Risks of Free Tissue Transfer in the Hypocoaguable Patient
Bibliographic record
Abstract
We read with great interest the excellent paper by Kotamarti et al, “Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review,” which highlighted the risk of late thrombosis for free flap patients with hypercoaguabilities.[ 1 ] When a patient with Quebec bleeding disorder presented to our plastic surgery clinic seeking elective microsurgical breast reconstruction with deep inferior epigastric perforator flaps, we conducted a systematic literature review with the intent of determining if hypocoaguable bleeding disorders affect outcomes in free tissue transfer (FTT). In accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol, the MEDLINE database was queried for a comprehensive list of relevant search terms without publication date restriction. Search terms included combinations of “coagulopathy AND free tissue transfer” and “bleeding disorders AND microsurgery.” Inclusion criteria included human studies of FTT with described outcomes in patients with acquired or congenital coagulopathies. Exclusion criteria were animal studies and studies unavailable in English. Ninety-five potential articles were identified, which after title/abstract screen yielded 24 records. These records were read and analyzed in full by two authors (K.R. and P.N.), and seven studies, all case reports, met criteria for inclusion in the review.[ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] There were seven free flaps performed in patients with hypocoaguable disorders. Diseases included hemophilia A and B, factor-XIII deficiency, and the von Wildebrand disease type I. The most common indication for reconstruction was lower extremity salvage in four cases (57.1%).[ 2 ] [ 3 ] [ 4 ] [ 7 ] Zero cases of flap loss were described but two cases (28.6%) described postoperative bleeding complications.[ 3 ] [ 7 ] One case required reoperation.[ 7 ] Seven unique regimens of antihemophilic agents, including recombinant factor VIII,[ 2 ] [ 7 ] factor IX,[ 4 ] [ 8 ] fibrogammin,[ 2 ] desmopressin (DDAVP),[ 6 ] and aminocaproic acid,[ 8 ] were presented. While these data demonstrate that FTT may be performed safely in patients with coagulopathies with the aid of recombinant clotting factors, there is a risk of increased postoperative bleeding. Further, there is a lack of clear guidelines to aid clinical decision-making, including the timing and dosing of pharmaceutical agents. As such, larger (possibly multicenter) studies are needed to better determine the risk of complications for this complicated patient population needing free tissue transfer. * These authors contributed equally to this article. Publication History Received: 25 November 2020 Accepted: 21 December 2020 Article published online: 06 February 2021 © 2021. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.019 | 0.138 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.002 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".