Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis

BACKGROUND: Despite significant improvements in survival rates, free flap failures still occur even in experienced hands and are most commonly due to arterial or venous thrombosis. In the absence of an evidence-based guideline on the prevention of thrombosis, we reviewed the literature to assess the evidence base for commonly used interventions aimed at its prevention. METHODS: A comprehensive literature search was performed using the following keywords “free flap” and microsurgery with “pre-operative screening,” “prevention of thrombosis,” “ketorolac,” “heparin,” “low molecular weight heparin,” “aspirin,” “dextran,” and “statins.” RESULTS: Thirteen clinical studies were included in this review. No high-level evidence is available to support any perioperative or postoperative interventions aimed at reducing the risk of flap thrombosis. CONCLUSIONS: Higher level studies are needed to investigate the clinical use of antithrombotic medications in microsurgery; however, given the small failure rates in modern practice, these will need to be large multicenter trials in order to reach sufficient power. Level of Evidence: Level III, risk/prognostic study.