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Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review

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 i...

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Autores principales: Malapati, Harsha, Hanwright, Philip J., Tuffaha, Sami H.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360463/
https://www.ncbi.nlm.nih.gov/pubmed/34408964
http://dx.doi.org/10.1097/GOX.0000000000003769
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author Malapati, Harsha
Hanwright, Philip J.
Tuffaha, Sami H.
author_facet Malapati, Harsha
Hanwright, Philip J.
Tuffaha, Sami H.
author_sort Malapati, Harsha
collection PubMed
description 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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spelling pubmed-83604632021-08-17 Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review Malapati, Harsha Hanwright, Philip J. Tuffaha, Sami H. Plast Reconstr Surg Glob Open Reconstructive 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. Lippincott Williams & Wilkins 2021-08-12 /pmc/articles/PMC8360463/ /pubmed/34408964 http://dx.doi.org/10.1097/GOX.0000000000003769 Text en Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) (https://creativecommons.org/licenses/by-nc-nd/4.0/) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
spellingShingle Reconstructive
Malapati, Harsha
Hanwright, Philip J.
Tuffaha, Sami H.
Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title_full Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title_fullStr Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title_full_unstemmed Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title_short Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review
title_sort utility of viscoelastic tests to predict flap thrombosis: a systematic review
topic Reconstructive
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360463/
https://www.ncbi.nlm.nih.gov/pubmed/34408964
http://dx.doi.org/10.1097/GOX.0000000000003769
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