Review article
Anticoagulation Therapy in Microsurgery: A Review

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The advent of microsurgical tissue transfer including replantation greatly has expanded the scope of reconstructive surgery. There are few recent innovations in anticoagulation therapies for microsurgery, however, and anastomotic thrombosis remains an occasional cause of surgical failure. No consensus exists on the ideal anticoagulation protocol for microsurgery. This article reviews major pharmacologic modalities of anticoagulation, delineates the mechanism of action and study of efficacy of each agent, and compares the risks and benefits of popular anticoagulation therapies. Finally, it examines available human outcomes–based data and attempts to provide a glimpse of the future direction of microsurgical anticoagulation research.

Section snippets

Overview of Thrombosis in Microsurgery

The pathogenesis of venous thrombosis differs from arterial thrombosis.8 Platelet aggregation is the underlying cause of arterial thrombosis whereas venous thrombosis is primarily the result of fibrin clotting.8 Because venous thrombosis occurs more frequently than arterial thrombosis as the cause of free flap failure, fibrin strand development is a more significant factor in microvascular occlusion than platelet aggregation.1, 9, 10

The risk for thromboses is highest (80%) during the first 2

Antithrombotic Therapy

The use of prophylactic antithrombotic agents is the most common strategy for avoiding vascular thrombosis after free flap surgery or vascular repair.17, 18, 19 As early as 1978 Ketchman20 proposed that to increase patency rates of microvascular repairs surgeons need agents that (1) decrease platelet function (eg, aspirin), (2) increase blood flow or decrease blood viscosity (eg, dextran), and (3) counteract the effects of thrombin on platelets and fibrinogen (eg, heparin). Today aspirin,

Clinical Studies

Despite refined microsurgical skills and antithrombotic therapeutic options, 6% to 25% of microsurgical cases result in re-operation because of thrombosis at vascular anastomoses.96, 97 Research in this field has been performed primarily in animal models. Some researchers have suggested that the rodent model has a uniquely higher rate of recanalization in thrombosed veins, which calls for caution in extrapolating rodent data to human problems. There is a paucity of data in the literature

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