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Free Tissue Transfer in Patients with Thrombophilia
Theresa Y. Wang, M.D., Joseph M. Serletti, MD, David W. Low, MD, Stephen J. Kovach, MD, Liza C. Wu, MD.
University of Pennsylvania, Philadelphia, PA, USA.
PURPOSE: Hypercoagulability or thrombophilia is a group of inherited or acquired conditions associated with a predisposition to thrombosis due to an abnormality in the coagulation cascade. Most hypercoagulable states alter the blood itself or affect the vasculature directly creating a detrimental environment for microsurgery. The inherent risk of thrombosis would deem these patients unsuitable candidates for free tissue reconstruction. We present our series of hypercoagulable patients who underwent free flap reconstruction.
METHODS: A review was conducted of all free flaps performed between January 1, 2005-October 1, 2010 by the division of plastic surgery at the University of Pennsylvania Health System. A total of 2032 flaps were performed. Thirty-nine (39) patients or 54 free flaps (3.2%) were identified to have a hypercoagulable disorder or previous hypercoagulable event. Diagnosis included Factor V Leiden mutation (2), Protein C deficiency (2), homocysteinemia (1), antiphospholipid antibody syndrome (2), prothrombin gene mutation (1), Factor VIII elevation (1), anticardiolipin antibody syndrome (2), essential thrombocytosis (1). The group of patients with prior thrombotic events (many with concomittant events and diagnoses) included deep vein thrombosis (20), pulmonary embolus (8), myocardial infarction before the age of 50 (4) and embolic stroke before the age of 50 (6).
RESULTS: Five patients were male, 34 patients were female. Mean age was 55 years. The average BMI was 28.1 kg/m2. Twelve patients (31%) were actively followed by a hematologist. A total of 54 free flap reconstructions were performed which included 44 breast (2 SIEA, 7 DIEP, 30 TRAM), 1 trunk (TRAM), 3 extremity (3 ALT ), and 6 head and neck (1 ALT, 1 vastus lateralis, 2 latissimus dorsi, 1 DIEP, 1 Fibula). The overall rate of thrombosis was 20.4% or 11 patients; 3 cases were intraoperative, none of which resulted in flap loss. Postoperatively, there were 8 cases of thrombosis which occurred on average in a delayed fashion at 3.5 days postop. Eighty percent of the veins were anastomosed using a coupler, all arterial anastomoses were hand-sewn. Unless there was an anticoagulation regimen recommended by the patient’s hematologist, most patients received the standard anticoagulation according to independent surgeon protocols customary for free flaps. Despite OR exploration, vein grafts, mechanical and chemical thrombolysis and systemic anticoagulation, the salvage rate for a postoperative thrombosed flap in this group was zero.
CONCLUSION: Although hypercoagulability produces an unfavorable condition for microvascular reconstruction, free tissue transfer is very much possible in this population. In this series, we had an 80% success rate. However, most importantly, prior to embarking on this endeavor, patients need to be cognizant of the increased risks of thrombosis and flap failure. Collaboration with a hematologist is essential. In this group, flap thrombosis seems to occur later than the immediate postoperative 48 hours and into the delayed period. This patient population needs to be carefully counseled that if a flap thrombosis occurs, even with operative reexploration and the current methods used to treat flap complications may not work for them; salvage rates have not been promising.
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