Nelson Jonas A, Chung Cyndi U, Bauder Andrew R, Wu Liza C
Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA, United States.
J Plast Reconstr Aesthet Surg. 2017 Mar;70(3):307-312. doi: 10.1016/j.bjps.2016.12.001. Epub 2016 Dec 18.
Hypercoagulable conditions are often considered relative contraindications to free flap reconstruction. This paper presents and critically examines a novel anticoagulation regimen developed to address this disease state.
Hypercoagulable patients who underwent free tissue transfer between 2007 and 2015 were identified. From 2011, all such patients were subjected to a novel anticoagulation protocol involving an intravenous bolus of 2000 U of unfractionated heparin prior to microvascular pedicle anastomosis, followed by a heparin infusion at 500 U/h, which was postoperatively increased to therapeutic levels. Patients were discharged on full anticoagulation for 1 month. Patients prior to 2011 received only subcutaneous heparin. Outcomes in patients receiving this novel anticoagulation protocol were compared to those of patients receiving standard therapy (postoperative subcutaneous heparin).
Twenty-three hypercoagulable patients underwent reconstruction with 32 flaps. Eleven patients were administered the novel protocol. No thromboses were noted in the novel protocol cohort, while three thrombotic events occurred in the control cohort (0% vs. 17.6%, p = 0.23). No flaps were salvaged after thrombosis. All losses occurred in the control cohort (0% vs. 17.6%, p = 0.23). The novel protocol cohort was more likely to have postoperative red blood cell transfusions (72.6% vs. 16.7%, p = 0.007), hematomas (26.7% vs. 0%, p = 0.04), and lower mean hemoglobin nadirs [6.9 (1.0) vs. 8.9 ± 1.8 g/dL, p = 0.01].
The key approach to hypercoagulable patients is likely prevention over treatment. Patients who received prophylactic heparin infusions had clinically lower rates of thrombotic events and flap loss. However, this encouraging finding must be balanced with the increased risk for postoperative bleeding complications.
高凝状态通常被视为游离皮瓣重建的相对禁忌证。本文介绍并严格审查了一种为应对这种疾病状态而制定的新型抗凝方案。
确定2007年至2015年间接受游离组织移植的高凝患者。从2011年起，所有此类患者均接受一种新型抗凝方案，即在微血管蒂吻合术前静脉推注2000单位普通肝素，随后以500单位/小时的速度输注肝素，术后将其提高至治疗水平。患者出院后进行1个月的全量抗凝治疗。2011年之前的患者仅接受皮下肝素治疗。将接受这种新型抗凝方案的患者的结果与接受标准治疗（术后皮下肝素）的患者的结果进行比较。
23例高凝患者用32个皮瓣进行了重建。11例患者采用了新型方案。新型方案组未发现血栓形成，而对照组发生了3例血栓形成事件（0%对17.6%，p = 0.23）。血栓形成后没有皮瓣得以挽救。所有皮瓣丢失均发生在对照组（0%对17.6%，p = 0.23）。新型方案组术后更有可能接受红细胞输血（72.6%对16.7%，p = 0.007）、出现血肿（26.7%对0%，p = 0.04），且平均血红蛋白最低点更低[6.9（1.0）对8.9±1.8克/分升，p = 0.01]。
对于高凝患者，关键方法可能是预防而非治疗。接受预防性肝素输注的患者临床血栓形成事件和皮瓣丢失率较低。然而，这一令人鼓舞的发现必须与术后出血并发症风险增加相权衡。
