Introduction
Methods
Search strategy
Results
Reference | Study type (level of evidence) | Population (n) | Intervention | Results | Weaknesses |
---|---|---|---|---|---|
Khouri et al. 2001 [4] | Multicenter RCT (level 1) | Free flap reconstruction (n = 622) | 1. rhTFPI 0.05 mg/ml | Thrombosis rates NS | No negative control group |
2. rhTFPI 0.15 mg/ml | Hematoma lower in low-dose rhTFPI group, − 3 versus 8% in high-dose group, and 9% in heparin group (p = 0.04) | ||||
3. 100 U/ml heparinized saline | |||||
Kroll et al. 1995 [5] | Retrospective cohort study (III) | Free flap reconstruction (n = 517) | Groups: | NS difference in flap failure of thrombosis rates (Bonferroni correction) | Non-randomized |
1. No anticoagulant | Higher risk given high-dose heparin | ||||
2. 2000–3000 IU heparin, intraoperative and postop 100–400 IU 5–7 days | Different surgeons used different anticoagulant protocols | ||||
3. 5000 IU intraoperative | Some groups underpowered | ||||
4. 5000–10,000 IU intraop and 500–1200 IU postop | |||||
5. Dextran 40 25 ml/h | |||||
Ashjian et al. 2007 [6] | Prospective cohort retrospective study (III) | N = 505, free flaps oncological defects | Microvascular thrombosis, partial or total flap loss, hematoma, bleeding | Flap loss (0.4% vs total flap loss (0.4%) vs 0.8%) NS | No data on thrombosis rates or flap takeback |
470 patients | Hematoma (2.3 vs 2.9%) NS | Procedures by 2 different surgeons | |||
1. Postoperative aspirin (A) 325 mg of 5 days (n = 260) | Non-randomized | ||||
2. Postoperative LMWH (B) 5000 units until ambulant | Publication from same group of same patient series comparing outcomes with or without heparin bolus, this difference is not mentioned in this paper | ||||
Chen et al. 2006 [7] | Retrospective cohort study (III) | Free flap reconstruction (n = 505) | Comparing 3000 units intraoperative IV administration of heparin bolus versus no bolus | Flap failure 0.4 versus 0.8% (p = 0.61) | No data on returns to theater or thrombosis incidence |
Nelson et al. 2014 [8] | Cohort study (III) | Hypercoagulable patients undergoing breast reconstruction (n = 32), personal history of VTE or thrombophilia | Heparin bolus IV, heparin infusion postop versus 5000 U sc heparin postop | Thrombosis rate 0 versus 17.6% (p = 0.23) | Non-randomized |
Non-contiguous | |||||
Study of change in unit practice | |||||
Jayaprasad et al. 2013 [9] | Retrospective cohort study (III) | N = 172, head and neck reconstruction | Papaverine intraoperatively | Flap survival rate 95.9% | Retrospective, non-contiguous, change in practice with dextran 40 with available evidence |
0.2 ml, LMWH 5 days postop | 7 postop hematomas | ||||
Vessels flushed with heparinized saline | No difference in failure of thrombotic complications | ||||
+/− dextran 40 for 5 days | Venous thrombosis 7 versus 9.3% (p = 0.78) | ||||
Arterial thrombosis 1.2 versus 3.5% (p = 0.62) | |||||
Deutinger et al. 1998 [10] | Retrospective cohort study (III) | Free flap reconstruction, mainly elective (n = 204) | 5000 IU heparin sc tid and dextran 40 bd 250 ml OR heparin 500–800 IU per hour up to 10 days Intraoperative irrigation with heparin | Flap failure 5%, dextran and heparin 7.4%, heparin 6.5% (p = 0.79) | Non-randomized, retrospective |
Disa et al. 2003 [11] | Randomized control trial (II) | Head and neck reconstruction (n = 100) | Dextran for 48 h, 120 h or aspirin for \5 days | Significantly higher systemic complications in dextran groups (p < 0.05) No effect on flap survival | Underpowered Designed to assess systemic complications related to anticoagulation All had intraoperative 3000 IU heparin |
Lighthall et al. 2011 [12] | Retrospective cohort study (III) | Head and neck reconstruction (n = 390) | 3 groups: no prophylaxis, aspirin only (dose not given) or combination of aspirin and prophylactic dose heparin or LMWH | No significant differences in flap failure or hematoma rates between groups, more complications with aspirin than no prophylaxis | Retrospective Non-contiguous Not randomized |
Sun et al. 2003 [13] | Retrospective cohort study (III) | Head and neck reconstruction (n = 55) | Dextran 40 20–33 cm3/h for 5–7 days postoperatively or no anticoagulation | Thrombosis: 4% dextran group, 0% no anticoagulant group (p > 0.05), 100% survival all groups No data re hematoma | Non-consecutive Underpowered Retrospective Not randomized |
Riva et al. 2012 [14] | Retrospective cohort study (III) | Head and neck reconstruction (n = 1351) | PGE1 or dextran-40 or no antithrombotic therapy | No significant difference in flap survival/thrombosis (p = 0.734) No significant increase in hematomas | Retrospective Choice of treatment was based on each surgeon’s preference |
Enajat et al. 2014 [15] | Retrospective cohort study (III) | DIEP/TRAM flaps for breast reconstruction, (n = 592) | 0.6 ml nadoparine =/− 40 mg aspirin | Non-significant difference in hematoma, failure or microvascular thrombosis | Non-randomized, retrospective, different hospital/surgeons |
Lee et al. 2012 [16] | Retrospective cohort study (III) | Free flaps for lower limb reconstruction (n = 128) | IV ketorolac 30 mg tid for first 2 postoperative days | Returns to theater 5 versus 16.7% (p = 0.03) No significant difference in flap failure rates | Also treated with PGE1 Non-randomized |
Quantitative analysis
Discussion
Preoperative
Intraoperative
Surgical technique
Topical heparin
Postoperative
Heparin
Low molecular weight heparin
Dextran
Aspirin
Ketorolac
Preoperative | |
Stop prothrombotic medications (e.g., tamoxifen, HRT) | Level 2 evidence [23] |
VTE risk assessment, prescribe 40 mg enoxaparin per day, adjust dependent on weight and renal function | Level 3 evidence [30] |
Liaise with hematologist for patients with known thrombotic disorders | Level 5 evidence [8] |
Intraoperative | |
Consider use of a venous coupler | Level 3 evidence [25] |
Consider intraluminal irrigation with heparinized saline | |
Postoperative | |
Heparin, aspirin, and dextran should not be routinely prescribed for free flap patients to prevent microvascular thrombosis |