Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision
Bishop JL, Vasudev M, Garcia N, Heslop G, Pham TT, Hicks MD, Chowdhury F, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM (2023) · Otolaryngology — Head and Neck Surgery (American Academy of Otolaryngology) · n=843
Perfil del estudio
- Diseño
- retrospective multicenter cohort (3 US academic centers: University of Alabama at Birmingham, University of Colorado, University of California Irvine; August 2013-July 2021) of n=843 head and neck microvascular free flaps with subgroup analysis of n=42 anastomotic-revision cases evaluating effect of perioperative antithrombotics (heparin bolus, tPA, prophylactic and therapeutic anticoagulation, antiplatelet therapy) and leech therapy on flap survival
- Tamaño de la muestra (n)
- 843
- Intervención
- Perioperative antithrombotic protocols (heparin bolus, tPA, anticoagulation, antiplatelet therapy) plus leech therapy as required in head and neck microvascular free flap reconstruction with anastomotic revision
- Comparador
- No antithrombotic therapy (within the anastomotic-revision subgroup)
- Punto final primario
- Free flap survival after anastomotic revision
- Resultado primario
- Overall free flap failure rate 4.0% (34/843); anastomotic revision rate 5.0% (42/843) with 47.6% post-revision failure rate (20/42); revision dramatically increased flap-failure risk (OR 52.68); failure rate after revision NOT significantly affected by postoperative antiplatelet, prophylactic anticoagulation, heparin bolus, tPA, or therapeutic anticoagulation
- Duración del seguimiento
- Variable across 8-year retrospective window
- PMID
- 36939436
Hallazgos clave
- 843-flap multicenter US cohort - largest contemporary dataset on antithrombotic use in head and neck flap salvage
- Anastomotic revision is the single strongest predictor of flap failure (OR 52.68)
- No antithrombotic intervention (heparin, tPA, anticoagulation, antiplatelet, leech) showed independent survival benefit after revision
- Suggests mechanical/surgical factors dominate over pharmacologic adjuncts
- Implications for cost-conscious and stewardship-aware free-flap protocols
Limitaciones
- Retrospective design with confounding by indication (sicker flaps got more interventions)
- Leech therapy use not separately analyzed in published statistics
- Small revision-subgroup numbers (n=42) limit statistical power
- 8-year window across 3 centers introduces practice-pattern heterogeneity
- Cannot establish causation
Implicaciones clínicas
Bishop 2023 provides a sobering signal that perioperative antithrombotic adjuncts — including leech therapy — do not independently improve flap survival after anastomotic revision in head and neck microsurgery. For US clinicians practicing under K040187, the data do not contraindicate leech therapy but reinforce that early surgical revision is the primary driver of salvage success and that adjunctive interventions should be selected case-by-case rather than reflexively. Consistent with the broader Rajaram 2024 and Troeltzsch 2016 systematic-review pattern.
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