SLR - March 2022 - HyunJi Boo
Reference: Mishu MD, Zolper EG, Dekker PK, Fleury CM, Bekeny JC, Fan KL, Attinger CE, Evans KK. Should Antiplatelet Therapy Be Withheld Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population. Plast Reconstr Surg. 2022 Jan 1;149(1):95e-103e. doi: 10.1097/PRS.0000000000008666. PMID: 34936629.Level of Evidence: III, therapeutic
Reviewed By: HyunJi Boo, DPM
Residency Program: New York Presbyterian, Queens – Flushing, NY
Podiatric Relevance: Patients with chronic lower extremity wounds have significant cardiovascular comorbidities. There is no consensus on whether to continue or withhold dual antiplatelet therapy perioperatively in patients undergoing free tissue transfer. Cardiovascular risk of discontinuing dual antiplatelet therapy must be balanced with flap survival and need for transfusion. This retrospective study hypothesizes that continuing dual antiplatelet therapy in patients undergoing free tissue transfer for chronic lower extremity wounds does not increase risk of bleeding complication or need for transfusion and does enhance flap outcomes.
Methods: All patients who underwent free tissue transfer for lower extremity wounds by a single surgeon from 2011 to 2019 were included in this retrospective study. Patients were noted to be on clopidogrel and/or acetylsalicylic acid and stratified to “none,” “withheld,” or “continued” groups for each antiplatelet agent. All antiplatelet therapies were resumed on postoperative day one. Patient demographics and comorbidities were noted. Bleeding outcomes, flap outcomes, and cardiovascular outcomes were analyzed. Appropriate statistical analysis was performed and study was adequately powered.
Results: Of 195 procedures, 34 occurred in patients on clopidogrel. It was withheld in 20 and continued in 14 cases. Patients not on clopidogrel were younger with less comorbidities. The continued clopidogrel group had the lowest preoperative hemoglobin level and shortest operative time.
Bleeding Outcomes:
The non clopidogrel group had lower incidence and volume of blood transfusion. The transfusion volume was lower for the continued clopidogrel group than the withheld. Flap hematoma incidence was similar across groups. Donor site hematoma incidence was highest in the continued group.
Flap Outcomes: Flap thrombosis occurred in 6.1 percent of all flaps. The withheld group had highest intraoperative flap thrombosis and lowest flap success; however the difference was not statistically significant.
Cardiovascular Outcomes: Cardiac events, such as demand ischemia or myocardial infarction (MI), occurred most in the continued group (21.4 percent) versus the withheld (5 percent) or non clopidogrel (0.6 percent). One patient who had MI was in the withheld group.
Multivariate Analysis for Transfusion: When accounting for variables, the clopidogrel groups were no longer more likely to receive intraoperative transfusion than the non clopidogrel group. Operative time increased odds and preoperative hemoglobin decreased odds of transfusion. Withholding clopidogrel increased risk of postoperative transfusion.
Conclusions: The three groups showed similar outcomes in flap success, thrombosis, and hematoma formation. Continuing clopidogrel did not increase odds of intraoperative transfusion but withholding clopidogrel did increase odds of postoperative transfusion. The only MI occurred in the withheld group. Authors conclude that continuation of dual antiplatelet therapy does not compromise flap success and does confer cardiovascular benefit in this population group.
There is a high burden of cardiovascular diseases such as coronary artery disease, stroke, peripheral arterial disease in this patient population. Many patients have arterial stents requiring antiplatelet therapy. If continuing antiplatelet therapy does not increase risk of blood loss or flap failure, it is prudent to continue therapy perioperatively. This investigation supports continuing dual antiplatelet therapy in patients undergoing lower extremity free tissue transfer for chronic wounds.