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Pamulapati S, Conroy M, Madireddy S, Kamaraju S, Cortina C, Moore H, Hartmann J. Applications of Viscoelastic Testing in Breast Cancer Patients: A Systematic Review Focusing on Hypercoagulability and Free Flap Thrombosis. Semin Thromb Hemost 2024; 50:413-422. [PMID: 37327882 DOI: 10.1055/s-0043-1769937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Viscoelastic testing is a clinically available method to assess hypercoagulability. This systematic review aims to provide a comprehensive overview of the existing literature and the potential use of such testing in patients with breast cancer. A systematic literature search for studies investigating the application of viscoelastic testing for patients with breast cancer was conducted. Studies were included as long as they were original, peer-reviewed, and in the English language. Studies were excluded if they were review articles, did not include breast cancer patients, or if the full text was unavailable. This review identified 10 articles that met the inclusion criteria. Two of the studies utilized rotational thromboelastometry, and an additional four studies used thromboelastography, to assess hypercoagulability in patients with breast cancer. Three of the identified articles discussed the use of thromboelastometry in free flap breast reconstruction for patients with breast cancer. One study was a retrospective chart review looking at thromboelastography and microsurgical breast reconstruction. Current literature regarding the application of viscoelastic testing in breast cancer and free flap breast reconstruction is limited, with no randomized trials thus far. However, some studies suggest that there may be potential utility in viscoelastic testing to assess risk for thromboembolism in breast cancer patients, and future research in this area is warranted.
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Affiliation(s)
| | | | | | - Sailaja Kamaraju
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Chandler Cortina
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hunter Moore
- Division of Surgery-Transplant, University of Colorado School of Medicine, Aurora, Colorado
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Marsee MK, Shariff FS, Wiarda G, Watson PJ, Sualeh AH, Brenner TJ, McCoy ML, Al-Fadhl HD, Jones AJ, Davis PK, Zimmer D, Folsom C. Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review. J Clin Med 2022; 11:jcm11041119. [PMID: 35207392 PMCID: PMC8876674 DOI: 10.3390/jcm11041119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023] Open
Abstract
In the field of otolaryngology—head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient’s real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.
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Affiliation(s)
- Mathew K. Marsee
- Department of Graduate Medical Education, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
- Correspondence:
| | - Faisal S. Shariff
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Grant Wiarda
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA;
| | - Patrick J. Watson
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Ali H. Sualeh
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Toby J. Brenner
- Department of Biochemistry, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Max L. McCoy
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Hamid D. Al-Fadhl
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Alexander J. Jones
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - Patrick K. Davis
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - David Zimmer
- Cleveland Clinic Foundation, Cleveland, OH 44195, USA;
| | - Craig Folsom
- Department of Otolaryngology, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
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Thakkar M, Rose A, Bednarz B. Thromboelastography in Microsurgical Reconstruction: A Systematic Review. JPRAS Open 2022; 32:24-33. [PMID: 35242985 PMCID: PMC8857410 DOI: 10.1016/j.jpra.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022] Open
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Spielbauer KK, Sunde J, Buchakjian M, Casper KA, Malloy KM, Stucken CL, Prince ME, Rosko AJ, Schechtman S, Chinn SB, Kumar SS, Spector ME. Use of rotational thromboelastometry (ROTEM®) to predict thrombotic complications of microvascular head and neck reconstruction. Oral Oncol 2021; 124:105515. [PMID: 34481704 DOI: 10.1016/j.oraloncology.2021.105515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Katie K Spielbauer
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States.
| | - Jumin Sunde
- University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR 72205, United States
| | - Marisa Buchakjian
- University of Iowa Health Care, 200 Hawkins Dr, Iowa City, IA 52242, United States
| | - Keith A Casper
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Kelly M Malloy
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Chaz L Stucken
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Mark E Prince
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Andrew J Rosko
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Samuel Schechtman
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Steven B Chinn
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Sathish S Kumar
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
| | - Matthew E Spector
- Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48105, United States
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Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3769. [PMID: 34408964 PMCID: PMC8360463 DOI: 10.1097/gox.0000000000003769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022]
Abstract
Background: Flap thrombosis is a rare but devastating complication in microsurgery. Preoperative identification of patients at increased risk for microvascular thrombosis remains challenging. Viscoelastic testing (VET) provides a comprehensive evaluation of the clotting process and can effectively identify hypercoagulability. However, the utility of VET in microvascular reconstruction remains unclear. Methods: A systematic review of the association between VET and pedicle thrombosis and free flap loss was performed in accordance with Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Identified studies were reviewed independently by two authors for pertinent data. Results: Six studies met inclusion criteria. Heterogenous study design and outcome reporting complicated direct comparisons and precluded a formal meta-analysis. Four studies found a statistically significant relationship between VET results and flap thrombosis or flap loss. The maximum clot strength and the fibrinogen-to-platelet ratio (FPR) were key viscoelastic parameters in these studies, both representing a measure of maximal clot strength. Specifically, an elevated FPR (>42%) generated a sensitivity and specificity for flap loss ranging from 57% to 75% and 60% to 82%, respectively. Notably, the negative predictive value for flap failure with a normal preoperative FPR was greater than 90% in all studies reporting a correlation. The remaining two studies reported no predictive value for VET with respect to flap failure or pedicle thrombosis. Conclusion: The results of this review suggest that VET, particularly parameters relating to clot strength, may help clinicians identify patients at risk for flap thrombosis. However, uncontrolled and heterogenous reporting limit definitive conclusions, and high-quality diagnostic studies are needed to better determine the clinical utility of viscoelastic testing for free flap patients.
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Walsh M, Kwaan H, McCauley R, Marsee M, Speybroeck J, Thomas S, Hatch J, Vande Lune S, Grisoli A, Wadsworth S, Shariff F, Aversa JG, Shariff F, Zackariya N, Khan R, Agostini V, Campello E, Simioni P, Scărlătescu E, Hartmann J. Viscoelastic testing in oncology patients (including for the diagnosis of fibrinolysis): Review of existing evidence, technology comparison, and clinical utility. Transfusion 2021; 60 Suppl 6:S86-S100. [PMID: 33089937 DOI: 10.1111/trf.16102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/23/2022]
Abstract
The quantification of the coagulopathic state associated with oncologic and hematologic diseases is imperfectly assessed by common coagulation tests such as prothrombin time, activated partial thromboplastin time, fibrinogen levels, and platelet count. These tests provide a static representation of a component of hemostatic integrity, presenting an incomplete picture of coagulation in these patients. Viscoelastic tests (VETs), such as rotational thromboelastometry (ROTEM) and thromboelastography (TEG), as whole blood analyses, provide data related to the cumulative effects of blood components and all stages of the coagulation and fibrinolytic processes. The utility of VETs has been demonstrated since the late 1960s in guiding blood component therapy for patients undergoing liver transplantation. Since then, the scope of viscoelastic testing has expanded to become routinely used for cardiac surgery, obstetrics, and trauma. In the past decade, VETs' expanded usage has been most significant in trauma resuscitation. However, use of VETs for patients with malignancy-associated coagulopathy (MAC) and hematologic malignancies is increasing. For the purposes of this narrative review, we discuss the similarities between trauma-induced coagulopathy (TIC) and MAC. These similarities center on the thrombomodulin-thrombin complex as it switches between the thrombin-activatable fibrinolysis inhibitor coagulation pathway and activating the protein C anticoagulation pathway. This produces a spectrum of coagulopathy and fibrinolytic alterations ranging from shutdown to hyperfibrinolysis that are common to TIC, MAC, and hematologic malignancies. There is expanding literature regarding the utility of TEG and ROTEM to describe the hemostatic integrity of patients with oncologic and hematologic conditions, which we review here.
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Affiliation(s)
- Mark Walsh
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA.,Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA.,Indiana University School of Medicine, South Bend, Indiana, USA
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Ross McCauley
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - Mathew Marsee
- Indiana University School of Medicine, South Bend, Indiana, USA
| | | | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA
| | - Jordan Hatch
- Indiana University School of Medicine, South Bend, Indiana, USA
| | | | - Anne Grisoli
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - Sarah Wadsworth
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faadil Shariff
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Nuha Zackariya
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Rashid Khan
- Michiana Hematology Oncology, Mishawaka, Indiana, USA
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts, USA
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Patel H, Srinivasa DR, Volod O, Wang ED, Kim EA. Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery. J Reconstr Microsurg 2021; 37:774-782. [PMID: 34010965 DOI: 10.1055/s-0041-1727190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. METHODS We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). RESULTS Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific. CONCLUSION Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.
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Affiliation(s)
- Harsh Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dhivya R Srinivasa
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oksana Volod
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric D Wang
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
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Vanags I, Stepanovs J, Ozolina A, Mukans M, Bjertnaes LJ, Mamaja B. Thromboelastometry for Assessing Risks of Free Flap Thrombosis in Patients Undergoing Microvascular Surgery. Front Med (Lausanne) 2020; 7:289. [PMID: 32656219 PMCID: PMC7324680 DOI: 10.3389/fmed.2020.00289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/22/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Coagulation assessment is often missing in microvascular surgery. We aimed at evaluating the predictive value of thromboelastometry for free flap thrombosis in microvascular surgery patients. Materials and Methods: We enrolled 103 adult patients with traumatic injuries scheduled for microvascular free flap surgery into a prospective observational study. Thirty-six patients with recent trauma underwent surgery within 30 days (ES group), and were compared with 67 trauma patients who underwent surgery later than 30 days (late surgery, LS group) after the injury. Rotational thromboelastometry (RTE) was performed before surgery. Functional fibrinogen to platelet ratio (FPR) ≥ 42 was selected as the main hypercoagulability index. Free flap thrombosis was set as primary outcome. Thrombotic risk factors and duration of surgery related to free flap thrombosis were secondary outcomes. Statistical significance p < 0.05; not significant NS. Results: Six patients (16.7%) in the ES group and 10 (14.9%) in the LS group had free flap thrombosis (NS). In the entire cohort, free flap thrombosis rate increased in the presence of thrombogenic comorbidities (OR 4.059, CI 1.33-12.37; p = 0.014) and prolonged surgery times (OR 1.007, CI 1 - 1.012; p = 0.05). Although hypercoagulability occurred more frequently in the ES group (44.4%) than in the LS group (11.9%; p < 0.001), it was not associated with higher free flap thrombosis rate. In ES group patients with surgery times > 240 min, the risk of free flap thrombosis increased (OR 3.5, CI 1.16-10.6; p = 0.026) with 93.3% sensitivity and 86.7% specificity (AUC 0.85; p = 0.007). In contrast, in LS patients hypercoagulability increased the odds of free flap thrombosis (OR 8.83, CI 1.74-44.76; p = 0.009). Moreover, a positive correlation was found between FPR ≥ 42 and free flap thrombosis rate (r = 0.362; p = 0.003). In the LS group, the presence of thrombogenic comorbidities correlated with free flap thrombosis rate (OR 7, CI 1.591-30.8; p = 0.01). Conclusions: In LS patients with thrombogenic comorbidities, thromboelastometry supports the detection of hypercoagulability and predicts free flap thrombosis risk. In ES patients, postoperative hypercoagulability did not predict free flap thrombosis. Prolonged surgery time should be considered as a risk factor.
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Affiliation(s)
- Indulis Vanags
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Jevgenijs Stepanovs
- Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Agnese Ozolina
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradinš University, Riga, Latvia
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Biruta Mamaja
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
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[Reconstruction of lower limbs in old age-an interdisciplinary approach : Geriatric assessment, perioperative management, diagnostics and treatment targets]. Chirurg 2019; 90:795-805. [PMID: 31463658 DOI: 10.1007/s00104-019-01022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Complex injuries of the lower extremities in geriatric patients with multiple pre-existing comorbidities represent an increasing challenge to an interdisciplinary team of surgeons. Functional reconstruction of the extremity through osteosynthesis, revascularization and defect coverage aims to preserve mobility and achieve an early return to activities of daily life at home, while avoiding major amputation and the associated risks regarding morbidity and mortality. An interdisciplinary assessment of geriatric patients regarding dystrophy of soft tissue and skín, cardiovascular and metabolic comorbidities as well as specific geriatric diagnostics are crucial steps in ensuring favorable outcomes. Perioperatively, all improvable risk factors should be actively optimized and a specialized interdisciplinary approach to treatment planning (extremity board) is absolutely necessary for success of treatment. It outlines the special features of the geriatric assessment, diagnostics, perioperative management and treatment targets.
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Walsh M, Moore EE, Moore H, Thomas S, Lune SV, Zimmer D, Dynako J, Hake D, Crowell Z, McCauley R, Larson EE, Miller M, Pohlman T, Achneck HE, Martin P, Nielsen N, Shariff F, Ploplis VA, Castellino FJ. Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review. Semin Thromb Hemost 2019; 45:354-372. [PMID: 31108555 PMCID: PMC7707018 DOI: 10.1055/s-0039-1688497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between malignancy and coagulopathy is one that is well documented yet incompletely understood. Clinicians have attempted to quantify the hypercoagulable state produced in various malignancies using common coagulation tests such as prothrombin time, activated partial thromboplastin time, and platelet count; however, due to these tests' focus on individual aspects of coagulation during one specific time point, they have failed to provide clinicians the complete picture of malignancy-associated coagulopathy (MAC). Viscoelastic tests (VETs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are whole blood analyses that have the advantage of providing information related to the cumulative effects of plasma clotting factors, platelets, leukocytes, and red cells during all stages of the coagulation and fibrinolytic processes. VETs have gained popularity in the care of trauma patients to objectively measure trauma-induced coagulopathy (TIC), but the utility of VETs remains yet unrealized in many other medical specialties. The authors discuss the similarities and differences between TIC and MAC, and propose a mechanism for the hypercoagulable state of MAC that revolves around the thrombomodulin-thrombin complex as it switches between activating the protein C anticoagulation pathway or the thrombin activatable fibrinolysis inhibitor coagulation pathway. Additionally, they review the current literature on the use of TEG and ROTEM in patients with various malignancies. Although limited research is currently available, early results demonstrate the utility of both TEG and ROTEM in the prediction of hypercoagulable states and thromboembolic complications in oncologic patients.
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Affiliation(s)
- Mark Walsh
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Ernest E. Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Hunter Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - David Zimmer
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Joseph Dynako
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Daniel Hake
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Zachary Crowell
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Ross McCauley
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Emilee E. Larson
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Michael Miller
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Tim Pohlman
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | | | - Peter Martin
- Department of Emergency Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Nathan Nielsen
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Victoria A. Ploplis
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
| | - Francis J. Castellino
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
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Ekin Y, Günüşen İ, Özdemir ÖY, Tiftikçioğlu YÖ. Effect of Coagulation Status and Co-Morbidity on Flap Success and Complications in Patients with Reconstructed Free Flap. Turk J Anaesthesiol Reanim 2019; 47:98-106. [PMID: 31080950 DOI: 10.5152/tjar.2019.07752] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/10/2018] [Indexed: 01/07/2023] Open
Abstract
Objective Free flap surgeries constitute the basis of reconstruction surgery in patients with major defects. Prediction of complications that cause flap loss in such patients is important in terms of reducing the length of hospital stay and expenses. We aimed to retrospectively investigate the effect of co-morbidities and the coagulation status on flap loss and complications in patients with reconstructed free flap. Methods Demographic data, smoking, alcohol habits, co-morbidities, coagulation tests and thromboelastogram results from preoperative, intraoperative and postoperative anaesthesia and surgical records of patients undergoing free flap surgeries between January 2015 and June 2017 were retrospectively screened. Results Flap success rate was found to be 96.1% in total 77 patients with free flap. Coagulation related complication rate, such as thrombosis, haematoma and partial necrosis, were 22.1%. There was a significant relationship between age, chronic obstructive pulmonary disease and hypercholesterolaemia and flap loss (p=0.006, p=0.025 ve p=0.025, respectively). Flap complications were more frequent in patients with chronic obstructive pulmonary disease and hypertension. Laboratory test results revealed no statistical correlation between flap complications and flap loss with preoperative and postoperative TEG. Conclusion Advanced age, co-morbidities such as hypertension and chronic obstructive pulmonary disease are associated with complications and flap loss in free flap surgery. However, there were no clinically significant association of complications and flap loss with laboratory tests showing coagulation. We believe that standardised protocols should be established in terms of preparation, intraoperative management and postoperative follow-ups because the time between taking the coagulation tests and postoperative anticoagulant administration should be standardised in such surgeries.
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Affiliation(s)
- Yusufcan Ekin
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - İlkben Günüşen
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Özlem Yakut Özdemir
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Yiğit Özer Tiftikçioğlu
- Department of Plastic, Aesthetic and Reconstructive Surgery, Ege University School of Medicine, İzmir, Turkey
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Abraham M, Badhey A, Hu S, Kadakia S, Rasamny JK, Moscatello A, Ducic Y. Thromboprophylaxis in Head and Neck Microvascular Reconstruction. Craniomaxillofac Trauma Reconstr 2018; 11:85-95. [PMID: 29892322 PMCID: PMC5993658 DOI: 10.1055/s-0037-1607068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 06/17/2017] [Indexed: 12/13/2022] Open
Abstract
Head and neck patients undergoing microvascular reconstruction are at high risk for thromboembolism. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The aim of this review was to evaluate the risks and benefits of prophylactic agents for thromboprophylaxis. A literature search was conducted in MEDLINE, Cochrane Library, and PubMed/NCBI databases. Articles discussing thromboprophylaxis in otolaryngology, head and neck surgery, or microvascular reconstruction were considered in the review from the past 30 years. The majority of patients undergoing microvascular surgery have multiple risk factors for thrombus formation. Several consensus guidelines exist for the prophylaxis in patients who are critically ill, undergoing surgery, or with malignancy. Significant evidence supports the routine use of mechanical means, such as early mobilization and pneumatic compression along with subcutaneous heparin. Low-molecular-weight heparin is also frequently utilized, although results are largely divided. Data on aspirin remain equivocal. Studies on microvascular failure and flap loss have demonstrated little to no association with chemoprophylaxis. The evidence for postoperative thromboprophylaxis regimens in patients undergoing head and neck free tissue transfer is variable. Multiple studies have supported the use of unfractionated heparin or low-molecular-weight heparin. There appears to be an expert consensus for the combined use of mechanical prophylactic methods and chemical prophylaxis. Prospective randomized trials are required to validate the most effective combination of chemoprophylaxis agents.
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Affiliation(s)
- Manoj Abraham
- Department of Otolaryngology, New York Medical College, Valhalla, New York
| | - Arvind Badhey
- Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Shirley Hu
- Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Sameep Kadakia
- Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - J. K. Rasamny
- Department of Otolaryngology, New York Medical College, Valhalla, New York
| | | | - Yadranko Ducic
- Department of Otolaryngology, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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Free flap surgery in Europe: an interdisciplinary survey. Int J Oral Maxillofac Surg 2017; 47:676-682. [PMID: 29275838 DOI: 10.1016/j.ijom.2017.11.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 10/02/2017] [Accepted: 11/26/2017] [Indexed: 11/24/2022]
Abstract
Free flap surgery is essential for the aesthetic and functional reconstruction of various parts of the body. The aim of this study was to compare current concepts of perioperative flap management between ENT, craniomaxillofacial, and plastic surgeons. A European survey was conducted among 570 surgical departments, covering all aspects of free flap surgery. Focus was placed on antibiotic and antithrombotic drug use, aspects of osseous reconstruction, and flap monitoring strategies. One hundred and seventy-two medical units participated. A broad spectrum of anticoagulant regimens and a trend towards prolonged antibiotic prophylaxis were found. Fixation with (CAD/CAM) reconstruction plates was more popular than monocortical locking with miniplates in the mandible. Visual assessment and Doppler systems were reported to be the most common monitoring modalities. The flap loss rate was stated to be higher after osseous reconstruction. Only a few differences in perioperative flap management were identified between the different surgical fields, and osseous reconstruction appears to be the most challenging.
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