Huynh Minh N Q, Bhagirath Vinai, Gupta Michael, Avram Ronen, Cheung Kevin
Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada.
Division of Hematology, McMaster University, Hamilton, Ontario, Canada.
Plast Surg (Oakv). 2022 Nov;30(4):343-352. doi: 10.1177/22925503211024742. Epub 2021 Jun 23.
Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.
静脉血栓形成是游离皮瓣失败的主要原因，可能会产生灾难性后果。许多抗血栓药物和方案已被描述用于游离皮瓣静脉血栓形成的预防和治疗。向显微外科医生（整形和耳鼻喉科培训方向）以及血液学和血栓形成专家发放了全国性调查问卷。收集了关于常规筛查做法、皮瓣失败的感知风险因素以及术前、术中和术后抗血栓策略的数据。共发放了722份调查问卷，有132名（18%）受访者，包括102名外科医生和30名血液科医生。65名外科医生和9名血液科医生常规进行游离皮瓣手术或管理此类患者。根据外科医生的看法，皮瓣失败的前三大感知风险因素是合并症、既往动脉血栓形成和血栓形成倾向。然而，血液科医生报告称糖尿病、吸烟和合并症是最重要的风险因素。54%的医生常规使用普通肝素（UFH）或低分子量肝素（LMWH）作为术前用药。外科医生术中常规用肝素冲洗皮瓣（37%）、静脉注射UFH（6%）或两者都用（8%）。外科医生使用一系列术后药物，如UFH、LMWH、阿司匹林和右旋糖酐，而血液科医生更倾向于LMWH。如果发生皮瓣血栓形成，管理策略会有所不同。不同的策略包括更换受区血管、静脉注射UFH、冲洗皮瓣、添加术后药物或多种策略联合使用。在游离组织移植的抗血栓策略方面存在多种不同的做法，并且在皮瓣失败的感知风险因素方面存在差异，这可能会影响患者的管理。
