Breast free flap complications related to haematoma formation - do the risks of multiple antithrombotics outweigh the benefits today?

Efficacy and Morbidity of Heparin Infusion in Salvaging Autologous Breast Reconstruction Free Flaps

BACKGROUND

Abdominal-based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well-documented. When flap compromise occurs, operative salvage is the gold standard. However, when-and if-to place these patients on heparin infusions is unclear. The goal of this study was to investigate abdominal-based free flap compromise and compare outcomes with and without heparin infusion.

MATERIALS AND METHODS

This was a single-institution, multiple-surgeon, retrospective chart review of patients undergoing autologous, abdominal-based free flap breast reconstruction who experienced anastomotic compromise within a 6-year period. Treatment and outcomes data collected include flap salvage, hematoma, seroma, surgical site infection (SSI), transfusion requirement, and length of hospital stay.

RESULTS

Fifty-one flaps had evidence of compromise. A total of 31 (60.8%) patients were placed on heparin infusions after experiencing anastomotic compromise, compared to 20 who did not receive heparin infusion. Thirty-five patients (68.6%) underwent deep inferior epigastric perforator flaps. Twenty-six patients (51%) experienced venous congestion, 22 patients (43.1%) experienced arterial compromise, and three (5.9%) experienced both. Twenty-eight patients (54.9%) received tissue plasminogen activator; in the heparin infusion group, 21 patients (67.7%) received tissue plasminogen activator. The total salvage rate of compromised flaps was 94.1% (48/51). There was no significant difference between heparin infusion and standard cares in length of hospital stay, length of drains in-place, successful salvage (93.5% vs. 95%), hematoma (19.4% vs. 15%), fat necrosis, SSI, hospital readmission (19.4% vs. 15%), and return rates to the operating room (48.4% vs. 50%). However, there was a significantly higher transfusion rate in patients receiving heparin infusion (38.7% vs. 10%). Of the 25 flaps with evidence of thrombosis, 72% were placed on heparin infusions while 28% were not; there was no significant difference in salvage rate in this sub-group.

CONCLUSIONS

This review of autologous breast reconstruction free flap compromise provides evidence of similar safety profiles, with similar salvage rates, when comparing salvage with and without heparin infusion; there is a higher transfusion requirement when treating with heparin infusion.

The use of dextran may not have positive effects on microvascular free flap reconstruction: A matched cohort study

BACKGROUND

Dextran had been used in free flap reconstruction surgery to increase the patency of anastomotic vessels. This study aimed to evaluate the outcome of perioperative and postoperative dextran in free flap surgery.

METHODS

This was a single-center, retrospective study that enrolled 622 patients who received free flap surgery from 2016 to 2020. Propensity score matching was done to minimize the effect of covariance. The outcome included flap-related complications, hospital stay, and mortality. Differences in outcomes were compared between patients treated with dextran and those treated without dextran.

RESULTS

After propensity score matching, a total of 378 cases of free flap surgery were included. No difference in total flap failure rate, partial flap failure rate, take-back rate, or major and minor complications were found between the 2 groups. Dextran did not increase the overall complication rate of free flap surgery. Vascular thrombosis remains the most common cause of take-back re-exploration reasons in both the dextran and non-dextran groups.

CONCLUSIONS

We found that the use of dextran perioperatively combined with postoperative treatment in microvascular free flap reconstruction showed no statistical difference in flap survival rate and complication rate.

Postoperative anticoagulation in patients with microvascular reconstruction - a systematic review

OBJECTIVE

To assess the currently applied regimens of antithrombotic therapy after microvascular reconstruction.

METHODS

A systematic literature review was performed using the MEDLINE/PubMed Database for work published until September 2022. Data synthesis and risk of bias were reported in accordance with NIH Study Quality Assessment Tools guidelines.

RESULTS

204 articles were found including the keywords either in the abstract or in the title. After screening their abstracts and titles, 41 articles were identified as suitable and the full texts were retrieved. 23 studies were included in this review. No gold standard could be shown; on the contrary, the applied antithrombotic regimens varied widely. A broad consensus could be obtained that Dextran should no longer be used after an increased complication rate was proven. The most commonly used agents are unfractionated (UFH) as well as low molecular weight (LMWH) heparin and acetylsalecylic acid (ASA), although the literature results are partly contradictory.

CONCLUSIONS

A consensus could be found that it is useful to perform thromboprophylaxis when the patient is immobilized, but there is no evidence for a survival advantage of the flap by chemical prophylaxis. On the contrary, it has been shown that there is an increased rate of bleeding complications and flap loss combined with the simultaneous use of multiple chemical anticoagulants. In conclusion the generalized use of anticoagulation is explained less by microvascular grafting than by general medical risk factors. Thus, large prospective RCTs will be needed to establish a gold standard therapeutic regimen.

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Background:

Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment.

Methods:

Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma.

Results:

Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001).

Conclusions:

Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Multidisciplinary Practice Variations of Anti-Thrombotic Strategies for Free Tissue Transfers

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

The chicken or the egg? Relationship between venous congestion and hematoma in free flaps

BACKGROUND

Postoperative hematoma and venous congestion after free tissue transfer may occur independently or concurrently. We aimed to explore the association between these two events.

METHODS

All free flap reconstructions for head and neck (HN) and breast from a single institution between 2004 and 2014 were retrospectively reviewed for reoperation for venous congestion and/or hematoma.

RESULTS

There were 2985 free flap cases for HN reconstruction and 2345 cases for breast reconstruction. In HN, 100 patients developed a hematoma (3.4%) and 84 patients developed venous congestion (2.8%). The prevalence of hematoma was 17.8% and 2.9% in the presence and absence of congestion, respectively (p<0.001). Among the 15 patients who had both hematoma and venous congestion were separate events that occurred from 1 to 9 days apart in 8 patients. Hematoma caused the compression of the pedicle vein in 4 patients, while venous congestion possibly caused hematoma in 3 patients. In breast, 56 patients developed a hematoma (2.4%) and 64 patients developed venous congestion (2.7%). The prevalence of hematoma was 12.5% and 2.1% in the presence and absence of congestion, respectively (p<0.001). In the 8 patients who developed both, hematoma and congestion were separate events in 4 patients. Venous congestion caused hematoma in 3 patients, and hematoma caused venous congestion in 1 patient.

CONCLUSIONS

Although postoperative hematoma and venous congestion often present concurrently, most events are not causally associated. When related, however, venous congestion leading to hematoma is more common in breast reconstruction, while hematoma preceding venous congestion is more common in HN reconstruction.

A randomised controlled feasibility trial to evaluate local heat preconditioning on wound healing after reconstructive breast surgery: the preHEAT trial

Objective

preHEAT was a randomised controlled feasibility trial to determine how best to measure skin necrosis in breast reconstruction to inform the design of a larger multicentre trial.

Background

Mastectomy skin flap necrosis (MSFN) is a serious complication resulting in prolonged wound healing. Local heat preconditioning of the MSF before surgery has been shown to reduce skin necrosis in immediate breast reconstruction patients (IBR).

Method

preHEAT was a single-centre, randomised control two-arm single-blind parallel arm feasibility trial of local heat preconditioning in breast cancer patients undergoing SSM and NSM at Guy’s and St Thomas’ Hospital, London, UK. All patients undergoing IBR above the age of 18 were included. Intervention patients heated breast skin to 43 °C in three, 30-min cycles interrupted by spontaneous cooling using hot water bottles. The primary aim was to compare measurement of skin necrosis using binary ‘yes/no’ assessment, the SKIN score, and wound area.

Results

One hundred forty-one patients were randomised over a 2-year period (71 heated group, 70 controls). There was near perfect agreement between assessors using the “yes/no” measurement of necrosis. The proportion of patients experiencing necrosis in controls was 35% (n = 23/66) in the heated 26% (n = 18/68]). In the control group, 17% (n = 4/23) patients experiencing necrosis required surgical intervention for necrosis compared to 11% (n = 2/18) in the heated group.

Conclusion

The binary outcome of MSFN “yes/no” is a suitable and reliable primary outcome measure of necrosis and was superior to the SKIN Score or necrosis area. The trial study design is feasible for a larger definitive trial.

Trial registration

ISRCTN15744669. Date of registration: 25/02/2018

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0392-y) contains supplementary material, which is available to authorized users.

The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability

Supplemental Digital Content is available in the text.

Background:

The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days.

Methods:

Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010–2015) and the ACS-NSQIP (2011–2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets.

Results:

For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30–60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days.

Conclusion:

For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.