Should antiplatelet therapy be held perioperatively? The first study examining outcomes in patients receiving dual anti-platelet therapy in the lower extremity free flap population
Mark Mishu, BA1, Elizabeth G. Zolper, BS2, Jenna Bekeny, BA2, Christopher Fleury, MD2, Kenneth L. Fan, MD2, Christopher E. Attinger, MD2, Karen K. Evans, MD2.
1Georgetown University School of Medicine, Washington, DC, USA, 2Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.
Background: Antiplatelet agents are typically held in the perioperative period due to intraoperative bleeding concerns. Dual antiplatelet therapy (DAPT), such as aspirin and clopidogrel, have significant morbidity and mortality benefit in patients with ischemic heart disease or peripheral vascular disease. Emerging evidence suggests perioperative holds on antiplatelet medication may carry thrombotic risks, and our institution has favorable outcomes in patients continuing dual therapy receiving skin grafts. The objective of our study is to evaluate the impact of DAPT on free tissue transfer (FTT) outcomes and need for transfusion in the setting of copious hemostasis. Methods: A retrospective review of lower extremity FTT at our institution from 2011-2019 was performed. Data collected included demographics, comorbidities, administration of antiplatelet agents, and FTT characteristics. Outcomes of interest were blood transfusion volume, postoperative hematoma, and flap success.Results: One hundred and ninety-six FTTs met inclusion criteria. Median age at time of FTT was 57 years (IQR 47-65). Median Charlson Comorbidity Index was 3.0 (IQR 1.0-5.0). Comorbidities included: diabetes (44%) and peripheral vascular disease (20%). Thirty-five patients were on DAPT; clopidogrel was continued throughout the operative course in 40% while it was held on day of surgery in 60%. The DAPT group was further analyzed by perioperative administration: continued (“cDAPT”, n=14) versus held (“hDAPT”, n=21). The volume of intraoperatively transfused blood products was significantly higher for the DAPT versus non-DAPT groups. Median CCI was significantly higher in the cDAPT versus hDAPT groups (5.0 versus 3.0, p<0.001). There was no significant difference in median intraoperative transfusion volume for the cDAPT (438mL) versus hDAPT (600mL, p=0.427) groups. Intraoperative thrombosis occurred in 2.5% of all FTT patients. The incidence was highest in the hDAPT cohort (n=2/21, 19%) but was not statistically significant. Incidence of postoperative hematoma (non-DAPT 7.5%, DAPT 17%; p=0.100) and flap success (non-DAPT 95%, DAPT 91%; p=0.418) were similar between groups. The incidence of perioperative cardiac events was 0.6% non-DAPT, 21% cDAPT, AND 4.8% hDAPT groups (p=0.001). The sole patient experiencing an NSTEMI was in the hDAPT group.Conclusions: Despite increases in volume of blood products transfused, FTT can be performed safely with perioperative dual antiplatelet therapy. Antiplatelet therapy can be given throughout the operative course; holding antiplatelet therapy may result in cardiovascular risk. Holding clopidogrel on the day of FTT was not associated with decreased intraoperative transfusion. A multidisciplinary approach to surgical bleeding versus thrombotic risk is necessary in this comorbid population.
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