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Known Pre-operative DVT and/or Pulmonary Embolus - To Flap or Not to Flap the Severely Injured Extremity?
Ian L. Valerio, MD, MS, MBA, Reed Heckert, MD, Scott Tintle, MD, Jennifer Sabino, MD, Mark Fleming, DO.
Walter Reed National Military Medical Center, Bethesda, MD, USA.
Introduction: Military reconstructive surgeons have cared for and treated a high volume of poly-extremity injured patients over the last decade of War. Our combat casualties often present with multi-extremity wounds and amputations accompanied with pelvic and/or long-bone fractures as well as massive soft tissue injuries. These combat wounded have high Injury Severity Scores (ISS), and their multitude of wounds and concomitant injuries predispose them to many independent risk factors for developing deep vein thromboses (DVTs) and/or pulmonary emboli (PEs). Despite the risk of these thrombotic events, the severe nature of their extremity injuries frequently necessitates flap coverage.
Methods: A retrospective review of all flap procedures for combat-related extremity injuries from 2004-2011 at a single institution was performed. The incidence of pre-operative DVT and/or PE was determined. For those patients requiring flap coverage with known pre-operative DVT or PE diagnosis, therapeutic anticoagulation was provided per accepted guidelines of care. During the date of definitive flap procedure, therapeutic anticoagulation therapy was held the morning of surgery only and re-started within 8 hours following completion of flap procedure. Outcomes evaluated in the DVT/PE cohort included flap and limb salvage success rates as well as complications such as rates of partial/total flap failure, donor and/or recipient site hematomas, seromas, or wound healing issues, and failed limb salvage.
Results: A total of 137 extremity flap procedures occurred over the respective time period reviewed, consisting of 76 pedicle and 61 free flaps. Of the 137 cases, 70 were lower extremity and 67 were upper extremity salvage cases. Twenty-two patients (16.1%) had radiographic evidence of preoperative DVT and/or PE before flap coverage, split evenly between pedicle (pf=11) and free flap cases (ff=11). Of note, upper extremity cases had a higher rate of confirmed preoperative DVT and/or PE (15 patients, 22.4% of all cases and 68.2% of DVT/PE cases). Anticoagulation therapy consisted predominantly of weight-based therapeutic LMWH in 15 cases (68.2%), IVC filter alone in 5 patients (22.7%), and heparin drip in 2 patients (8.9%). The average duration of anticoagulation therapy prior to definitive flap coverage was 16 days (range 4-50days). Complications included partial flap necrosis in 1 free flap case (4.5%), 1 recipient site hematoma (4.5%). There were no incidences of total flap failure, donor site hematoma, infection, or adverse outcome secondary to progression of an existing DVT or PE in any of the war wounded that required flap coverage.
Conclusion: In this study, DVT and/or PE rates in war-related casualties occurred in 16.1% of all cases requiring extremity flap coverage procedures. The PE and DVT rate was even higher for those cases requiting upper extremity flap coverage (22.4%), which may be accounted for the higher severity of these patients’ injuries prior to flap procedure. Despite known preoperative thrombotic DVT/PE events in this series of cases, flap transfers, particularly free tissue transfers, were performed with high success and low complication rates. Either pedicle and/or free flaps can be successfully performed in patients with preoperative DVT and/or PE if appropriately selected and treated.
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