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
Характеристика исследования
- Дизайн
- 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
- Размер выборки (n)
- 843
- Вмешательство
- 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
- Компаратор
- No antithrombotic therapy (within the anastomotic-revision subgroup)
- Первичная конечная точка
- Free flap survival after anastomotic revision
- Основной результат
- 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
- Длительность наблюдения
- Variable across 8-year retrospective window
- PMID
- 36939436
Ключевые выводы
- 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
Ограничения
- 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
Клиническое значение
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.
Связанные исследования
Medicinal leech therapy in venous congestion of microsurgical flaps: a randomized comparison with heparin pinprick scarification
Merlino G, Carbone S, Servillo G, Marletta DA (2020)
Adjunctive medicinal leech therapy for venous congestion in free flaps: a German multicenter randomized trial
Lehnhardt M, Daigeler A, Behr B, Schmidt SV, Wallner C (2021)
Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review
Whitaker IS, Josty IC, Hawkins S, Azzopardi E, Naderi N, Graf J, Damaris L, Lineaweaver WC, Kon M (2011)
Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction
Pannucci CJ, Nelson JA, Chung CU, Fischer JP, Kanchwala SK, Kovach SJ, Serletti JM, Wu LC (2014)