Download PDF
J Reconstr Microsurg 2023; 39(09): 705-714
DOI: 10.1055/a-2040-1532
Original Article

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Shannon S. Wu 
1   Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Charles Raymer
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Rachel Schafer
1   Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
August Culbert
1   Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Steven Bernard
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Risal Djohan
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Graham Schwarz
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Sarah N. Bishop
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Raffi Gurunian
3   Department of Plastic Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction.

Methods This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE.

Results This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1–30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46–252.76, p < 0.001).

Conclusion In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Keywords

breast reconstruction - Caprini score - deep inferior epigastric perforator - deep venous thrombosis - venous thromboembolism

Presented at: Accepted for podium presentation at American Society of Plastic Surgeons Plastic Surgery The Meeting, Oct 27-30, 2022. Boston, MA.


Note

This study was accepted for podium presentation at the American Society of Plastic Surgeons Plastic Surgery Meeting, Oct 27–30, 2022, Boston, MA.




Publication History

Received: 06 September 2022

Accepted: 08 January 2023

Accepted Manuscript online:
21 February 2023

Article published online:
22 March 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Yueh JH, Slavin SA, Adesiyun T. et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (06) 1585-1595
    CrossrefPubMedGoogle Scholar
  • 2 Enajat M, Damen THC, Geenen A, Timman R, van der Hulst RRWJ, Mureau MAM. Pulmonary embolism after abdominal flap breast reconstruction: prediction and prevention. Plast Reconstr Surg 2013; 131 (06) 1213-1222
    CrossrefPubMedGoogle Scholar
  • 3 Cubitt J, Barber Z, Khan AA, Tyler M. Breast reconstruction with deep inferior epigastric perforator flaps. Ann R Coll Surg Engl 2012; 94 (08) 552-558
    CrossrefPubMedGoogle Scholar
  • 4 Lemaine V, McCarthy C, Kaplan K. et al. Venous thromboembolism following microsurgical breast reconstruction: an objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis. Plast Reconstr Surg 2011; 127 (04) 1399-1406
    CrossrefPubMedGoogle Scholar
  • 5 Pannucci CJ, Chang EY, Wilkins EG. Venous thromboembolic disease in autogenous breast reconstruction. Ann Plast Surg 2009; 63 (01) 34-38
    CrossrefPubMedGoogle Scholar
  • 6 Guerra AB, Metzinger SE, Bidros RS. et al. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. Ann Plast Surg 2004; 52 (03) 246-252
    CrossrefPubMedGoogle Scholar
  • 7 Hamdi M, Blondeel P, Van Landuyt K, Tondu T, Monstrey S. Bilateral autogenous breast reconstruction using perforator free flaps: a single center's experience. Plast Reconstr Surg 2004; 114 (01) 83-89
    CrossrefPubMedGoogle Scholar
  • 8 Agnelli G, Bolis G, Capussotti L. et al. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project. Ann Surg 2006; 243 (01) 89-95
    CrossrefPubMedGoogle Scholar
  • 9 Modarressi A, Schettini A-V, Rüegg EM, Pittet-Cuénod B. Venous thromboembolism events after breast reconstructions with DIEP free flaps in 192 consecutive case. Ann Chir Plast Esthet 2018; 63 (01) 11-19
    CrossrefPubMedGoogle Scholar
  • 10 McKean AR, Knox J, Harris P, Ramsey K, James S, Power KT. Audit of venous thromboembolism in DIEP free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2017; 70 (07) 970-972
    CrossrefPubMedGoogle Scholar
  • 11 Momeni A, Sorice SC, Li AY, Nguyen DH, Pannucci C. Breast reconstruction with free abdominal flaps is associated with persistent lower extremity venous stasis. Plast Reconstr Surg 2019; 143 (06) 1144e-1150e
    CrossrefPubMedGoogle Scholar
  • 12 Momeni A, Tecce MG, Lanni MA. et al. Increased lower extremity venous stasis may contribute to deep venous thrombosis formation after microsurgical breast reconstruction---an ultrasonographic study. J Reconstr Microsurg 2017; 33 (03) 173-178
    PubMedGoogle Scholar
  • 13 McDonald CC, Alexander FE, Whyte BW, Forrest AP, Stewart HJ. The Scottish Cancer Trials Breast Group. Cardiac and vascular morbidity in women receiving adjuvant tamoxifen for breast cancer in a randomised trial. BMJ 1995; 311 (7011): 977-980
    CrossrefPubMedGoogle Scholar
  • 14 Baum M, Budzar AU, Cuzick J. et al; ATAC Trialists' Group. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet 2002; 359 (9324): 2131-2139
    CrossrefPubMedGoogle Scholar
  • 15 Chew HK, Wun T, Harvey DJ, Zhou H, White RH. Incidence of venous thromboembolism and the impact on survival in breast cancer patients. J Clin Oncol 2007; 25 (01) 70-76
    CrossrefPubMedGoogle Scholar
  • 16 Patiar S, Kirwan CC, McDowell G, Bundred NJ, McCollum CN, Byrne GJ. Prevention of venous thromboembolism in surgical patients with breast cancer. Br J Surg 2007; 94 (04) 412-420
    CrossrefPubMedGoogle Scholar
  • 17 Khan UT, Walker AJ, Baig S, Card TR, Kirwan CC, Grainge MJ. Venous thromboembolism and mortality in breast cancer: cohort study with systematic review and meta-analysis. BMC Cancer 2017; 17 (01) 747
    CrossrefPubMedGoogle Scholar
  • 18 Pannucci CJ, Swistun L, MacDonald JK, Henke PK, Brooke BS. Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis. Ann Surg 2017; 265 (06) 1094-1103
    CrossrefPubMedGoogle Scholar
  • 19 Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005; 51 (2-3): 70-78
    CrossrefPubMedGoogle Scholar
  • 20 Pannucci CJ, Bailey SH, Dreszer G. et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg 2011; 212 (01) 105-112
    CrossrefPubMedGoogle Scholar
  • 21 Zarb RM, Ramamurthi A, Doren EL, LoGiudice JA, Hijjawi JB, Adamson KA. Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: a case series. J Plast Reconstr Aesthet Surg 2021; 74 (10) 2550-2556
    CrossrefPubMedGoogle Scholar
  • 22 Rochlin DH, Sheckter CC, Pannucci C, Momeni A. Venous thromboembolism following microsurgical breast reconstruction: a longitudinal analysis of 12,778 patients. Plast Reconstr Surg 2020; 146 (03) 465-473
    CrossrefPubMedGoogle Scholar
  • 23 Kim NE, Conway-Pearson L, Kavanah M. et al. Standardized risk assessment and risk-stratified venous thromboembolism prophylaxis for patients undergoing breast operation. J Am Coll Surg 2020; 230 (06) 947-955
    CrossrefPubMedGoogle Scholar
  • 24 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 American Society of Breast Surgeons. Consensus Guideline on Venous Thromboembolism (VTE) Prophylaxis for Patients Undergoing Breast Operations.; 2016. Accessed March 3, 2023 at: https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Venous-Thromboembolism-VTE-Prophylaxis-for-Patients-Undergoing-Breast-Operations.pdf
    PubMedGoogle Scholar
  • 26 Shoeb M, Fang MC. Assessing bleeding risk in patients taking anticoagulants. J Thromb Thrombolysis 2013; 35 (03) 312-319
    CrossrefPubMedGoogle Scholar
  • 27 Salomon B, Dasa V, Krause PC, Hall L, Chapple AG. Hospital length of stay is associated with increased likelihood for venous thromboembolism after total joint arthroplasty. Arthroplast Today 2021; 8: 254-257.e1
    CrossrefPubMedGoogle Scholar
  • 28 Kearon C. Duration of venous thromboembolism prophylaxis after surgery. Chest 2003; 124 (6, Suppl): 386S-392S
    CrossrefPubMedGoogle Scholar
  • 29 Pittelkow EM, DeBrock WC, Mailey B. et al. Evaluation of an extended-duration chemoprophylaxis regimen for venous thromboembolism after microsurgical breast reconstruction. Plast Reconstr Surg Glob Open 2021; 9 (08) e3741
    CrossrefPubMedGoogle Scholar
  • 30 Huang H, Bernstein JL, Otterburn DM. Prolonged venous thromboembolism prophylaxis may not be necessary for DIEP flap breast reconstruction: a tertiary center's 10-year experience. J Reconstr Microsurg 2022; 38 (08) 647-653
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Huo MH, Muntz J. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review. Clin Ther 2009; 31 (06) 1129-1141
    CrossrefPubMedGoogle Scholar
  • 32 Murphy R, Schmitz D, Rosolowski K. Evidence-based practices for thromboembolism prevention: a report from the asps venous thromboembolism task force approved by ASPS Executive Committee: July 2011; 2011.
    PubMed
  • 33 Pannucci CJ, MacDonald JK, Ariyan S. et al. Benefits and risks of prophylaxis for deep venous thrombosis and pulmonary embolus in plastic surgery: a systematic review and meta-analysis of controlled trials and consensus conference. Plast Reconstr Surg 2016; 137 (02) 709-730
    CrossrefPubMedGoogle Scholar
  • 34 Rowan BO, Kuhl DA, Lee MD, Tichansky DS, Madan AK. Anti-Xa levels in bariatric surgery patients receiving prophylactic enoxaparin. Obes Surg 2008; 18 (02) 162-166
    CrossrefPubMedGoogle Scholar
  • 35 Karas LA, Nor Hanipah Z, Cetin D. et al. Assessment of empiric body mass index-based thromboprophylactic dosing of enoxaparin after bariatric surgery: evidence for dosage adjustment using anti-factor Xa in high-risk patients. Surg Obes Relat Dis 2021; 17 (01) 153-160
    CrossrefPubMedGoogle Scholar
  • 36 Pannucci CJ, Fleming KI, Varghese Jr TK. et al. Low anti-factor Xa level predicts 90-day symptomatic venous thromboembolism in surgical patients receiving enoxaparin prophylaxis: a pooled analysis of eight clinical trials. Ann Surg 2022; 276 (06) e682-e690
    CrossrefPubMedGoogle Scholar
  • 37 Ambani SW, Bengur FB, Varelas LJ. et al. Standard fixed enoxaparin dosing for venous thromboembolism prophylaxis leads to low peak anti-factor Xa levels in both head and neck and breast free flap patients. J Reconstr Microsurg 2022; 38 (09) 749-756
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Bertolaccini CM, Prazak AMB, Goodwin IA. et al. Prevention of venous thromboembolism in microvascular surgery patients using weight-based unfractionated heparin infusions. J Reconstr Microsurg 2022; 38 (05) 395-401
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Bertolaccini CM, Prazak AMB, Agarwal J, Goodwin IA, Rockwell WB, Pannucci CJ. Adequacy of fixed-dose heparin infusions for venous thromboembolism prevention after microsurgical procedures. J Reconstr Microsurg 2018; 34 (09) 729-734
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Matthay ZA, Flanagan CP, Sanders K. et al. Risk factors for venous thromboembolism after vascular surgery and implications for chemoprophylaxis strategies. J Vasc Surg Venous Lymphat Disord 2022; 10 (03) 585-593.e2
    CrossrefPubMedGoogle Scholar
  • 41 Holcomb CN, DeRussy A, Richman JS, Hawn MT. Association between inpatient surveillance and venous thromboembolism rates after hospital discharge. JAMA Surg 2015; 150 (06) 520-527
    CrossrefPubMedGoogle Scholar
  • 42 Najjar PA, Madenci AL, Zogg CK. et al. Implementation of a comprehensive post-discharge venous thromboembolism prophylaxis program for abdominal and pelvic surgery patients. J Am Coll Surg 2016; 223 (06) 804-813
    CrossrefPubMedGoogle Scholar
  • 43 Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care 2014; 18 (05) 518
    CrossrefPubMedGoogle Scholar
  • 44 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
    CrossrefPubMedGoogle Scholar
  • 45 Zavlin D, Chegireddy V, Jubbal KT, Agrawal NA, Spiegel AJ. Management of microsurgical patients using intraoperative unfractionated heparin and thromboelastography. J Reconstr Microsurg 2019; 35 (03) 198-208
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Rydén L, Heibert Arnlind M, Vitols S, Höistad M, Ahlgren J. Aromatase inhibitors alone or sequentially combined with tamoxifen in postmenopausal early breast cancer compared with tamoxifen or placebo---meta-analyses on efficacy and adverse events based on randomized clinical trials. Breast 2016; 26: 106-114
    CrossrefPubMedGoogle Scholar
  • 47 Cuzick J, Forbes J, Edwards R. et al; IBIS investigators. First results from the International Breast Cancer Intervention Study (IBIS-I): a randomised prevention trial. Lancet 2002; 360 (9336): 817-824
    CrossrefPubMedGoogle Scholar
  • 48 Fisher B, Costantino JP, Wickerham DL. et al. Tamoxifen for the prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst 2005; 97 (22) 1652-1662
    CrossrefPubMedGoogle Scholar
  • 49 Mirzabeigi MN, Nelson JA, Fischer JP. et al. Tamoxifen (selective estrogen-receptor modulators) and aromatase inhibitors as potential perioperative thrombotic risk factors in free flap breast reconstruction. Plast Reconstr Surg 2015; 135 (04) 670e-679e
    CrossrefPubMedGoogle Scholar
  • 50 Salibian AA, Bokarius AV, Gu J. et al. The effects of perioperative tamoxifen therapy on microvascular flap complications in transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2016; 77 (06) 630-634
    CrossrefPubMedGoogle Scholar
  • 51 Tran BNN, Ruan QZ, Cohen JB. et al. Does hormone therapy use increase perioperative complications in abdominally based microsurgical breast reconstruction?. Plast Reconstr Surg 2018; 141 (06) 805e-813e
    CrossrefPubMedGoogle Scholar
  • 52 Spera LJ, Cook JA, Dolejs S, Fisher C, Lester ME, Hassanein AH. Perioperative use of antiestrogen therapies in breast reconstruction: a systematic review and treatment recommendations. Ann Plast Surg 2020; 85 (04) 448-455
    CrossrefPubMedGoogle Scholar
  • 53 Billon R, Bosc R, Belkacemi Y. et al. Impact of adjuvant anti-estrogen therapies (tamoxifen and aromatase inhibitors) on perioperative outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg 2017; 70 (11) 1495-1504
    CrossrefPubMedGoogle Scholar
  • 54 Nicola A, Crowley M, See M. A novel algorithm to reduce VTE in peri-operative patients on tamoxifen. Breast 2021; 58: 88-92
    CrossrefPubMedGoogle Scholar
  • 55 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 56 Kim JYS, Khavanin N, Rambachan A. et al. Surgical duration and risk of venous thromboembolism. JAMA Surg 2015; 150 (02) 110-117
    CrossrefPubMedGoogle Scholar
  • 57 Nwaogu I, Yan Y, Margenthaler JA, Myckatyn TM. Venous thromboembolism after breast reconstruction in patients undergoing breast surgery: an American College of Surgeons NSQIP Analysis. J Am Coll Surg 2015; 220 (05) 886-893
    CrossrefPubMedGoogle Scholar
  • 58 Fischer JP, Wes AM, Tuggle CT, Wu LC. Venous thromboembolism risk in mastectomy and immediate breast reconstruction: analysis of the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets. Plast Reconstr Surg 2014; 133 (03) 263e-273e
    CrossrefPubMedGoogle Scholar
  • 59 Masoomi H, Paydar KZ, Wirth GA, Aly A, Kobayashi MR, Evans GRD. Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery. Ann Plast Surg 2014; 72 (01) 30-33
    CrossrefPubMedGoogle Scholar