Recurrent Venous Thrombosis following Free Flap Surgery: The Role of Heparin-Induced Thrombocytopenia (original) (raw)

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Plastic and Reconstructive Surgery - Global Open

Background: Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment. Methods: Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma. Results: Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event...

Complications of free flap transfers for head and neck reconstruction following cancer resection

Oral Oncology, 2004

The reported success rate of microvascular free flap reconstruction ranges between 95% and 97%. However when complications occur, they must be identified early and managed efficiently because there is a narrow window of opportunity to salvage potential flap failure. While technical advances in instrumentation and magnification have improved overall success rates, the rare complication may prove devastating for the patient, his/her hospital stay, and the optimum rehabilitation. Complications of microvascular free tissue transfer may occur at the recipient site or at the donor site. Complications occurring at the recipient site are largely a result of vessel thrombosis while complications occurring at the donor site may result from many causes, ranging from infection to those related to the harvesting of the flap. Irrespective of the site of the complication, it is essential that complications be recognized and addressed early in their course to prevent or minimize devastating consequences.

Complications and outcome after free flap surgery for cancer of the head and neck

British Journal of Oral and Maxillofacial Surgery

This study evaluated the complications following free flap surgery for cancer of the head and neck, assessed factors associated with the complications, and analyzed the impact of the complications on outcome. This retrospective single-center study included 136 patients who underwent free flap surgery for cancer of the head and neck between 2008 and 2015. Preoperative and perioperative data and surgical and medical complications were recorded. The impact of the complications on hospital length of stay (LOS) and survival were assessed. A total of 86/136 (63.2%) patients had complications. Compared to patients without complications, these patients had a higher rate of alcohol abuse (24.4% vs. 10.0%, p=0.039), longer operation time (565 [458-653] vs. 479 [418-556] min, p<0.001) and higher intraoperative blood loss (725 [400-1150] vs. 525 [300-800] mL, p=0.042). Fibular flap surgery and stage T4 were more frequent in patients with complications (26% vs. 8%, p=0.010; 55% vs. 34%, p=0.015, respectively). Patients with complications had longer hospital LOS (9 [7-12] vs. 15 [10-21] days, p<0.001) than those without complications. The cumulative mortality was higher for patients with late (occurred after the fourth postoperative day) complications (61.4% vs. 35.5%, p=0.004). In conclusion, more than half of the patients had complications that were related to alcohol abuse, a more complicated intraoperative course and fibular flap surgery. The complications were related to longer hospital LOS, and patients with late complications had higher mortality than those without.

Perioperative Care of Free Flap Patients

Seminars in Plastic Surgery, 2019

Microvascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.

Autologous Mandible Reconstruction in a Hypercoagulable Patient following Multiple Failed Free Flaps

Plastic and Reconstructive Surgery Global Open, 2022

Summary: Coagulopathies affect 3% of free flap patients and are among the leading causes of free flap failure. This report describes the case of a head and neck cancer patient that experienced two remote free flap failures before successful autologous mandibular reconstruction. Following identification of an unrecognized thrombophilic state, a focused anticoagulation strategy was executed, including an intraoperative heparin drip, stringent postoperative maintenance of Factor Xa levels between 0.3 and 0.5 IU per mL, and transition to an outpatient enoxaparin regimen of 1 mg per kg twice daily for 1.5 months following surgery. Here, we demonstrate that free tissue transfer following multiple previous failed attempts in the setting of hypercoagulability remains a viable reconstructive option with close interdisciplinary collaboration, close clinical monitoring, and patient-specific antithrombotic protocols.

Anatomy of Free Flap Failures: Dissection of a Series

Modern Plastic Surgery, 2013

Introduction: Free flap success rates have remained stable in recent years ranging 93% to 98%. Historically, the causes of free flap failures were attributed to the surgeon's inexperience and technique. However, there are factors beyond the surgical anastomosis that contribute to flap failure. The purpose of this study is to review each case of total flap loss in detail to develop a better understanding of complications. Methods: A retrospective study was performed over eleven years in a single surgeon's practice, a predominantly head and neck reconstructive practice. All charts were independently reviewed. In patients who sustained total flap loss, a review was conducted of patient comorbidites, anesthesia records, perioperative and follow-up notes. Results: A total of 514 free flaps were performed. 76% (392) of these flaps were for head and neck reconstruction. There were 22 total flap losses (4%) and 26 partial flap losses (5%). Of the 22 total flap losses, four flaps were avulsed, five flaps were in patients later found to have coagulation disorders (homozygous mutations of the MTHFR gene and factor V Leiden), four patients were exposed to neosynephrine, two patients remained hypotensive perioperatively, and four delayed flap losses were attributed to pseudomonal infection. Five losses were technical or related to flap inexperience. Several representative case scenarios are illustrated. Conclusion: Careful review of free flap failures indicates that a thorough workup (particularly coagulation disorders), flap selection, surgeon to anesthesia communication, proper securing of the flap, and postoperative patient blood pressure and infection control have a greater part to play in this new era of anastomotic success.

Etiology of Late Free Flap Failures Occurring After Hospital Discharge

The Laryngoscope, 2007

Objectives: Vascular compromise of free flaps most commonly occurs in the immediate postoperative period in association with failure of the microvascular anastomosis. Rarely do flaps fail in the late postoperative period. It is not well understood why free flaps can fail after 7 postoperative days. We undertook a case review series to assess possible causes of late free flap failure.

Factors Affecting the Risk of Free Flap Failure in Microvascular Surgery

Proceedings of the Latvian Academy of Sciences. Section B. Natural, Exact, and Applied Sciences., 2016

Microvascular free flap surgery, has become an important part of reconstructive surgery during the last decades, as it allows closure of various tissue defects and recovery of organs function. Despite surgical progress resulting in high rates of transferred tissue survival, the risk of pedicle vessels thrombosis still remains a significant problem. A total of 108 articles from Pubmed and Science Direct databases published in 2005–2015 were analysed. This review of the literature assessed the influence of patient-dependent risk factors and different perioperative management strategies on development of microvascular free flap thrombosis. Sufficient evidence for risk associated with hypercoagulation, advanced age and certain comorbidities was identified. Presently, rotational thromboelastometry allows early hypercoagulability detection, significantly changing further patient management. Identification of flap thrombosis promoting surgery-related aspects is also essential in preoperati...