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J Reconstr Microsurg 2020; 36(03): e5
DOI: 10.1055/s-0041-1723818
Letter to the Editor

Risks of Free Tissue Transfer in the Hypocoaguable Patient

Katherine D. Reuter‡   *
1   Department of Surgery, Division of Plastic and Reconstructive Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
,
Peter J. Nicksic‡   *
2   Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
,
Samuel O. Poore 
2   Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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We read with great interest the excellent paper by Kotamarti et al, “Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review,” which highlighted the risk of late thrombosis for free flap patients with hypercoaguabilities.[1] When a patient with Quebec bleeding disorder presented to our plastic surgery clinic seeking elective microsurgical breast reconstruction with deep inferior epigastric perforator flaps, we conducted a systematic literature review with the intent of determining if hypocoaguable bleeding disorders affect outcomes in free tissue transfer (FTT).

In accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol, the MEDLINE database was queried for a comprehensive list of relevant search terms without publication date restriction. Search terms included combinations of “coagulopathy AND free tissue transfer” and “bleeding disorders AND microsurgery.” Inclusion criteria included human studies of FTT with described outcomes in patients with acquired or congenital coagulopathies. Exclusion criteria were animal studies and studies unavailable in English. Ninety-five potential articles were identified, which after title/abstract screen yielded 24 records. These records were read and analyzed in full by two authors (K.R. and P.N.), and seven studies, all case reports, met criteria for inclusion in the review.[2] [3] [4] [5] [6] [7] [8]

There were seven free flaps performed in patients with hypocoaguable disorders. Diseases included hemophilia A and B, factor-XIII deficiency, and the von Wildebrand disease type I. The most common indication for reconstruction was lower extremity salvage in four cases (57.1%).[2] [3] [4] [7] Zero cases of flap loss were described but two cases (28.6%) described postoperative bleeding complications.[3] [7] One case required reoperation.[7] Seven unique regimens of antihemophilic agents, including recombinant factor VIII,[2] [7] factor IX,[4] [8] fibrogammin,[2] desmopressin (DDAVP),[6] and aminocaproic acid,[8] were presented. While these data demonstrate that FTT may be performed safely in patients with coagulopathies with the aid of recombinant clotting factors, there is a risk of increased postoperative bleeding. Further, there is a lack of clear guidelines to aid clinical decision-making, including the timing and dosing of pharmaceutical agents. As such, larger (possibly multicenter) studies are needed to better determine the risk of complications for this complicated patient population needing free tissue transfer.

* These authors contributed equally to this article.




Publication History

Received: 25 November 2020

Accepted: 21 December 2020

Article published online:
06 February 2021

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