Reducing postoperative venous thromboembolism in DIEP free flap breast reconstruction: Extended pharmacological thromboprophylaxis within an enhanced recovery programme

Extended vs Inpatient Chemoprophylaxis for Venous Thromboembolism in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-analysis

Venous thromboembolism (VTE) is a significant complication following deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The optimal duration of chemoprophylaxis remains debated, with differing recommendations on short-term chemoprophylaxis (STC) vs long-term chemoprophylaxis (LTC) for VTE prevention. This systematic review and meta-analysis compared the efficacy and safety of STC vs LTC in preventing VTE and hematoma in patients undergoing DIEP flap reconstruction. Four studies with a total of 1114 patients were included, with no significant differences in patient characteristics, including Caprini scores, between the STC and LTC groups. The pooled incidence of VTE was 1.83%, with 2.19% in the STC group and 1.33% in the LTC group, yielding a risk ratio (RR) of 1.42 for STC compared to LTC, although this was not statistically significant (P = .62). The mean incidence of hematoma was 8.65%, with 8.32% in the STC group and 9.02% in the LTC group, resulting in an RR of 0.78 for STC compared to LTC, which was also not statistically significant (P = .25). These findings suggest that extending chemoprophylaxis beyond hospitalization does not significantly reduce VTE incidence and underscores the importance of individualized risk-based anticoagulation strategies. Future studies are necessary to further refine guidelines for chemoprophylaxis duration in this population, balancing the risks of VTE and anticoagulation-related complications to optimize patient outcomes.

LEVEL OF EVIDENCE: 2

An Effective Protocol for Perioperative Venous Thromboembolism Prophylaxis in DIEP Flap Breast Reconstruction: A Single Institution Retrospective Review

Background

Deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction is one of the most highly used procedures for autologous breast reconstruction. Many venous thromboembolism (VTE) risk assessment models have been proposed in breast reconstructive surgery, including the widely used Caprini score. However, a paucity of data suggests an effective standardized VTE protocol. The purpose of this study was to determine the rate of VTE in our DIEP flap patients who were treated with this protocol.

Methods

A retrospective single-center review of DIEP flap breast reconstruction from 2016 to 2021 was performed. Data were collected on 554 patients and 893 flaps including demographics, intraoperative and perioperative details, and postoperative course. Patients who were not treated with our standard protocol were excluded. Data were analyzed with alpha = 0.05.

Results

The average age was 50.4 ± 9.9 years, and the total follow-up time was 16.9 ± 12.6 months. The average body mass index for the cohort was 30.1 ± 5.2. During the 90 postoperative days, the mean length of hospital stay was 4.3 days. There were six cases of postoperative VTE: five patients presented with pulmonary embolism (0.9%) and one patient (0.2%) had deep venous thrombosis with an overall VTE prevalence of 1.1%. No specific single factor could be attributed to VTE occurrence.

Conclusions

Using our standardized VTE prophylaxis protocol, our institution was effective at keeping VTE rates low. Additional studies would be beneficial to determine optimal VTE prophylaxis protocols in higher-risk patients, such as those with known clotting disorders.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes.

Methods

The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis.

Results

In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk.

Conclusions

This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

A UK consensus statement on thromboprophylaxis for autologous breast reconstruction ,

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base.

METHODS

Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached.

RESULTS

The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis.

CONCLUSION

To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.