History of a Previous Venous Thromboembolism Event as a Risk Factor for Complications in Head and Neck Free Flap Reconstruction
Fuat Baris Bengur, MD; Rakan Saadoun, MD; Elizabeth A. Moroni, MD, MHA; Nayel Khan, MD; Shaum Sridharan, MD; Mario G. Solari, MD; Mark Kubik, MD
University of Pittsburgh, Department of Plastic Surgery
Background: Venous thromboembolism (VTE) results in increased mortality, postoperative complications, length of hospitalization, and hospital-related costs in head and neck patients. Some patients may present with a history of prior VTE. The impact of prior VTE on complications after head and neck microvascular free flap surgery, specifically relating to the incidence of postoperative VTE and flap vascular compromise is not well studied. We aimed to assess the complication rates of patients with a history of thrombotic event, undergoing free flap reconstruction of the head and neck region.
Methods: A retrospective review of the patients who underwent head and neck free flap reconstruction at a tertiary center between 2012-2021 was performed from a prospectively maintained database. Data regarding patient demographics, past medical history, VTE chemoprophylaxis and overall outcomes was collected. History of VTE was defined as reported past pulmonary embolism or deep venous thrombosis events. Patients with a history of a VTE event were compared with the rest of the cohort. Outcomes studied included postoperative 30-day VTE rates, bleeding events requiring an intervention or return to the OR, vascular compromise of the flap requiring return to the OR, and total and partial flap failure rates.
Results: Free flap reconstruction of the head and neck region was performed in 928 patients. Fifty-nine patients (6%) had a history of a prior VTE event. Patients with a positive history of VTE had a higher Caprini score (9±3vs6±2, p<0.001), higher percentage of cardiac (76%vs62%, p=0.032), pulmonary (46%vs26%, p=0.001), and gastrointestinal (48%vs35%, p=0.044) comorbidities. Patients with a VTE history had lower rates of vascular compromise of the flap requiring return to the OR (0%vs8%, p=0.029) but there was no difference between the flap loss rates (0%vs3%, p=0.161). In both cohorts, the primary mode of postoperative VTE chemoprophylaxis was enoxaparin 30 mg BID. There was a trend towards increased rates of major postoperative bleeding events in patients with a history of VTE (15%vs8%, p=0.073). Postoperative 30-day VTE rates were not different than the rest of the cohort (3%vs4%, p=0.874).
Conclusion: Successful free flap transfer for head and neck reconstruction is possible in patients with a preoperative history of thrombotic events. Management of these high-risk patients requires careful preoperative evaluation and adequate prophylaxis in the postoperative period. The chemoprophylaxis regimens can be adjusted to prevent recurring VTEs but may incur a greater bleeding risk.
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