Decrease of Thrombosis in Microsurgical Anastomoses: The Use of Intraoperative Pure Intraluminal Unfractionated Heparin

Abstract

Background Unfractionated heparin has anticoagulant properties by catalyzing antithrombin III, which inactivates coagulation enzymes. Used in microsurgery, it would prevent the occurrence of thrombosis during microsurgical anastomoses. The objective of this study was to evaluate the role of intraoperative irrigation of the vascular lumen with pure sodium heparin to prevent vascular thrombosis after end-to-end microsurgical anastomoses.

Methods End-to-end anastomoses were performed on rats by 21 operators. Three surgical sites were studied (cervical, femoral, and rat tail). The first vessel was irrigated with physiological salt solution (0.9%) before, during, and before the end of the anastomosis. Whenever possible, the contralateral vessel was irrigated with pure unfractionated heparin 5,000 UI/mL. The primary endpoint was the occurrence of thrombosis 60 minutes after anastomosis.

Results From November 2015 to April 2018, 247 anastomoses were performed on 229 arteries and 18 veins. One hundred twenty-five anastomoses were irrigated with physiological salt solution, 122 with pure unfractionated heparin. A 60-minute thrombosis was found on 31 anastomoses (25%) irrigated with physiological salt solution compared with 16 anastomoses (13%) irrigated with heparin, that is, a decrease in the thrombosis rate of 2.6 (p = 0.01).

Conclusion The use of pure unfractionated heparin in intraoperative lumen irrigation during microsurgical end-to-end anastomoses reduces the rate of vascular 60-minute thrombosis compared with physiological salt solution irrigation. It is an effective intraoperative procedure for the prevention of microsurgical thrombosis.

Keywords

heparin - thrombosis - end-to-end anastomosis - microsurgery - free flap

• References

• 1 McLEAN J. The discovery of heparin. Circulation 1959; 19 (01) 75-78
• 2 Fukui A, Tamai S. Present status of replantation in Japan. Microsurgery 1994; 15 (12) 842-847
• 3 Fukui A, Maeda M, Sempuku T, Tamai S, Mizumoto S, Inada Y. Continuous local intra-arterial infusion of anticoagulants for digit replantation and treatment of damaged arteries. J Reconstr Microsurg 1989; 5 (02) 127-136
• 4 Hahn HO, Jung SG. Results of replantation of amputated fingertips in 450 patients. J Reconstr Microsurg 2006; 22 (06) 407-413
• 5 Goldner RD, Urbaniak JR. Replantation. In: Green DP, Pederson WC, Hotchkiss RN, Wolfe SW. , eds. Green’s operative hand surgery. New York, NY: Elsevier/Churchill Livingstone; 2005: 1569-1586
• 6 Khouri RK. Avoiding free flap failure. Clin Plast Surg 1992; 19 (04) 773-781
• 7 Shridharani SM, Folstein MK, Chung TL, Silverman RP. Prevention of microsurgical thrombosis. In: Agullo F. , ed. Current Concepts in Plastic Surgery. China: InTech; 2012: 257-264
• 8 Dumont LA, Rongières M, Tchénio P, Gangloff D, Garrido-Stowhas I. ; Fédération européenne des services d'urgence mains (Fesum). Multicentric study of thrombosis prevention in upper-extremity microsurgery. Survey at the Fesum centers [article in French]. Chir Main 2010; 29 (02) 100-108
• 9 Péan D, Béliard C. Should adjuvant treatments (antiplatelet agents, anticoagulants, normovolaemic haemodilution and vasodilators) be used in cervicofacial and maxillofacial free flaps reconstructive surgery? [article in French]. Ann Fr Anesth Reanim 2004; 23 (09) 905-911
• 10 Khouri RK, Cooley BC, Kunselman AR. , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
• 11 Andresen DM, Barker JH, Hjortdal VE. Local heparin is superior to systemic heparin in preventing arterial thrombosis. Microsurgery 2002; 22 (06) 265-272
• 12 Tomaru T, Nakamura F, Fujimori Y. , et al. Local treatment with antithrombotic drugs can prevent thrombus formation: an angioscopic and angiographic study. J Am Coll Cardiol 1995; 26 (05) 1325-1332
• 13 Fabris F, Luzzatto G, Stefani PM, Girolami B, Cella G, Girolami A. Heparin-induced thrombocytopenia. Haematologica 2000; 85 (01) 72-81
• 14 Sinclair S. The importance of topical heparin in microvascular anastomoses: a study in the rat. Br J Plast Surg 1980; 33 (04) 422-426
• 15 Braam MJ, Cooley BC, Gould JS. Topical heparin enhances patency in a rat model of arterial thrombosis. Ann Plast Surg 1995; 34 (02) 148-151 , discussion 151–153
• 16 Zinberg EM, Choo DI, Zotter LA. Effect of heparinized irrigating solutions on patency of experimental microvascular anastomoses. Microsurgery 1989; 10 (02) 103-107 , discussion 108–109
• 17 Cox GW, Runnels S, Hsu HS, Das SK. A comparison of heparinised saline irrigation solutions in a model of microvascular thrombosis. Br J Plast Surg 1992; 45 (05) 345-348
• 18 Rumbolo PM, Cooley BC, Hanel DP, Gould JS. Comparison of the influence of intralumenal irrigation solutions on free flap survival. Microsurgery 1992; 13 (01) 45-47
• 19 Khouri RK, Sherman R, Buncke Jr. HJ. , et al. A phase II trial of intraluminal irrigation with recombinant human tissue factor pathway inhibitor to prevent thrombosis in free flap surgery. Plast Reconstr Surg 2001; 107 (02) 408-415 , discussion 416–418
• 20 Hassanpour SE, Tarahomi M, Daryani A. Thrombosis prevention with botulinum toxin A after traumatic crush injury in a rat model. J Reconstr Microsurg 2018; 34 (03) 206-210
• 21 Askari M, Fisher C, Weniger FG, Bidic S, Lee WP. Anticoagulation therapy in microsurgery: a review. J Hand Surg Am 2006; 31 (05) 836-846
• 22 Pederson WC. Clinical use of anticoagulants following free tissue transfer surgery. J Hand Surg Am 2008; 33 (08) 1435-1436
• 23 Hanasono MM, Butler CE. Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg 2008; 24 (05) 305-314