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

 -  2023 
<br/><br/> 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. 
<br/><br/><br/>English 
<br/><br/><label>ISSN: </label>0032-1052 
<br/><br/><label>Standard No.: </label>00006534-990000000-01567 [pii] 10.1097/PRS.0000000000010293 [doi] 
<br/><br/><label>Subjects--Topical Terms: </label><br/>IN PROCESS -- NOT YET INDEXED
<br/><br/><label>Subjects--Geographic Terms: </label><br/>MedStar Washington Hospital Center
<br/><br/><label>Index Terms--Occupation: </label><br/>MedStar General Surgery Residency<br/>MedStar Georgetown University Hospital/MedStar Washington Hospital Center<br/>Plastic Surgery Residency G<br/>Surgery/Plastic Surgery
<br/><br/><label>Index Terms--Function: </label><br/>Journal Article