From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital.
Georgetown University School of Medicine.
Plast Reconstr Surg. 2023 Sep 1;152(3):653-666. doi: 10.1097/PRS.0000000000010293. Epub 2023 Feb 14.
Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and achieve high rates of microsurgical success. At the authors' institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. The authors present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for nontraumatic lower extremity (LE) wounds.
The authors retrospectively reviewed patients who underwent FTT to an LE from 2012 to 2021. Their risk-stratification AC protocol was implemented in July of 2015. Low-risk and moderate-risk patients received subcutaneous heparin. High-risk patients received heparin infusion titrated to a goal partial thromboplastin time of 50 to 70 seconds. Before July of 2015, nonstratified patients were treated with either subcutaneous heparin or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (nonstratified and risk-stratified) based on date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success.
Two hundred nineteen hypercoagulable patients who underwent FTT to an LE were treated with nonstratified ( n = 26) or risk-stratified ( n = 193) thromboprophylaxis. The overall flap success rate was 96.8% ( n = 212). Flap loss was lower among risk-stratified patients (1.6% versus 15.4%; P = 0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% versus 15.4%; P = 0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% versus 0%; P = 0.048). Intraoperative anastomotic revision (OR, 6.10; P = 0.035) and nonrisk stratification (OR, 9.50; P = 0.006) were independently associated with flap failure.
Hypercoagulability can significantly affect microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
为避免皮瓣血栓形成和提高显微外科成功率，围手术期最佳的血栓预防至关重要。在作者所在机构，实施风险分层抗凝（AC）方案初步显示可降低术后血栓形成事件和皮瓣丢失率。作者报告了在接受非创伤性下肢（LE）伤口游离组织转移（FTT）重建的血栓形成患者中，使用风险分层 AC 的手术结果的最新分析。
作者回顾性分析了 2012 年至 2021 年接受 FTT 治疗的 LE 患者。他们的风险分层 AC 方案于 2015 年 7 月实施。低危和中危患者接受皮下肝素治疗。高危患者接受肝素输注，目标部分凝血活酶时间为 50-70 秒。2015 年 7 月之前，非分层患者接受皮下肝素或低剂量肝素输注（500 U/小时）治疗。根据 FTT 重建日期，患者分为两组（非分层和风险分层）。主要结局包括术后并发症、皮瓣存活率和皮瓣成功率。
219 例接受 FTT 治疗 LE 的高凝患者接受非分层（n=26）或风险分层（n=193）血栓预防治疗。总体皮瓣成功率为 96.8%（n=212）。风险分层患者的皮瓣丢失率较低（1.6%比 15.4%；P=0.004），术后血栓形成事件也显著减少（2.6%比 15.4%；P=0.013）。风险分层组更常实现皮瓣挽救（80%比 0%；P=0.048）。术中吻合口修正（OR，6.10；P=0.035）和非风险分层（OR，9.50；P=0.006）与皮瓣失败独立相关。
高凝状态可显著影响显微外科结果。实施风险分层 AC 方案可显著改善皮瓣结局。
临床问题/证据水平：治疗性，III 级。
