Health Technology Assessment Professional, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
Faculty of Medicine, McGill University, Montréal, Québec, Canada.
Microsurgery. 2022 Sep;42(6):622-630. doi: 10.1002/micr.30895. Epub 2022 May 12.
Digital replants and revascularization (DRV) have been performed since the 1960s but there are no recognized standard peri-operative anticoagulation practices. A narrative systematic review of the clinical effectiveness and safety of therapeutic peri-operative unfractionated heparin following DRV was undertaken.
A review of the literature from 1985 to March 2022 was conducted using Medline, Embase, CINAHL and EBM reviews. Unfractionated heparin (UFH) use following DRV was compared to low-molecular weight heparin, other anticoagulants or no anticoagulation. Randomized trials, observational studies as well as guidelines were selected and independently screened. The Revised Cochrane risk-of-bias (RoB 2) tool and ROBINS-I were used to appraise risk of bias.
While the search strategy identified 1490 references, only six studies met the inclusion criteria. Significant heterogeneity and the low methodological quality of the evidence precluded a meta-analysis. Among the four studies that documented the surgical success rate associated with the use of a therapeutic dose of UFH post DRV, only two reported improved clinical outcomes. Evidence of a higher complication rate related to UFH use was found in four studies. Low quality evidence suggests that a therapeutic dose of unfractionated heparin leads to a higher risk of complications when compared with heparin given as an intermittent bolus of unfractionated heparin or subcutaneous heparin, or prostaglandin E1 or no heparin.
Current evidence suggests that IV UFH use following DRV has no significant impact on the success of the intervention. Heparin use may not be innocuous as some studies showed increased bleeding complications.
自 20 世纪 60 年代以来，已经进行了数字再植和血运重建（DRV），但没有公认的围手术期抗凝标准实践。对 DRV 后治疗性围手术期普通肝素的临床效果和安全性进行了系统的叙述性评价。
使用 Medline、Embase、CINAHL 和 EBM 综述对 1985 年至 2022 年 3 月的文献进行了综述。将 DRV 后使用普通肝素（UFH）与低分子量肝素、其他抗凝剂或不抗凝进行比较。选择并独立筛选了随机试验、观察性研究以及指南。使用修订后的 Cochrane 偏倚风险（RoB 2）工具和 ROBINS-I 来评估偏倚风险。
尽管搜索策略确定了 1490 条参考文献，但只有 6 项研究符合纳入标准。由于存在显著的异质性和证据的低方法学质量，因此无法进行荟萃分析。在四项记录 DRV 后使用治疗剂量 UFH 与手术成功率相关的研究中，只有两项报告了改善的临床结果。四项研究均发现 UFH 使用与更高的并发症发生率相关。低质量证据表明，与间断推注普通肝素或皮下肝素、前列腺素 E1 或不使用肝素相比，使用治疗剂量普通肝素会增加并发症的风险。
目前的证据表明，DRV 后使用 IV UFH 对干预的成功没有显著影响。肝素的使用可能并非无害，因为一些研究表明出血并发症增加。
