Thromboprophylaxis in breast microvascular reconstruction: a review of the literature

Microsurgical breast reconstruction patients are at an increased risk for venous thromboembolism (VTE) due to numerous risk factors. A meta-analysis focusing on anti-thrombotics in breast microsurgery has yet to be completed. We aimed to perform a systematic review of the literature to examine the effects of thromboprophylaxis in breast microsurgical reconstruction with a focus on patient and flap complications. A PubMed, Cochrane, and Medline database search was conducted with the following keywords: “venous thrombosis, thromboprophylaxis, mechanical, pneumatic compression, aspirin, heparin, dextran, ketorolac, toradol, warfarin, and coumadin.” Results were combined with the terms “breast microsurgery” and “breast free flap.” All articles that resulted were analyzed. The reference list for each included article was analyzed for other applicable articles. Only articles that addressed pre-operative or post-operative anti-coagulation were included. For data analysis, if the article reported that there were no flap complications, it was assumed there were no operative hematomas, vessel thrombosis, or flap loss. Two hundred and fifty-seven studies were screened from the abovementioned search results and 17 fit inclusion criteria. The majority of included studies were retrospective chart reviews and the type of thromboprophylaxis and its effect on complications was rarely the primary end point. Due to lack of reporting on patient and flap characteristics that could impact outcomes, subgroup analysis was impossible. There has yet to be a consensus on the most effective way to prevent VTE in women undergoing microsurgical breast reconstruction without increasing the risk of hematoma and flap compromise. Studies published to date vary in their thromboprophylatic regimens and rarely include a control or comparison group to allow for intra- or inter-group analysis. There is a need for well-done, randomized, controlled trials in order to determine the best approach to thromboprophylaxis in these patients.