Intraoperative unfractionated heparin may prevent thrombotic complications and enhance flap viability in reconstructive surgery: Study

In reconstructive surgery, specifically free flap reconstructive surgery, concerns persist regarding the risk of failures due to thrombosis and bleeding complications, leading to flap loss. Even with advancements in surgical techniques and perioperative care, standardized protocols for anticoagulation management remain lacking. Recent study aimed to investigate the role of anticoagulation and perioperative practices in free flap reconstructive surgery and their impact on surgical outcomes.

The retrospective single-center study included 489 free flap surgeries from 2009 to 2020, with most flaps taken from the upper extremity for tumor-related reconstructions. Flap loss occurred in 14.5% of cases, with intraoperative unfractionated heparin (UFH) significantly predicting flap survival. Prothrombin time (PTT) values on day 1 post-surgery were also significantly related to flap survival, with each unit increase reducing the relative probability of flap loss by 5.2%. There was no significant difference in flap survival between patients treated with heparin alone and those treated with both heparin and aspirin. However, the aspirin-only group was limited in size. The study highlighted the importance of intraoperative UFH and PTT-guided postoperative management in enhancing free flap survival. The findings emphasized the need for standardized anticoagulation protocols to optimize outcomes in free flap reconstructive surgery. Moreover, the study noted that factors such as the location of the defect, flap origin, and duration of surgery significantly influenced perioperative flap survival rates.

Recommendations for Anticoagulation Strategies

The study recommended intraoperative UFH administration and continued postoperative therapy with PTT-controlled UFH to minimize bleeding risk. It suggested targeting a PTT range of 40–60 seconds for an effective balance between thrombosis and bleeding risks. There was no significant benefit observed from combining UFH with aspirin postoperatively. The research emphasized the importance of a standardized perioperative anticoagulation protocol to improve flap survival rates and surgical success in free flap surgery. Although the study had limitations like its retrospective nature and diverse patient cohort, it concluded that anticoagulation is crucial for free flap preservation. The authors called for future research, suggesting a prospective multicenter study to address the lack of consensus in perioperative anticoagulation therapy. Ultimately, the study underlined the significance of optimized anticoagulation practices in achieving successful outcomes in free flap reconstructive surgery.

Key Points

- Anticoagulation management in free flap reconstructive surgery is crucial to prevent complications such as thrombosis and bleeding, which can lead to flap loss.

- A retrospective single-center study of 489 free flap surgeries revealed that intraoperative unfractionated heparin (UFH) significantly predicted flap survival, and higher prothrombin time (PTT) values on day 1 post-surgery were associated with reduced relative probability of flap loss.

- Patients treated with UFH alone showed no significant difference in flap survival compared to those receiving both UFH and aspirin, although the aspirin-only group was small. - Intraoperative UFH administration and postoperative therapy with PTT-controlled UFH were recommended to minimize bleeding risk, with a target PTT range of 40–60 seconds proposed for balancing thrombosis and bleeding risks effectively.

- The study emphasized the necessity for standardized anticoagulation protocols in free flap surgery to enhance flap survival rates and ensure surgical success.

- Despite limitations of the study, such as its retrospective design and diverse patient population, the importance of anticoagulation for free flap preservation was underscored, urging the need for future prospective multicenter studies to establish consensus on perioperative anticoagulation therapy.

Reference –

Saeed Torabi et al. (2025). Impact Of Perioperative Anticoagulation Management On Free Flap Survival In Reconstructive Surgery: A Retrospective Analysis. *BMC Anesthesiology*, 25. https://doi.org/10.1186/s12871-025-02975-6