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Practical Guidelines for Venous Thromboembolism Prophylaxis in Free Tissue Transfer
Joseph A. Ricci, MD, Olivia Ho, MD, Bernard T. Lee, MD, MBA, MPH, Matthew L. Iorio, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

Venous thromboembolism (VTE) is a complication that results in a wide range of patient morbidity and potential mortality. An estimated 2 million cases of deep vein thrombosis (DVT) occur in the United States annually, with 350,000 to 600,000 of those cases converting to pulmonary embolus (PE) and about 150,000 deaths annually. VTE awareness has led to advances in both the perioperative planning of prophylaxis and the stratification of risk factors. Together, these modifications have helped reduce the incidence and severity of VTE. However, although patients undergoing microsurgical reconstruction are among those with the highest risk for VTE, guidelines for VTE prevention in this patient group do not exist.
A literature review was performed to identify all papers discussing the rates of VTE in patients undergoing microsurgical procedures. The data from these manuscripts was summarized based on body area, including hand, breast, lower extremity and head/neck. Guidelines for VTE prophylaxis in microsurgical cases were established. In the absence of available data, guidelines were extrapolated from the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Specific questions addressed using evidence-based answers included: 1) In microsurgery, is a procedure-based or patient risk factor-based model applicable? 2) What procedures are at higher or lower risk for VTE? 3) What type and dose of chemoprophylaxis are appropriate? 4). What is the ideal timing of prophylaxis?
The risk posed by VTE is not only real, but its complications may be life threatening. Accordingly, VTE has been cited as preventable and is on the Centers for Medicare & Medicaid Services’ list of “never events.” Overall, there is a paucity of research about VTE prophylaxis in microsurgical procedures; however the available studies demonstrate a reduction in postoperative VTE. Unfortunately, chemoprophylaxis continues to be underused throughout plastic surgery, amid surgeon concern, despite clear evidence in numerous studies that chemoprophylaxis doses does not increase the risk of bleeding complications. Therefore, based on the best available data, the use of chemoprophylaxis should be strongly considered in all microsurgical cases. A preoperative screening algorithm based on a risk-assessment model should be used in all cases to preoperatively characterize and modify risk factors when possible, and plan for perioperative prophylaxis. In addition, given the limited morbidity, mechanical prophylaxis should be strongly considered for all patients and started at least 30 minutes before induction or the start of the procedure.
It is clear in the literature and in the clinical practice of medicine that prevention of VTE is a high priority and plastic surgery is not immune to these risks. As in all disciplines of surgery, VTE can be a devastating complication. Although not completely preventable, VTE risks can be reduced with careful preoperative planning and medical history and the judicious use of chemoprophylaxis, especially as there does not appear to be an increase in the rate of postoperative bleeding when chemoprophylaxis is administered appropriately.

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