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J Reconstr Microsurg 2019; 35(04): 270-286
DOI: 10.1055/s-0038-1675145
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

Michael V. DeFazio
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
James M. Economides
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Ersilia L. Anghel
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Eshetu A. Tefera
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Karen K. Evans
1   Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, District of Columbia
› Author Affiliations
Further Information

Publication History

24 April 2018

30 August 2018

Publication Date:
16 October 2018 (online)

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Abstract

Background No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols.

Methods Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods.

Results Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure.

Conclusion Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.

Keywords

anticoagulation - free tissue transfer - hypercoagulability - microsurgery - thrombophilia
 

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