Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching
Background Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis.
Methods The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications.
Results A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications.
Conclusion Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.
The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
Received: 07 May 2020
Accepted: 26 July 2020
06 September 2020 (online)
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Atisha DM, Tessiatore KM, Rushing CN, Dayicioglu D, Pusic A, Hwang S. A national snapshot of patient-reported outcomes comparing types of abdominal flaps for breast reconstruction. Plast Reconstr Surg 2019; 143 (03) 667-677
- 2 Khajuria A, Smith OJ, Prokopenko M, Greenfield M, Mosahebi A. Protocol for a systematic review and meta-analysis on the clinical outcomes and cost of deep inferior epigastric perforator (DIEP) flap versus implants for breast reconstruction. Syst Rev 2017; 6 (01) 232
- 3 Kankam HKN, Hourston GJM, Fopp LJ. , et al. Trends in post-mastectomy breast reconstruction types at a breast cancer tertiary referral centre before and after introduction of acellular dermal matrices. J Plast Reconstr Aesthet Surg 2018; 71 (01) 21-27
- 4 Fischer JP, Nelson JA, Sieber B. , et al. Transfusions in autologous breast reconstructions: an analysis of risk factors, complications, and cost. Ann Plast Surg 2014; 72 (05) 566-571
- 5 Bosboom JJ, Klanderman RB, Migdady Y. , et al. Transfusion-associated circulatory overload: a clinical perspective. Transfus Med Rev 2019; 33 (02) 69-77
- 6 Semple JW, Rebetz J, Kapur R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood 2019; 133 (17) 1840-1853
- 7 Goel R, Tobian AAR, Shaz BH. Noninfectious transfusion-associated adverse events and their mitigation strategies. Blood 2019; 133 (17) 1831-1839
- 8 Norris PJ, Schechtman K, Inglis HC. , et al. Influence of blood storage age on immune and coagulation parameters in critically ill transfused patients. Transfusion 2019; 59 (04) 1223-1232
- 9 Spinella PC, Sniecinski RM, Trachtenberg F. , et al. Effects of blood storage age on immune, coagulation, and nitric oxide parameters in transfused patients undergoing cardiac surgery. Transfusion 2019; 59 (04) 1209-1222
- 10 Yoshida T, Prudent M, D'alessandro A. Red blood cell storage lesion: causes and potential clinical consequences. Blood Transfus 2019; 17 (01) 27-52
- 11 Koch CG, Duncan AI, Figueroa P. , et al. Real Age: red blood cell aging during storage. Ann Thorac Surg 2019; 107 (03) 973-980
- 12 Cornejo A, Ivatury S, Crane CN, Myers JG, Wang HT. Analysis of free flap complications and utilization of intensive care unit monitoring. J Reconstr Microsurg 2013; 29 (07) 473-479
- 13 Zoccali G, Molina A, Farhadi J. Is long-term post-operative monitoring of microsurgical flaps still necessary?. J Plast Reconstr Aesthet Surg 2017; 70 (08) 996-1000
- 14 Mlodinow AS, Ver Halen JP, Rambachan A, Gaido J, Kim JYS. Anemia is not a predictor of free flap failure: a review of NSQIP data. Microsurgery 2013; 33 (06) 432-438
- 15 O'Neill AC, Barandun M, Cha J, Zhong T, Hofer SOP. Restrictive use of perioperative blood transfusion does not increase complication rates in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (08) 1092-1096
- 16 Nelson JA, Fischer JP, Grover R. , et al. The impact of anemia on microsurgical breast reconstruction complications and outcomes. Microsurgery 2014; 34 (04) 261-270
- 17 Ydy LRA, Slhessarenko N, de Aguilar-Nascimento JE. Effect of perioperative allogeneic red blood cell transfusion on the immune-inflammatory response after colorectal cancer resection. World J Surg 2007; 31 (10) 2044-2051
- 18 The Lancet Haematology. Updates on blood transfusion guidelines. Lancet Haematol 2016; 3 (12) e547
- 19 Fischer JP, Nelson JA, Mirzabeigi MN, Serletti JM, Kanchwala S. Perioperative hemodynamics in free flap breast reconstruction: incidence, predictors, and management of tachycardia. Ann Plast Surg 2012; 69 (04) 356-360
- 20 Appleton SE, Ngan A, Kent B, Morris SF. Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 127 (05) 1773-1782
- 21 Sultan SM, Jackson DS, Erhard HA. , et al. Risk factors for postoperative venous thromboembolic complications after microsurgical breast reconstruction. J Reconstr Microsurg 2018; 34 (04) 227-234
- 22 Kim BD, Ver Halen JP, Mlodinow AS, Kim JYS. Intraoperative transfusion of packed red blood cells in microvascular free tissue transfer patients: assessment of 30-day morbidity using the NSQIP dataset. J Reconstr Microsurg 2014; 30 (02) 103-114
- 23 Zhao EH, Nishimori K, Brady J. , et al. Analysis of risk factors for unplanned reoperation following free flap surgery of the head and neck. Laryngoscope 2018; 128 (12) 2790-2795
- 24 Puram SV, Yarlagadda BB, Sethi R. , et al. Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. Otolaryngol Head Neck Surg 2015; 152 (03) 449-457
- 25 Rossmiller SR, Cannady SB, Ghanem TA, Wax MK. Transfusion criteria in free flap surgery. Otolaryngol Head Neck Surg 2010; 142 (03) 359-364
- 26 Szakmany T, Dodd M, Dempsey GA. , et al. The influence of allogenic blood transfusion in patients having free-flap primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Cancer 2006; 94 (05) 647-653
- 27 Sanati-Mehrizy P, Massenburg BB, Rozehnal JM, Ingargiola MJ, Hernandez Rosa J, Taub PJ. Risk factors leading to free flap failure: analysis from the National Surgical Quality Improvement Program Database. J Craniofac Surg 2016; 27 (08) 1956-1964
- 28 Cepeda MS, Boston R, Farrar JT, Strom BL. Comparison of logistic regression versus propensity score when the number of events is low and there are multiple confounders. Am J Epidemiol 2003; 158 (03) 280-287
- 29 Magno-Padron DA, Collier W, Kim J, Agarwal JP, Kwok AC. A nationwide analysis of early and late readmissions following free tissue transfer for breast reconstruction. J Reconstr Microsurg 2020; 36 (06) 450-457
- 30 Kwok AC, Edwards K, Donato DP. , et al. Operative time and flap failure in unilateral and bilateral free flap breast reconstruction. J Reconstr Microsurg 2018; 34 (06) 428-435
- 31 Qiu CS, Jordan SW, Dorfman RG, Vu MM, Alghoul MS, Kim JYS. Surgical duration impacts venous thromboembolism risk in microsurgical breast reconstruction. J Reconstr Microsurg 2018; 34 (01) 47-58
- 32 Lee H-K, Kim D-H, Jin US, Jeon YT, Hwang JW, Park HP. Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction. Microsurgery 2014; 34 (06) 434-438