…Recent studies have suggested that heparin improves results and that aspirin could reduce the thrombotic properties of platelets (Iamaguchi et al, ). In a 2014 case series by Cho et al () it was demonstrated that two free flap procedures requiring salvage were successfully managed with intravenous eptifibatide (Cho et al, ). Another study by Natelson () generated the following recommendations: combination of antimetabolite treatment (cytarabine or hydroxyurea), anagrelide (Phosphodiesterase (PDE) inhibitor that antagonizes maturation of platelets), and/or plateletpheresis to reduce platelet count to <400,000 prior to any interventional vascular surgical procedure (Natelson, ).…”

“…Recent studies have suggested that heparin improves results and that aspirin could reduce the thrombotic properties of platelets (Iamaguchi et al, 2018). In a 2014 case series by Cho et al (2014) it was demonstrated that two free flap procedures requiring salvage were successfully managed with intravenous eptifibatide (Cho et al, 2014).…”

Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps

“…In our clinical experience, preoperative thrombocytosis in the setting of severe tissue damage should alert the surgeon to a greater risk of microvascular complications. Future studies are warranted to determine whether high‐risk patients undergoing free flap reconstruction stand to benefit from targeted antiplatelet therapies …”

Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis

“…[41,56] This combination of fibrin production and platelet activation/aggregation are central events in arterial and venous thrombosis by contributing to intimal hyperplasia, smooth muscle cell degeneration, and formation of intraluminal thrombi at the anastomotic site. [41,57–59,40,60] The role of tamoxifen in increasing platelet activation and aggregation is considered the primary mechanism by which it induces a prothrombotic environment in patients with breast cancer. Recently, investigators demonstrated tamoxifen promotes calcium entry into platelets, which is critical to platelet activation and aggregation, and may lead to prothrombotic platelet phenotypes in breast cancer patients on hormone therapy.…”