Preoperative Deep and Superficial Venous Thrombosis in Limb Salvage Candidates: A Contraindication to Microsurgical Free Flap Reconstruction? Lessons Learned from Our 13-year Institutional Experience

Although arterial inflow considerations dominate microsurgical planning, venous outflow is equally vital for flap survival. Patients requiring free tissue transfer (FTT) for lower extremity (LE) reconstruction frequently present with occult preoperative venous thrombosis (VT), yet there are little data guiding perioperative management in this setting. This study examines the prevalence and clinical characteristics of patients with preoperative venous thrombosis (VT) undergoing LE FTT, as well as postoperative outcomes, to evaluate the feasibility of successful microsurgery in this high-risk cohort.A retrospective review of patients with preoperative VT undergoing LE FTT at a single institution was conducted.Among 279 patients, 43 (15.4%) were positive for VT. The overall deep VT (DVT) incidence in this population was 5.7% (n = 16/279) and the superficial VT (SVT) incidence was 10.0% (n = 28/279). Most thromboses were chronic (67.8%). There were two cases of takeback (4.7%) due to thrombosis (one arterial and one venous), of which one flap was salvaged. By a median follow-up duration of 9.7 months, a limb salvage rate of 88.4% was achieved.Preoperative VT is common in microsurgical candidates for limb salvage; however, it is not a contraindication to FTT if proper adjustments are made perioperatively. Considerations include (1) routine use of venous ultrasound to identify VT; (2) perioperative anticoagulation management, including IVC filter placement when indicated; (3) selection of recipient veins that are unaffected by VT; (4) prioritizing the use of two deep veins for anastomosis when feasible; and (5) incorporating implantable devices to monitor venous outflow.

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Among 279 patients undergoing lower-extremity free tissue transfer, 43 (15.4%) had preoperative venous thrombosis; with adjusted perioperative management, only two takebacks occurred and limb salvage reached 88.4%, suggesting preoperative VT is not a contraindication.

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