Risk-Stratified Anticoagulation Protocol Increases Success of Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia.

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Citation: Plastic & Reconstructive Surgery. 152(3):653-666, 2023 09 01.PMID: 36790787Institution: MedStar Washington Hospital CenterDepartment: MedStar General Surgery Residency | MedStar Georgetown University Hospital/MedStar Washington Hospital Center | Surgery/Plastic SurgeryForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Free Tissue Flaps | *Leg Injuries | *Thrombophilia | *Thrombosis | *Venous Thromboembolism | Anticoagulants/tu [Therapeutic Use] | Free Tissue Flaps/ae [Adverse Effects] | Heparin/tu [Therapeutic Use] | Humans | Leg Injuries/su [Surgery] | Postoperative Complications/ep [Epidemiology] | Postoperative Complications/et [Etiology] | Postoperative Complications/pc [Prevention & Control] | Retrospective Studies | Thrombophilia/co [Complications] | Thrombophilia/dt [Drug Therapy] | Thrombosis/et [Etiology] | Thrombosis/pc [Prevention & Control] | Treatment Outcome | Year: 2023ISSN:
  • 0032-1052
Name of journal: Plastic and reconstructive surgeryAbstract: BACKGROUND: Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and achieve high rates of microsurgical success. At the authors' institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. The authors present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for nontraumatic lower extremity (LE) wounds.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Copyright © 2023 by the American Society of Plastic Surgeons.CONCLUSIONS: Hypercoagulability can significantly affect microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes.METHODS: The authors retrospectively reviewed patients who underwent FTT to an LE from 2012 to 2021. Their risk-stratification AC protocol was implemented in July of 2015. Low-risk and moderate-risk patients received subcutaneous heparin. High-risk patients received heparin infusion titrated to a goal partial thromboplastin time of 50 to 70 seconds. Before July of 2015, nonstratified patients were treated with either subcutaneous heparin or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (nonstratified and risk-stratified) based on date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success.RESULTS: Two hundred nineteen hypercoagulable patients who underwent FTT to an LE were treated with nonstratified ( n = 26) or risk-stratified ( n = 193) thromboprophylaxis. The overall flap success rate was 96.8% ( n = 212). Flap loss was lower among risk-stratified patients (1.6% versus 15.4%; P = 0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% versus 15.4%; P = 0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% versus 0%; P = 0.048). Intraoperative anastomotic revision (OR, 6.10; P = 0.035) and nonrisk stratification (OR, 9.50; P = 0.006) were independently associated with flap failure.All authors: Deldar R, Gupta N, Bovill JD, Zolper EG, Kim KG, Fan KL, Evans KKFiscal year: FY2024Digital Object Identifier: Date added to catalog: 2023-11-22
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Journal Article MedStar Authors Catalog Article 36790787 Available 36790787

BACKGROUND: Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and achieve high rates of microsurgical success. At the authors' institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. The authors present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for nontraumatic lower extremity (LE) wounds.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Copyright © 2023 by the American Society of Plastic Surgeons.

CONCLUSIONS: Hypercoagulability can significantly affect microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes.

METHODS: The authors retrospectively reviewed patients who underwent FTT to an LE from 2012 to 2021. Their risk-stratification AC protocol was implemented in July of 2015. Low-risk and moderate-risk patients received subcutaneous heparin. High-risk patients received heparin infusion titrated to a goal partial thromboplastin time of 50 to 70 seconds. Before July of 2015, nonstratified patients were treated with either subcutaneous heparin or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (nonstratified and risk-stratified) based on date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success.

RESULTS: Two hundred nineteen hypercoagulable patients who underwent FTT to an LE were treated with nonstratified ( n = 26) or risk-stratified ( n = 193) thromboprophylaxis. The overall flap success rate was 96.8% ( n = 212). Flap loss was lower among risk-stratified patients (1.6% versus 15.4%; P = 0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% versus 15.4%; P = 0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% versus 0%; P = 0.048). Intraoperative anastomotic revision (OR, 6.10; P = 0.035) and nonrisk stratification (OR, 9.50; P = 0.006) were independently associated with flap failure.

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