Subscribe to RSS
Rotational Thromboelastometry Derivative Fibrinogen–Platelet Ratio Predicts Thrombosis in MicrosurgeryFunding This study was funded by Plastic Surgery Foundation, University of California San Francisco, Resource Allocation Grant Program.
Background Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability.
Methods We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR).
Results Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific.
Conclusion Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.
Keywordsthromboelastometery - microvascular thrombosis - microsurgery - coagulation - hypercoagulability
This study was presented at 2016 Meeting of the Plastic Surgery Research Council and 2017 American Society of Reconstructive Microsurgery Meeting.
* These are first coauthors.
Received: 23 June 2020
Accepted: 15 February 2021
19 May 2021 (online)
© 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
- 1 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
- 2 Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol 2009; 1: 33
- 3 Deykin D. Thrombogenesis. N Engl J Med 1967; 276 (11) 622-628
- 4 Baumeister S, Follmar KE, Zenn MR, Erdmann D, Levin LS. Strategy for reoperative free flaps after failure of a first flap. Plast Reconstr Surg 2008; 122 (03) 962-971
- 5 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
- 6 Davison SP, Kessler CM, Al-Attar A. Microvascular free flap failure caused by unrecognized hypercoagulability. Plast Reconstr Surg 2009; 124 (02) 490-495
- 7 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
- 8 Whiting D, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol 2014; 89 (02) 228-232
- 9 Wang TY, Serletti JM, Cuker A. et al. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 2012; 129 (02) 443-453
- 10 Vekris MD, Ovrenovits M, Dova L. et al. Free functional muscle transfer failure and thrombophilic gene mutations as a potential risk factor: a case report. Microsurgery 2007; 27 (02) 88-90
- 11 Kolbenschlag J, Daigeler A, Lauer S. et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery?. Microsurgery 2014; 34 (04) 253-260
- 12 Parker RJ, Eley KA, Von Kier S, Pearson O, Watt-Smith SR. Functional fibrinogen to platelet ratio using thromboelastography as a predictive parameter for thrombotic complications following free tissue transfer surgery: a preliminary study. Microsurgery 2012; 32 (07) 512-519
- 13 Chien W, Varvares MA, Hadlock T, Cheney M, Deschler DG. Effects of aspirin and low-dose heparin in head and neck reconstruction using microvascular free flaps. Laryngoscope 2005; 115 (06) 973-976
- 14 Khouri RK, Cooley BC, Kenna DM, Edstrom LE. Thrombosis of microvascular anastomoses in traumatized vessels: fibrin versus platelets. Plast Reconstr Surg 1990; 86 (01) 110-117
- 15 Kotamarti VS, Shiah E, Rezak KM, Patel A, Ricci JA. Does anticoagulation improve flap outcomes in hypercoagulable patients? A systematic review. J Reconstr Microsurg 2020; 36 (03) 204-212
- 16 Ayala C, Blackwell KE. Protein C deficiency in microvascular head and neck reconstruction. Laryngoscope 1999; 109 (2 Pt 1): 259-265
- 17 Olsson E, Höijer P. Activated protein C resistance due to factor V Leiden, elevated coagulation factor VIII and postoperative deep vein thrombosis in late breast reconstruction with a free TRAM flap: a report of two cases. Br J Plast Surg 2005; 58 (05) 720-723
- 18 Höijer P, Olsson E. Elevated coagulation factor VIII, postoperative thrombosis and flap failure in late breast reconstruction with a free TRAM flap: a case report. J Plast Reconstr Aesthet Surg 2006; 59 (01) 102-104
- 19 Herrera FA, Lee CK, Kryger G. et al. Microsurgery in the hypercoagulable patient: review of the literature. J Reconstr Microsurg 2012; 28 (05) 305-312
- 20 Nguyen TT, Egan KG, Crowe DL, Nazir N, Przylecki WH, Andrews BT. Outcomes of head and neck microvascular reconstruction in hypercoagulable patients. J Reconstr Microsurg 2020; 36 (04) 271-275
- 21 DeFazio MV, Economides JM, Anghel EL, Tefera EA, Evans KK. Lower extremity free tissue transfer in the setting of thrombophilia: analysis of perioperative anticoagulation protocols and predictors of flap failure. J Reconstr Microsurg 2019; 35 (04) 270-286
- 22 Cho EH, Bauder AR, Centkowski S. et al. Preoperative platelet count predicts lower extremity free flap thrombosis: a multi-institutional experience. Plast Reconstr Surg 2017; 139 (01) 220-230
- 23 Wikner J, Beck-Broichsitter BE, Schlesinger S. et al. Thromboelastometry: a contribution to perioperative free-flap management. J Craniomaxillofac Surg 2015; 43 (07) 1065-1071
- 24 Ekin Y, Günüşen İ, Özdemir OY, Tiftikçioğlu YO. Effect of coagulation status and co-morbidity on flap success and complications in patients with reconstructed free flap. Turk J Anaesthesiol Reanim 2019; 47 (02) 98-106