Free tissue transfer in the hypercoagulable patient: A review of 58 flaps

Background: Hypercoagulability or thrombophilia is a group of inherited or acquired conditions associated with a predisposition to thrombosis. Most hypercoagulable states alter the blood itself or affect the vasculature, directly creating a detrimental environment for microsurgery. The authors present their series of hypercoagulable patients who underwent free flap reconstruction. Methods: A retrospective review was conducted of all free flaps performed between January 1, 2005, and October 1, 2010, at the University of Pennsylvania. A total of 2032 flaps were performed. Forty-one patients or 58 free flaps (2.9 percent) were identified as having a diagnosed thrombophilia or previous thromboembolic event. Results: Of the 41 patients, 36 were women and five were men. Diagnosis included factor V Leiden mutation, protein C deficiency, hyperhomocysteinemia, antiphospholipid antibody syndrome, prothrombin gene mutation, factor VIII elevation, anticardiolipin antibody syndrome, and essential thrombocytosis. The group of patients with prior thrombotic events (many with concomitant events and diagnoses) included deep vein thrombosis, pulmonary embolus, myocardial infarction before the age of 50, and embolic stroke. Twelve patients (29.3 percent) were actively followed by a hematologist. The rate of thrombosis was 20.7 percent (12 flaps), including those occurring intraoperatively. The salvage rate for a postoperative thrombosed flap in this group was 0 percent. The flap loss rate was 15.5 percent. Conclusions: Although hypercoagulability produces an unfavorable condition for microvascular reconstruction, free tissue transfer is feasible. In this series, the authors had an 80 percent success rate. Collaboration with a hematologist may be helpful. In this group, flap thrombosis seems to occur in the delayed period. Even with operative reexploration, salvage rates have not been promising.