Management of perioperative microvascular thrombotic complications – The use of multiagent anticoagulation algorithm in 395 consecutive free flaps

Summary Background Thrombotic complications remain a major barrier to successful microsurgical reconstruction, but their effective management remains controversial. Methods A retrospective review of 395 consecutive microvascular transfers was performed with the focus on treatment of thrombotic complications utilizing an algorithm, which employed multiagent anticoagulation. Results Three-hundred-ninety-five free flaps were performed in 255 patients for breast (n = 316), head and neck (n = 57), extremity (n = 16), trunk (n = 3), and pelvis (n = 3) defects that were oncologic in 95.2% and irradiated in 33.4% of cases. Patients with a hypercoagulable history (8 of 9) and intraoperative thrombosis (16 of 16) were anticoagulated without developing postoperative thrombotic events. The hematoma exploration rate among the patients anticoagulated during the initial free flap procedure was 27%. Twenty four (9.4%) patient were returned to the operating room postoperatively for threatened free flaps: 6 had non-microvascular issues and 18 (7.1%) patients underwent microsurgical explorations. Fourteen (5.5%) patients had 15 postoperative free flap thrombotic events in 14 free flaps, of which 12 flaps were successfully salvaged with a combination of flap intra-arterial (n = 15), subcutaneous/intramuscular (n = 6), and intravenous (n = 3) tissue plasminogen activator ( t PA), microvascular explorations (n = 20), and therapeutic multiagent anticoagulation/antiplatelet therapy (n = 17); none had a hematoma of the reconstructed site. Two free flaps were lost to arterial thrombosis, with an overall microvascular salvage rate of 89% and a free flap success rate of 99.5%. Conclusions Thrombophilia uncovered by microvascular procedures can be effectively treated with anticoagulation upon discovery and prevent postoperative free flap thrombotic events. High free flap salvage can be achieved with the early intervention combined with thrombolysis and multiagent anticoagulation and antiplatelet therapy.