An Evaluation of Risk Factors for Flap Loss and Anti-thrombotic Strategies by Surgeons and Hematologists
Minh Q Huynh, BSc; Kevin Cheung, MSc, MD, FRCSC; Vinai Bhagirath, MD, FRCP; Michael Gupta, MD, FRCSC; Ronen Avram, MD, FRCSC
University of Ottawa, Ottawa, ON, Canada
Introduction Thrombosis,a leading cause of flap failure,has devastating consequences.This results from technical factors,such as vessel kinks,or non-technical factors such as medical co-morbidities.As an intervention or prophylaxis,a variety of anti-thrombolytic agents can be used.However,the literature is sparse on the efficacy and guidelines for the different pharmacological strategies for flap failure.The goal is to characterize the current practice patterns for anti-thrombotic strategies for flap management.
Materials & Methods Surveys were distributed to Thrombosis Canada,ENT Canada,and the Canadian Society of Plastic Surgeons.Data was collected on routine screening,risk factors for flap failure,pre-,intra-,and post-operative strategies.Physicians were asked how they would change their management if patients had a risk factor or flap thrombosis.
Results There were 722 surveys distributed with 132 respondents(18%),consisting of 102 surgeons and 30 hematologists.Sixty-five surgeons and nine hematologists routinely see flaps.A quarter of physicians who manage flaps screen patients for hematological conditions through past medical history or lab tests.The top three risk factors for flap failure according to surgeons were surgeon experience,medical co-morbidities or past arterial thrombosis,and thrombophilia whereas hematologists reported diabetes,smoking,and medical co-morbidities.Surgeons ranked thrombophilia as one of the top three risk factors for flap failure and the primary reason to change patient management while hematologists did not rate this in the top three risk factors or reason to change management.Half of surgeons would add an anti-thrombolytic if a patient had thrombophilia.
Fifty-four percent of physicians routinely use either unfractionated heparin(UFH) or low-molecular weight heparin(LMWH) pre-operatively.Only surgeons were involved in intra-operative management.Surgeons routinely flushed the flap with heparin(37%),used IV heparin(6%),or both(8%).There was a large diversity of management strategies if an intra-operative thrombosis occurred.Different strategies consisted of changing recipient vessels,IV UFH,flushing the flap,adding post-operative agents,or a combination of strategies.Surgeons used a range of post-operative agents such as UFH,LWMH,aspirin,and dextran while hematologists preferred LMWH.Patients who had post-operative thrombosis were more likely to receive anti-thrombolytics if technical factors were not identified.
Conclusions There currently exists a difference in opinions on risk factors for flap failure between surgeons and hematologists that would change management,especially the importance of thrombophilia.Most surgeons add an anti-thrombolytic agent if a patient had thrombophilia whereas hematologists would not change their management.The practice variation in agents used for routine flap is diverse for surgeons,with no routine protocol.In hematology,anti-thrombolytic agents are used less,with a preference for LMWH post-operatively.
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