Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
권호 표지
DOI QR코드

DOI QR Code

Free flap thrombosis in patients with hypercoagulability: A systematic review

  • Biben, Johannes Albert (Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia) ;
  • Atmodiwirjo, Parintosa (Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia)
  • Received : 2019.06.14
  • Accepted : 2019.09.29
  • Published : 2019.11.15
Download PDF
⟨ Previous Next ⟩

Abstract

Background Even with satisfactory anastomosis technique and adequate experience of the surgeon, flap loss due to thrombosis can still occur due to the patient's underlying condition. Patients with hypercoagulability due to etiologies such as malignancy, hereditary conditions, and acquired thrombophilia are among those who could benefit from free flap procedures. This review aimed to evaluate the risk of free flap thrombosis in patients with hypercoagulability and to identify the most effective thromboprophylaxis regimen. Methods This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The PubMed, Embase, and Cochrane Library databases were explored. Types of free flaps, types of hypercoagulable states, thrombosis prevention protocols, thrombosis complication rates, and flap vitality outcomes were reviewed. Samples from the included studies were pooled to calculate the relative risk of free flap thrombosis complications in patients with hypercoagulability compared to those without hypercoagulability. Results In total, 885 articles underwent title, abstract, and full-text screening. Six articles met the inclusion criteria. The etiologies of hypercoagulability varied. The overall incidence of thrombosis and flap loss in hypercoagulable patients was 13% and 10.3%, respectively. The thrombosis risk was two times higher in hypercoagulable patients (P=0.074) than in controls. Thromboprophylaxis regimens were variable. Heparin was the most commonly used regimen. Conclusions Hypercoagulability did not significantly increase the risk of free flap thrombosis. The most effective thromboprophylaxis regimen could not be determined due to variation in the regimens. Further well-designed studies should be conducted to confirm this finding.

Keywords

References

  1. Buncke HJ Jr, Schulz WP. Total ear reimplantation in the rabbit utilizing microminiature vascular anastomoses. Br J Plast Surg 1966;19:15-22. https://doi.org/10.1016/S0007-1226(66)80003-6
  2. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102:711-21. https://doi.org/10.1097/00006534-199809010-00015
  3. Baumeister S, Follmar KE, Zenn MR, et al. Strategy for reoperative free flaps after failure of a first flap. Plast Reconstr Surg 2008;122:962-71. https://doi.org/10.1097/PRS.0b013e3181811ca0
  4. Davison SP, Clemens MW, Kochuba AL. Anatomy of free flap failures: dissection of a series. Mod Plast Surg 2013;03: 89-95. https://doi.org/10.4236/mps.2013.33018
  5. Srikanthan K, Viswanathan N, Yuen JC. Free-flap failure in thrombophilia: case report and systematic review of the literature. Ann Plast Surg 2013;71:675-81. https://doi.org/10.1097/SAP.0b013e3182586b47
  6. Khansa I, Colakoglu S, Tomich DC, et al. Factor V Leiden associated with flap loss in microsurgical breast reconstruction. Microsurgery 2011;31:409-12. https://doi.org/10.1002/micr.20879
  7. Sezgin B, Ayhan S, Tuncer S, et al. Hypercoagulability in microvascular breast reconstruction: an algorithmic approach for an underestimated situation. J Reconstr Microsurg 2012; 28:515-20. https://doi.org/10.1055/s-0032-1315771
  8. Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist's perspective. Plast Reconstr Surg 2015;136:545e-552e. https://doi.org/10.1097/PRS.0000000000001591
  9. Herrera FA, Lee CK, Kryger G, et al. Microsurgery in the hypercoagulable patient: review of the literature. J Reconstr Microsurg 2012;28:305-12. https://doi.org/10.1055/s-0032-1311687
  10. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336-41. https://doi.org/10.1016/j.ijsu.2010.02.007
  11. National Heart, Lung, and Blood Institute. Quality Assessment Tool for Case Series Studies [Internet]. Bethesda, MD: National Institutes of Health; c2014 [cited 2018 Apr 5]. Available from: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools.
  12. Handschel J, Burghardt S, Naujoks C, et al. Parameters predicting complications in flap surgery. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:589-94. https://doi.org/10.1016/j.oooo.2012.09.007
  13. Senchenkov A, Lemaine V, Tran NV. Management of perioperative microvascular thrombotic complications: the use of multiagent anticoagulation algorithm in 395 consecutive free flaps. J Plast Reconstr Aesthet Surg 2015;68:1293-303. https://doi.org/10.1016/j.bjps.2015.05.011
  14. Endara M, Nahabedian M. Free flap breast reconstruction in the hypercoagulable patient with a concomitant bleeding diathesis. Plast Reconstr Surg 2013;132:180e-181e. https://doi.org/10.1097/PRS.0b013e3182910e79
  15. Davison SP, Kessler CM, Al-Attar A. Microvascular free flap failure caused by unrecognized hypercoagulability. Plast Reconstr Surg 2009;124:490-5. https://doi.org/10.1097/PRS.0b013e3181adcf35
  16. Wang TY, Serletti JM, Cuker A, et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 2012;129:443-53. https://doi.org/10.1097/PRS.0b013e31823aec4d
  17. Wang TY, Serletti JM, Kolasinski S, et al. A review of 32 free flaps in patients with collagen vascular disorders. Plast Reconstr Surg 2012;129:421e-427e. https://doi.org/10.1097/PRS.0b013e3182412a0b
  18. Arnljots B, Soderstrom T, Svensson H. No correlation between activated protein C resistance and free flap failures in 100 consecutive patients. Plast Reconstr Surg 1998;101:1850-3. https://doi.org/10.1097/00006534-199806000-00011
  19. Olsson E, Svartling N, Asko-Seljavaara S, et al. Activation of coagulation and fibrinolysis during reconstructive microsurgery in patients with cancer. Microsurgery 2001;21:208-13. https://doi.org/10.1002/micr.1040
  20. Nelson JA, Chung CU, Bauder AR, et al. Prevention of thrombosis in hypercoagulable patients undergoing microsurgery: a novel anticoagulation protocol. J Plast Reconstr Aesthet Surg 2017;70:307-12. https://doi.org/10.1016/j.bjps.2016.12.001
  21. DeFazio MV, Hung RW, Han KD, et al. Lower extremity flap salvage in thrombophilic patients: managing expectations in the setting of microvascular thrombosis. J Reconstr Microsurg 2016;32:431-44. https://doi.org/10.1055/s-0035-1571249
  22. Moll S. Thrombophilia: clinical-practical aspects. J Thromb Thrombolysis 2015;39:367-78. https://doi.org/10.1007/s11239-015-1197-3
  23. Pan XL, Chen GX, Shao HW, et al. Effect of heparin on prevention of flap loss in microsurgical free flap transfer: a meta-analysis. PLoS One 2014;9:e95111. https://doi.org/10.1371/journal.pone.0095111
  24. Motakef S, Mountziaris PM, Ismail IK, et al. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015;135:290-9. https://doi.org/10.1097/PRS.0000000000000839
  25. Bowman KG, Carty MJ. Flap complications and thrombophilia: an evidence-based model and cost analysis for preoperative screening. Eplasty 2011;11:e32.

Cited by

  1. Surgical treatment of pressure ulcer: various flaps and other surgical methods vol.64, pp.1, 2019, https://doi.org/10.5124/jkma.2021.64.1.34
  2. Overcoming severe calcified lower extremity artery in lower limb salvage operation by using the Fogarty catheter and vein graft vol.41, pp.8, 2019, https://doi.org/10.1002/micr.30816