Abstract
ABSTRACT
Objective
Existing literature on anticoagulation in head and neck free flap reconstruction largely focuses on postoperative thromboprophylaxis. Less is known about preoperative therapeutic anticoagulation, including how perioperative anticoagulation holds, timing of resumption, and anticoagulant class relate to hemorrhagic, thromboembolic, and flap‐related complications. This study evaluates these outcomes in anticoagulated patients undergoing head and neck free flap reconstruction and compares complication rates with matched non‐anticoagulated controls.
Methods
A retrospective chart review was performed on patients who underwent free flap reconstruction between 2009 and 2023 and had been on therapeutic anticoagulation for over 1 month preoperatively. A matched control group of non‐anticoagulated patients was included for comparison.
Results
126 anticoagulated patients (mean age 71.8 years, 75.4% male) were included. The most common indications for anticoagulation were atrial fibrillation (62.7%) and venous thromboembolism (30.2%). Anticoagulation medications included warfarin (49.2%), apixaban (36.5%), rivaroxaban (12.7%), and dabigatran (1.6%). Anticoagulation was stopped an average of 4.4 days preoperatively and resumed 7.8 days postoperatively. Hemorrhagic complications occurred in 14 patients (11.1%), including hematomas and unrelated bleeding. Thromboembolic complications occurred in 9 patients (7.1%), 6 of which resulted in flap failure. On matched cohort analysis, controls had lower odds of any complication (OR 0.41, 95% CI 0.21–0.81,
p
= 0.010), hemorrhagic or thromboembolic complications (OR 0.27, 95% CI 0.11–0.63,
p
= 0.003), and hemorrhagic complications specifically (OR 0.26, 95% CI 0.09–0.81,
p
= 0.020), while thromboembolic complication odds were not significantly different between groups (OR 0.47, 95% CI 0.15–1.44,
p
= 0.19).
Conclusions
This study highlights the challenges of managing therapeutic anticoagulation in head and neck free flap surgery, where thromboembolic risk during interruption and hemorrhagic complications upon resumption point to the need for clearer guidelines. Evidence‐based protocols are needed to replace discretionary practices and improve outcomes.