Does Anticoagulation Improve Free Tissue Transfer Outcomes in Hypercoagulable Patients? A Systematic Review of the Literature
Vasanth S. Kotamarti, MD1, Eric Shiah, BA2, Kristen M. Rezak, MD, FACS1, Ashit Patel, MBChB, FACS1.
1Albany Medical Center, Albany, NY, USA, 2Albany Medical College, Albany, NY, USA.
Background: Advances in microsurgery have increased the success rates for free tissue transfers. With improved outcomes and expertise, surgeons have expanded the pool of free flap candidates. Several authors have assessed methods for free flaps in hypercoagulable patients. Thrombophilias are relatively common problems with potentially catastrophic results for patients undergoing free tissue transfer. Consequently, some authors have attempted novel anticoagulation protocols to improve outcomes in these patients. Our aim was to assess the published literature on free tissue transfer in the hypercoagulable population in order to develop evidence-based recommendations for management of these patients.
Methods: A systematic review of the literature was performed in June 2018 using the Pubmed, Ebsco, and Cochrane databases. Two independent researchers performed the search and screened articles while a third independent researcher acted as a tie-breaker. Studies assessing outcomes of anticoagulation regimens on free tissue transfer performed in patients with established hypercoagulability diagnoses were included. Exclusion criteria included review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes.
Results: Following the search, 64 articles were read in their entirety, and five articles were included for analysis. In total free tissue transfers were performed in 385 patients, 123 of whom had established thrombophilic histories or diagnoses. Diagnoses included history of thromboembolism, factor V Leiden, antiphospholipid syndrome, and methylenetetrahydrofluororeductase mutation. Anticoagulation regimens often included intraoperative continuous heparin with-or-without additional bolus with postoperative continuous heparin with transition to an outpatient anticoagulation therapy. Hypercoagulable patients demonstrated propensity for intraoperative and late postoperative thromboses, as well as increased risk for arterial thromboses. Worsened flap success and salvage were observed with postoperative thromboses as opposed to intraoperative thromboses. Anticoagulation increased risk for hematoma formation as well.
|First author||Title||Hypercoagulable patients||Level of Evidence|
|Defazio et al.||Lower extremity flap salvage in thrombophilic patients: managing expectations in the setting of microvascular thrombosis||25||III|
|Nelson et al.||Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: a novel anticoagulation protocol||23||III|
|Senchenkov et al.||Management of perioperative microvascular thrombotic complications - the use of multiagent anticoagulation algorithm in 395 consecutive free flaps||9*||III|
|Wang et al.||Free tissue transfer in the hypercoagulable patient: A review of 58 flaps||41||IV|
*Patients with established hypercoagulable histories.
Conclusion: Successful microvascular free tissue transfer is possible in many hypercoagulable patients. More aggressive anticoagulation initiated intraoperatively may be required to prevent thrombotic complications as salvage after postoperative thrombosis is relatively poor. The benefits of a free flap must be weighed against the risk of bleeding in each patient prior when developing a reconstructive plan.
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