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Known Pre-operative DVT and/or Pulmonary Embolus – To Flap or Not to Flap the Severely Injured Extremity?
Ian L. Valerio, MD, MS, MBA1; Jennifer Sabino, MD1; Reed Heckert, MD1; Scott M. Tintle, MD1; Mark Fleming, DO1; Anand Kumar, MD2;
1Walter Reed National Military Medical Center, 2University of Pittsburgh Medical Center
Introduction: Combat casualties typically present with multi-extremity wounds and amputations, pelvic and/or long-bone fractures, and massive soft tissue injuries. These patients have high Injury Severity Scores (ISS), and their concomitant injuries predispose them venous thrombolic events (VTE), deep vein thromboses (DVTs) and/or pulmonary emboli (PEs). Despite the risk of thrombotic events, the severe nature of their extremity injuries frequently necessitates flap coverage.
Methods: A retrospective review of flap procedures for war-related extremity injuries from 2003-2011 was completed. The incidence of DVT/PE was determined. For those patients requiring flap coverage with known DVT/PE, therapeutic anticoagulation was provided per accepted guidelines or standards of care. Outcomes evaluated in the DVT/PE cohort included flap and limb salvage success rates, complications such as rates of partial/total flap failure, donor and recipient site hematomas, and failed limb salvage.
Results: A total of 173 extremity flap procedures were performed (100 pedicle, 73 free flaps). Eighty-nine cases were upper extremity versus 84 lower extremity cases. Thirty-seven patients had radiographic evidence of preoperative VTE. These VTEs affected 46 flap cases, consisting of 27 free flap and 19 pedicle flap cases, respectively. Upper extremity cases had a higher rate of confirmed preoperative DVT/ PE than lower extremity cases (29.2 versus 23.8%). The VTE was proximal to the flap in 7 cases. Anticoagulation therapy consisted predominantly of weight-based therapeutic LMWH in 39 cases (64.7%), IVC filter alone in 5 cases (10.8%), and heparin drip in 2 cases (4.3%). The average duration of anticoagulation therapy was 23 days (range 3-70 days) prior to flap transfer. The complication rate in VTE cases was 24%, most commonly flap or donor site hematoma. While the total complication rate was similar between the VTE and non-VTE groups (24 versus 21%, p-value 0.392), the hematoma rate was significantly different (15 versus 5%, p-value 0.040). There were no flap failures in the VTE group.
Conclusion: VTE rate in war-related casualties was high for those cases requiring extremity flap coverage. Despite preoperative VTE and risks of therapeutic anticoagulation, flap transfers were performed with high success rates and comparable complication rates between our non-VTE and our VTE extremity flap cohorts. Despite the statistically significant yet expected increased hematoma rate in the therapeutically anticoagulated VTE cohort, an increased flap failure rate was not evident. Pedicle and/or free flaps can be successfully performed in patients with preoperative DVT/PE in carefully selected and appropriately treated cases.
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