The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis

Abstract

Background Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, that allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking. Objective of review To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction. Type of review Systematic review and multicenter, individual patient data meta-analysis. Search strategy MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of ‘anticoagulants’ and ‘free flap reconstruction’. Evaluation method Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis. Results Five studies were of adequate quality and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were: aspirin (12%), low-molecular weight dextran (18.3%), unfractioned heparin (28.1%), low-molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one percent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications. Conclusions The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition some anticoagulants may cause systemic complications.

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

“…Interestingly, studies in which no anticoagulation was used demonstrated flap failure, thrombosis, and hematoma rates that were similar to the rates of the various anticoagulation therapies . This may suggest that anticoagulation offers no or minimal improvement in flap survival and could be an unnecessary adjunct to postoperative care in this complex population, with studies proving that anticoagulation drugs have minimal effect on free flap survival or flap‐related complications . Regardless, the side effects of many anticoagulation medications can lead to significant complications of which the reconstructive surgeon needs to be aware.…”

“…15,18,21 This may suggest that anticoagulation offers no or minimal improvement in flap survival and could be an unnecessary adjunct to postoperative care in this complex population, with studies proving that anticoagulation drugs have minimal effect on free flap survival or flap-related complications. 32 Regardless, the side effects of many anticoagulation medications can lead to significant complications of which the reconstructive surgeon needs to be aware. Aspirin can cause nephrotoxicity and gastric ulceration.…”

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

“…40 Reviews of aspirin use in microsurgical breast, and head and neck reconstructions have not demonstrated improved flap success and an increased rate of bleeding. 41,42 Additionally, a Cochrane meta-analysis of antiplatelet agents in peripheral arterial bypasses found no benefit of aspirin in the patency of autogenous bypasses. 43 Commonly described anticoagulants include heparin and LMWH.…”

“…2,5,25,47 Unfortunately, these studies are limited by insufficient sample size to adequately assess the effect of various interventions on relatively rare events such as flap thrombosis and failure or are not designed to assess potential impacts in specific patient populations like those in our study. 42 Additionally, the available literature does not assess the potential role of newer anticoagulants, which effectively prevent thrombosis while allowing physiological hemostasis. 48 Even with the assistance of hematologists, optimal regimens will likely need further clarification and will likely vary for each individual.…”

Adequacy of Fixed-Dose Heparin Infusions for Venous Thromboembolism Prevention after Microsurgical Procedures

“…Microvascular procedures, including free flap reconstructions, replantantion, and revascularizations, are commonly used in head, neck, breast, and extremity surgery with estimated success rates of 80 to 99%. 1,2 While failure rates are low, flap or replant loss is most commonly caused by thrombosis at the anastomoses. 3,4 Anticoagulant and antiplatelet agents are often administered perioperatively to help minimize the risk for microvascular thrombosis.…”