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Preoperative Deep and Superficial Venous Thrombosis in Limb Salvage Candidates: A Contraindication to Microsurgical Free Flap Reconstruction?
Hannah Soltani*
1, Rachel N. Rohrich
*1, Ryan Lin
1, Sami Ferdousian
1, Karen Li
1, Richard C. Youn
1, Christopher E. Attinger
1, Cameron Akbari
2, Karen K. Evans
1, Stephen Baker
11Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, ; 2Department of Vascular Surgery, Medstar Georgetown University Hospital, Washington,
Background: Venous pathology is an underappreciated yet central factor in microsurgical limb salvage. While arterial inflow considerations dominate surgical planning, venous outflow is equally vital for flap survival. Patients requiring free tissue transfer (FTT) for lower extremity (LE) reconstruction frequently present with preoperative venous thrombosis (VT), yet there is little data guiding recipient vein selection and perioperative management in this high-risk population. This study therefore examines the prevalence and characteristics of patients with preoperative VT undergoing LE free tissue transfer (FTT).
Methods: A retrospective review of patients with preoperative VT undergoing lower extremity FTT at a single institution was conducted. VT characteristics (affected system, chronicity, occlusiveness) and venous reflux (VR) were assessed via preoperative venous duplex ultrasound.
Results: Among 279 LE FTT patients, 43 (15.4%) were positive for VT. The overall DVT incidence in this population was 5.7% (n=16/279) and the SVT incidence was 10.0% (n=28/279). Most thromboses were chronic (67.8%). Venous reflux also was present in 77.5% of patients. There were two cases of takeback (4.7%) due to thrombosis (1 arterial and 1 venous), of which one flap was salvaged. By a median follow-up duration of 9.7 months, a limb salvage rate of 88.4% was achieved.
Conclusion: Preoperative VT is common in microsurgical candidates for limb salvage and significantly influences management; however, it is not a contraindication to FTT if proper adjustments are made perioperatively. Considerations in these patients include (1) routine use of venous ultrasound to identify VT; (2) perioperative anticoagulation management, including IVC filter placement when indicated; (3) selection of recipient veins that are unaffected by VT or venous reflux; (4) prioritizing the use of two deep veins for anastomosis when feasible; and (5) incorporating implantable devices to monitor venous outflow.
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