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J Reconstr Microsurg 2020; 36(08): 549-555
DOI: 10.1055/s-0040-1710553
Original Article

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

Kaushik P. Venkatesh   *
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Shoshana W. Ambani   *
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
2   Department of Plastic Surgery, Henry Ford Allegiance Health System, Jackson, Michigan
,
Aris R.L. Arakelians
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Jonas T. Johnson
3   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Mario G. Solari
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
3   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Funding None.
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Abstract

Background Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States.

Methods An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link.

Results There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1–190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases.

Conclusion The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.

Keywords

survey - free flap - venous thromboembolism

Note

Preliminary results were presented as a podium presentation at the 63th Annual Robert H. Ivy Pennsylvania Plastic Surgery Society Meeting, in Philadelphia, PA, April 2017, and as a poster at the 60th Annual Meeting of the Ohio Valley Society of Plastic Surgeons, in Pittsburgh, PA, June 2017. This manuscript presents our final data and analysis.


Ethical Considerations

This study was approved by the University of Pittsburgh Institutional Review Board and was performed in accordance with the principles set forth in the Declaration of Helsinki.


* These authors acted as co-first authors.




Publikationsverlauf

Eingereicht: 08. Februar 2020

Angenommen: 11. April 2020

Artikel online veröffentlicht:
14. Mai 2020

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Geerts WH, Bergqvist D, Pineo GF. , et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (06) 381S-453S
    CrossrefPubMedSuche in Google Scholar
  • 2 Pengo V, Lensing AWA, Prins MH. , et al; Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350 (22) 2257-2264
    CrossrefPubMedSuche in Google Scholar
  • 3 Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107 (23) (Suppl. 01) I22-I30
    PubMedSuche in Google Scholar
  • 4 National Quality Forum Press Release. Available at: http://www.qualityforum.org . Accessed July 23, 2018
    PubMed
  • 5 The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. 2008 . Available at: http://www.surgeongeneral.gov/library/calls/index.html . Accessed July 11, 2019
    PubMedSuche in Google Scholar
  • 6 Pannucci CJ, Jaber RM, Zumsteg JM, Golgotiu V, Spratke LM, Wilkins EG. Changing practice: implementation of a venous thromboembolism prophylaxis protocol at an academic medical center. Plast Reconstr Surg 2011; 128 (05) 1085-1092
    CrossrefPubMedSuche in Google Scholar
  • 7 Clayburgh DR, Stott W, Cordiero T. , et al. Prospective study of venous thromboembolism in patients with head and neck cancer after surgery. JAMA Otolaryngol Head Neck Surg 2013; 139 (11) 1143-1150
    CrossrefPubMedSuche in Google Scholar
  • 8 Kakei Y, Akashi M, Hasegawa T, Minamikawa T, Usami S, Komori T. Incidence of venous thromboembolism after oral oncologic surgery with simultaneous reconstruction. J Oral Maxillofac Surg 2016; 74 (01) 212-217
    CrossrefPubMedSuche in Google Scholar
  • 9 Thai L, McCarn K, Stott W. , et al. Venous thromboembolism in patients with head and neck cancer after surgery. Head Neck 2013; 35 (01) 4-9
    CrossrefPubMedSuche in Google Scholar
  • 10 Yarlagadda BB, Brook CD, Stein DJ, Jalisi S. Venous thromboembolism in otolaryngology surgical inpatients receiving chemoprophylaxis. Head Neck 2014; 36 (08) 1087-1093
    CrossrefPubMedSuche in Google Scholar
  • 11 Ricci JA, Crawford K, Ho OA, Lee BT, Patel KM, Iorio ML. Practical guidelines for venous thromboembolism prophylaxis in free tissue transfer. Plast Reconstr Surg 2016; 138 (05) 1120-1131
    CrossrefPubMedSuche in Google Scholar
  • 12 Chen CM, Disa JJ, Cordeiro PG, Pusic AL, McCarthy CM, Mehrara BJ. The incidence of venous thromboembolism after oncologic head and neck reconstruction. Ann Plast Surg 2008; 60 (05) 476-479
    CrossrefPubMedSuche in Google Scholar
  • 13 Garritano FG, Lehman EB, Andrews GA. Incidence of venous thromboembolism in otolaryngology-head and neck surgery. JAMA Otolaryngol Head Neck Surg 2013; 139 (01) 21-27
    CrossrefPubMedSuche in Google Scholar
  • 14 Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions. Bone Joint J 2017; 99-B (11) 1420-1430
    CrossrefPubMedSuche in Google Scholar
  • 15 Garritano FG, Andrews GA. Current practices in venous thromboembolism prophylaxis in otolaryngology-head and neck surgery. Head Neck 2016; 38 (Suppl. 01) E341-E345
    CrossrefPubMedSuche in Google Scholar
  • 16 Ong HS, Gokavarapu S, Al-Qamachi L. , et al. Justification of routine venous thromboembolism prophylaxis in head and neck cancer reconstructive surgery. Head Neck 2017; 39 (12) 2450-2458
    CrossrefPubMedSuche in Google Scholar
  • 17 Jaggi R, Taylor SM, Trites J, Anderson D, MacDougall P, Hart RD. Review of thromboprophylaxis in otolaryngology-head and neck surgery. J Otolaryngol Head Neck Surg 2011; 40 (03) 261-265
    PubMedSuche in Google Scholar
  • 18 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135 (01) 290-299
    CrossrefPubMedSuche in Google Scholar
  • 19 Pannucci CJ, Oppenheimer AJ, Wilkins EG. Practice patterns in venous thromboembolism prophylaxis: a survey of 606 reconstructive breast surgeons. Ann Plast Surg 2010; 64 (06) 732-737
    CrossrefPubMedSuche in Google Scholar
  • 20 Pannucci CJ, Wachtman CF, Dreszer G. , et al. The effect of postoperative enoxaparin on risk for reoperative hematoma. Plast Reconstr Surg 2012; 129 (01) 160-168
    CrossrefPubMedSuche in Google Scholar
  • 21 Deleyiannis FWB, Clavijo-Alvarez JA, Pullikkotil B. , et al. Development of consensus guidelines for venous thromboembolism prophylaxis in patients undergoing microvascular reconstruction of the mandible. Head Neck 2011; 33 (07) 1034-1040
    CrossrefPubMedSuche in Google Scholar
  • 22 Bahl V, Shuman AG, Hu HM. , et al. Chemoprophylaxis for venous thromboembolism in otolaryngology. JAMA Otolaryngol Head Neck Surg 2014; 140 (11) 999-1005
    CrossrefPubMedSuche in Google Scholar
  • 23 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
    CrossrefPubMedSuche in Google Scholar
  • 24 Fukuiwa T, Nishimoto K, Hayashi T, Kurono Y. Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction. Auris Nasus Larynx 2008; 35 (03) 390-396
    CrossrefPubMedSuche in Google Scholar
  • 25 Chen YC, Chi CC, Chan FC, Wen YW. Low molecular weight heparin for prevention of microvascular occlusion in digital replantation. Cochrane Database Syst Rev 2013; 7 (07) CD009894
    PubMedSuche in Google Scholar
  • 26 Khouri RK, Cooley BC, Kunselman AR. , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    CrossrefPubMedSuche in Google Scholar
  • 27 Kearns MC, Baker J, Myers S, Ghanem A. Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis. Eur J Plast Surg 2018; 41 (04) 379-386
    CrossrefPubMedSuche in Google Scholar
  • 28 Spiegel JH, Polat JK. Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope 2007; 117 (03) 485-490
    CrossrefPubMedSuche in Google Scholar
  • 29 Hardin CK, Kirk WC, Pederson WC. Osmotic complications of low-molecular-weight dextran therapy in free flap surgery. Microsurgery 1992; 13 (01) 36-38
    CrossrefPubMedSuche in Google Scholar
  • 30 Kaplan AI, Sabin S. Dextran 40: another cause of drug-induced noncardiogenic pulmonary edema. Chest 1975; 68 (03) 376-377
    CrossrefPubMedSuche in Google Scholar
  • 31 Disa JJ, Polvora VP, Pusic AL, Singh B, Cordeiro PG. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks? A prospective randomized analysis. Plast Reconstr Surg 2003; 112 (06) 1534-1539
    CrossrefPubMedSuche in Google Scholar
  • 32 Jayaprasad K, Mathew J, Thankappan K. , et al. Safety and efficacy of low molecular weight dextran (dextran 40) in head and neck free flap reconstruction. J Reconstr Microsurg 2013; 29 (07) 443-448
    Thieme ConnectPubMedSuche in Google Scholar
  • 33 Sun TB, Chien SH, Lee JT, Cheng LF, Hsu LP, Chen PR. Is dextran infusion as an antithrombotic agent necessary in microvascular reconstruction of the upper aerodigestive tract?. J Reconstr Microsurg 2003; 19 (07) 463-466
    Thieme ConnectPubMedSuche in Google Scholar
  • 34 Davison SP, Massoumi W. Our complication, your problem. Plast Reconstr Surg 2007; 120 (05) 1428-1429
    CrossrefPubMedSuche in Google Scholar
  • 35 Pannucci CJ, Dreszer G, Wachtman CF. , et al. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg 2011; 128 (05) 1093-1103
    CrossrefPubMedSuche in Google Scholar
  • 36 Pugh CM, Dennis II RH, Massac EA. Evaluation of intraoperative anticoagulants in microvascular free-flap surgery. J Natl Med Assoc 1996; 88 (10) 655-657
    PubMedSuche in Google Scholar
  • 37 Broughton II G, Rios JL, Rohrich RJ, Brown SA. Deep venous thrombosis prophylaxis practice and treatment strategies among plastic surgeons: survey results. Plast Reconstr Surg 2007; 119 (01) 157-174
    CrossrefPubMedSuche in Google Scholar
  • 38 Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg 2006; 117 (06) 1797-1808
    CrossrefPubMedSuche in Google Scholar