Implementation of a 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. 2023 Feb 14PMID: 36790787Institution: MedStar Washington Hospital CenterDepartment: MedStar General Surgery Residency | MedStar Georgetown University Hospital/MedStar Washington Hospital Center | Plastic Surgery Residency G | Surgery/Plastic SurgeryForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: IN PROCESS -- NOT YET INDEXEDYear: 2023ISSN:
  • 0032-1052
Name of journal: Plastic and reconstructive surgeryAbstract: CONCLUSION: Hypercoagulability can significantly impact microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes. Copyright © 2023 by the American Society of Plastic Surgeons.INTRODUCTION: Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and to achieve high rates of microsurgical success. At our institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. We present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for non-traumatic lower extremity (LE) wounds.METHODS: We retrospectively reviewed patients who underwent FTT to the LE from 2012 to 2021. Our risk-stratification AC protocol was implemented in July 2015. Low-risk and moderate-risk patients received subcutaneous heparin (SQH). High-risk patients received heparin infusion titrated to a goal PTT of 50-70 seconds. Prior to July 2015, non-stratified patients were treated with either SQH or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (non-stratified 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 LE were treated with non-stratified (n=26) or risk-stratified (n=193) thromboprophylaxis. Overall flap success rate was 96.8% (n=212). Flap loss was lower among risk-stratified patients (1.6% vs. 15.4%, p=0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% vs. 15.4%, p=0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% vs. 0%, p=0.048). Intraoperative anastomotic revision (OR: 6.10; p=0.035) and non-risk 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: FY2023Digital Object Identifier: Date added to catalog: 2023-04-11
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CONCLUSION: Hypercoagulability can significantly impact microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes. Copyright © 2023 by the American Society of Plastic Surgeons.

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

METHODS: We retrospectively reviewed patients who underwent FTT to the LE from 2012 to 2021. Our risk-stratification AC protocol was implemented in July 2015. Low-risk and moderate-risk patients received subcutaneous heparin (SQH). High-risk patients received heparin infusion titrated to a goal PTT of 50-70 seconds. Prior to July 2015, non-stratified patients were treated with either SQH or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (non-stratified 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 LE were treated with non-stratified (n=26) or risk-stratified (n=193) thromboprophylaxis. Overall flap success rate was 96.8% (n=212). Flap loss was lower among risk-stratified patients (1.6% vs. 15.4%, p=0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% vs. 15.4%, p=0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% vs. 0%, p=0.048). Intraoperative anastomotic revision (OR: 6.10; p=0.035) and non-risk stratification (OR: 9.50; p=0.006) were independently associated with flap failure.

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