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Open Access 01-12-2024 | Microvascular Surgery | Case report

Successful microvascular surgery in patients with thrombophilia in head and neck surgery: a case series

Authors: Julian Faber, Frank Schuster, Stefan Hartmann, Roman C. Brands, Andreas Fuchs, Anton Straub, Markus Fischer, Urs Müller-Richter, Christian Linz

Published in: Journal of Medical Case Reports | Issue 1/2024

Abstract

Background

In this case series, a perioperative anticoagulation protocol for microvascular head and neck surgery in patients with thrombophilia is presented. Microvascular free-flap surgery is a standard procedure in head and neck surgery with high success rates. Nevertheless, flap loss—which is most often caused by thrombosis—can occur and has far-reaching consequences, such as functional impairment, prolonged hospitalization, and increased costs. The risk of flap loss owing to thrombosis is significantly increased in patients with thrombophilia. Therefore, perioperative anticoagulation is mandatory. To date, no perioperative anticoagulation protocol exists for these high-risk patients.

Case presentation

We present three exemplary male Caucasian patients aged 53–57 years with free flap loss owing to an underlying, hidden thrombophilia.

Conclusion

We present a modified anticoagulation protocol for microvascular surgery in these high-risk patients, enabling successful microsurgical reconstruction.

Pohlenz P, Klatt J, Schon G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg. 2012;41:739–43.CrossRefPubMed

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;41:379–86.CrossRefPubMedPubMedCentral

Handschel J, Burghardt S, Naujoks C, Kubler NR, Giers G. Parameters predicting complications in flap surgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115:589–94.CrossRefPubMed

Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H, van der Velden PA, Reitsma PH. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature. 1994;369:64–7.ADSCrossRefPubMed

Dahlback B. Advances in understanding pathogenic mechanisms of thrombophilic disorders. Blood. 2008;112:19–27.CrossRefPubMed

Segers K, Dahlback B, Nicolaes GA. Coagulation factor V and thrombophilia: background and mechanisms. Thromb Haemost. 2007;98:530–42.CrossRefPubMed

Friedman T, O’Brien Coon D, Michaels VJ, Bontempo F, Young VL, Clavijo JA, Rubin JP. Hereditary coagulopathies: practical diagnosis and management for the plastic surgeon. Plast Reconstr Surg. 2010;125:1544–52.CrossRefPubMed

Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist’s perspective. Plast Reconstr Surg. 2015;136:545e–52e.CrossRefPubMed

Kotamarti VS, Shiah E, Rezak KM, Patel A, Ricci JA. Does anticoagulation improve flap outcomes in hypercoagulable patients? A systematic review. J Reconstr Microsurg. 2019. https://doi.org/10.1055/s-0039-3400531.CrossRefPubMed

10.

Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg. 2012;130:579–89.CrossRefPubMed

11.

Wang TY, Serletti JM, Cuker A, McGrath J, Low DW, Kovach SJ, Wu LC. Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg. 2012;129:443–53.CrossRefPubMed

12.

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;112:1534–9.CrossRefPubMed

13.

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. 2019. https://doi.org/10.1055/s-0039-3401846.CrossRefPubMed

14.

Kindelin NM, Anthes AM, Providence SM, Zhao X, Aspinall SL. Effectiveness of a calculation-free weight-based unfractionated heparin nomogram with anti-xa level monitoring compared with activated partial thromboplastin time. Ann Pharmacother. 2020. https://doi.org/10.1177/1060028020961503.CrossRefPubMed

15.

Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S. The weight-based heparin dosing nomogram compared with a “standard care” nomogram. A randomized controlled trial. Ann Intern Med. 1993;119:874–81.CrossRefPubMed

16.

Rivey MP, Peterson JP. Pharmacy-managed, weight-based heparin protocol. Am J Hosp Pharm. 1993;50:279–84.PubMed

17.

Shalansky KF, FitzGerald JM, Sunderji R, Traboulay SJ, O’Malley B, McCarron BI, Naiman S. Comparison of a weight-based heparin nomogram with traditional heparin dosing to achieve therapeutic anticoagulation. Pharmacotherapy. 1996;16:1076–84.CrossRefPubMed

18.

Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:188S-203S.CrossRefPubMed

19.

Sievert M, Goncalves M, Tamse R, Mueller SK, Koch M, Gostian AO, Iro H, Scherl C. Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin. Eur Arch Otorhinolaryngol. 2020. https://doi.org/10.1007/s00405-020-06219-w.CrossRefPubMedPubMedCentral

20.

Andersson LO, Barrowcliffe TW, Holmer E, Johnson EA, Sims GE. Anticoagulant properties of heparin fractionated by affinity chromatography on matrix-bound antithrombin iii and by gel filtration. Thromb Res. 1976;9:575–83.CrossRefPubMed

21.

Hirsh J. Heparin. N Engl J Med. 1991;324:1565–74.CrossRefPubMed

22.

Lam LH, Silbert JE, Rosenberg RD. The separation of active and inactive forms of heparin. Biochem Biophys Res Commun. 1976;69:570–7.CrossRefPubMed

23.

Maclean PS, Tait RC. Hereditary and acquired antithrombin deficiency: epidemiology, pathogenesis and treatment options. Drugs. 2007;67:1429–40.CrossRefPubMed

Title: Successful microvascular surgery in patients with thrombophilia in head and neck surgery: a case series
Authors: Julian Faber
Frank Schuster
Stefan Hartmann
Roman C. Brands
Andreas Fuchs
Anton Straub
Markus Fischer
Urs Müller-Richter
Christian Linz
Publication date: 01-12-2024
Publisher: BioMed Central
Keywords: Microvascular Surgery
Heparin
Enoxaparin
Thrombosis
Published in: Journal of Medical Case Reports / Issue 1/2024
Electronic ISSN: 1752-1947
DOI: https://doi.org/10.1186/s13256-024-04403-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Successful microvascular surgery in patients with thrombophilia in head and neck surgery: a case series

Abstract

Background

Case presentation

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Case presentation

Conclusion

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