Thromboprophylaxis in microsurgery

Dpts of Anesthesia and Intensive Care Medicine, University Hospital Sart Tilman, University of Liège, Liège, Belgium.
Acta chirurgica Belgica (Impact Factor: 0.41). 04/2006; 106(2):158-64.
Source: PubMed


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: The reported incidence of free flap failure varies from 4% to 5%, but pedicle thrombosis occurs in a higher percentage than indicated by the failure rate, the difference resulting from successful salvage of failing flaps. Often these failures are attributed to postoperative venous thrombosis, reported salvages being 42%; the poorer salvage rate in case of venous thrombosis has been related to a delay in recognition, because of the ongoing presence of an arterial Doppler signal. The physical engorgement of the flap and the microvascular changes lead to a more rapid and less reversible no-reflow phenomenon, occurring within 6 hours. This report shows the efficacy of thrombolytic therapy after 6 hours, confirming that the mechanism of free flap failure is not yet well known. A reliable and simple protocol of thrombolytic therapy applied in a well documented case of vascular compromise is described. Urokinase is the drug chosen to treat the thrombosis, owing to its easy availability, low cost, short half-life and absence of antigenicity.
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    ABSTRACT: Despite increasing advances in microvascular free tissue transfer, flap failures, most commonly resulting from thrombosis at the anastomotic vascular site, remain a significant concern. Although several experimental and clinical studies have been carried out, no consensus has been reached so far on the efficacy, dosage and timing of anticoagulant agents available for the prevention and treatment of thrombosis in microvascular surgery. Inhibition of fibrin formation and platelet function or the use of thrombolytic agents is a common approach in the antithrombotic management. However, some agents exhibit serious side effects and all of them carry the risk of bleedings. The current literature on the use of antithrombotic agents, targeting at clinical trials in microvascular surgery, is therefore reviewed, to provide an informative basis for recommendations for an appropriate pharmacological approach.
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    ABSTRACT: Thrombosis is still the first cause of microsurgery failure. Lots of publications have been made but no consensus exists. We first analysed the results of our study in 53 French expert surgeons, then we compared them with the last published datas, most of all, with the similar surveys. If a big majority (81 %) of the surgeons use a preventing method, we observed majors variations between them and also compared to the anglosaxons surgeons habits. This survey permits to make the point on today's practice and to show that some of them are based on low proof level and something even done without any medical references. After datas analysis, we observed that none of the medical treatments proved efficiency on preventing vascular thrombosis. The low molecular weight heparins (LMWH) could be used on postops without increase bleeding but not to lower specially the microvascular thrombosis rate. Aspirin did not improve the positive rates and its adjonction to LMWH increased the bleeding. Until scientific studies prove efficacy of a treatment, the surgeon has to make a personal choice: keeping habits or following evidence-based medicine.
    No preview · Article · Mar 2010 · Chirurgie de la Main
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