Thromboprophylaxis in microsurgery.

Dpts of Anesthesia and Intensive Care Medicine, University Hospital Sart Tilman, University of Liège, Liège, Belgium.
Acta chirurgica Belgica (Impact Factor: 0.44). 106(2):158-64.
Source: PubMed

ABSTRACT Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.

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    ABSTRACT: No consensus exists among microsurgeons regarding the role of intravenous (IV) heparin in digital replantation/revascularization. The current experience of the Provincial Replantation Center in Quebec was reviewed over a 4-year period. An initial retrospective review of all revascularized or reimplanted digits at our Replantation Center from April 2004 to April 2006 was conducted. Then, data of all patients treated at our center from January 08 to September 08 were prospectively collected. The two cohorts were compared with regards to demographics, injury characteristics, postoperative thromboprophylaxis medication as well as complication and success rates. Proportions were compared using χ(2) tests/Fisher's exact tests. Multivariate analysis was conducted with logistic regression. 175 digits were treated from April 2004 to April 2006, including 104 revascularizations and 71 amputations. IV heparin was used in 35.1% of the cases and was associated with a 3.59-fold (95% CI, 1.55-8.31) increase risk of developing a complication compared with cases where heparin was not used (P = 0.001). In 2008, 106 digits were treated. IV heparin was used in 14.6% of the cases and was not significantly associated with a higher complication rate compared with cases where heparin was not used (P = 0.612). Both cohorts' success rates were very similar (P = 0.557). The number of complications decreased from the first period (20.5%) to the second one (12.8%). Routine use of IV heparin following digital replantation and revascularization is not warranted. Surgical technique and type of injury remains the most important predictors for success in these complex procedures.
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    ABSTRACT: The effectiveness of heparin for thromboprophylaxis during microvascular free flap transfer is uncertain. The purpose of this meta-analysis was to determine the effect of heparin on the prevention of flap loss in microsurgical free flap transfer.A search of PubMed, Cochrane databases, and Google Scholar using combinations of the search terms heparin, free flap, flap loss, free tissue transfer was conducted on March 15, 2013. Inclusion criteria were: 1) Prospective randomized trials. 2) Retrospective, non-randomized studies. 3) Patients received free tissue transfer. Flap loss rate was used to evaluate treatment efficacy. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated and compared between therapies. Four studies meet the criteria for analysis and were included. Two studiescompared aspirin and heparin, and the ORs of the 2 studies were 1.688 and 2.087. The combined OR of 2.003 (95% CI 0.976-4.109, p = 0.058) did not indicate any significant difference between heparin and aspirin therapies. Two studiescompared high and low doses of dalteparin/heparin therapies, and the ORs of the 2 studies were 4.691 and 11.00. The combined OR of 7.810 (95% CI 1.859-32.808, p = 0.005) revealed a significant difference indicating that high dose dalteparin or heparin therapy is associated with a greater flap loss rate than low dose therapy. Heparin and aspirin prophylaxis are associated with similar flap loss rates after free flap transfer, and high dose dalteparin or heparin therapy is associated with a greater flap loss rate than low dose therapy.
    PLoS ONE 04/2014; 9(4):e95111. · 3.53 Impact Factor
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    ABSTRACT: Prevention of thrombosis in microsurgery was the point of numerous publications without any referenced protocol. The question of this article was to know if it existed, for a patient who needed a microsurgical procedure, any medical treatment used, proved to lower the thrombotic risk. Using principles of evidence-based medicine, we observed that none of the medical treatments proved efficiency on preventing vascular thrombosis, arterial or venous. The low molecular weight heparins (LMWH) could be used on postoperatives to prevent the deep venous thrombosis of lower limbs but not to lower specially the microvascular thrombosis rate. Aspirin did not improve the positive rates and its adjunction to LMWH increased the bleeding. The evidence-based medicine, as we used it here, permits to conclude that the microsurgeon should not wait any miracle of the medical treatments. Until scientific studies prove efficacity of a treatment, the surgeon has to make a personal choice: keeping habits or following evidence-based medicine. The experience of the surgeon, of the anesthetist and of the paramedical team seem to be the main point to decrease the thrombotic risk during the multidisciplinary healing care of the patient.
    Annales de chirurgie plastique et esthetique 06/2011; 56(3):219-31. · 0.33 Impact Factor

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