1. Incidence of Venous Thromboembolism and its Effects on Outcomes in Lower Extremity Salvage
Ido Badash, BA, Karen E. Burtt, BS, Hyuma A. Leland, MD, Daniel J. Gould, MD, PhD, Alexis Rounds, BS, Ketan M. Patel, MD, Joseph N. Carey, MD
Division of Plastic and Reconstructive Surgery
Keck School of Medicine of USC, Los Angeles, California
ASRM Presentation by Ido Badash 7:47AM)

2. Disclosures No financial disclosures
No funding was utilized for the preparation of this chart review

3. Background
Venous thromboembolism (VTE): deep vein thrombosis (DVT) or pulmonary embolism (PE).
VTE is the leading preventable cause of in-hospital deaths1
Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE).
VTE is the leading preventable cause of in-hospital deaths, affecting nearly 900,000 individuals and leading to about 300,000 deaths in the United States annually
The effects of VTE on lower extremity salvage are not well reported

4. Background VTE may complicate soft tissue reconstruction.
Thrombophilia and previous VTE increase risk of flap thrombosis and flap failure2, 3. 
The effects of perioperative VTE on lower extremity salvage are not well reported.
VTE may complicate soft tissue reconstruction by incuding endothelial injury and limiting venous return thorugh hercoagulability, stasis and mechanical outflow obstruction by the actual thrombus.
A 2012 study investigated the effects of thrombophilia, including factor V Leiden mutation, protein C deficiency, hyperhomocysteinemia, antiphospholipid antibody syndrome, prothrombin gene mutation, factor VIII elevation, anticardiolipin antibody syndrome, and essential thrombocytosis, or previous thromboembolic events including deep vein thrombosis, pulmonary embolus, myocardial infarction before the age of 50, and embolic stroke was conducted in 58 free flaps and found an increased rate of flap thrombosis and flap loss.
The effects of perioperative VTE on the flap survival and limb salvage in lower extremity trauma have not been well reported.

5. Purpose
To investigate the incidence of VTE, the risk factors predisposing to its development, and its effects on flap survival and limb salvage in lower extremity trauma.
To investigate the incidence of VTE in trauma patients requiring soft tissue reconstruction of the lower extremity, the demographic characteristics of VTE patients, and flap survival and limb salvage in the presence of perioperative VTE

6. Methods
IRB approved retrospective review from at LAC+USC trauma center.
All trauma patients with LE trauma requiring flap reconstruction (N=190).
Demographics, perioperative data, flap type, and outcomes evaluated.
Add picture of flap

7. Methods
Thromboembolic events defined as clinically significant DVT or PE occurring during inpatient stay.
Diagnosis of VTE confirmed through duplex ultrasound or CTPA.
All patients standardly received chemical VTE prophylaxis and sequential compression devices.

8. Demographics and Fracture Information
Results
Demographics and Fracture Information
All Patients N
Mean Age ± 16
BMI ± 7.0
Males %
Smokers %
Hypertension %
Diabetes Mellitus %
Fractures %
Open Fracture %
Closed Fracture %
Tibial/Fibular Fractures %
*Would this be better presented in bullet points?
A total of 190 patients, 12 of which developed VTE (incidence 6.3%)
The mean age of all patients was 41 +/- 16
The Majority of Fractures were Gustilo 3B.
82% of patients had fractures of the tibia or fibula
Smaller percentages of patients suffered ankle and foot fractures
12.6% suffered open wounds without fractures.
Add hypertension back and diabetes.
Take out smokers.
Take out open wound without fractues

9. Results VTE Information VTE Group n % Patients with VTE Events 12 6.3
Preoperative
Postoperative
Patients with Pulmonary Embolism
Patients with Deep Vein Thrombosis
Ipsilateral
Location
Superficial Femoral Vein
Posterior Tibial Vein
External Iliac Vein
Peroneal Vein
12 Patients had VTE events as confirmed by dupplex ultrasound reports or provider notes.
9 occurred in the preoperative period after the original plastic surgery consult, while 3 were postoperative.
3 of the 12 patients had a pulmonary embolism
11 patients had a DVT, including 2 patients that had both a DVT and a PE.
8 of the DVTs were on the leg ipsilateral to the open wound requiring flap coverage.
The most common location was the superfical femoral vein (54.5% of all locations, followed by the posterior tibial and external iliac vein at 18.2% each.)

10. Results Flap Characteristics Non-VTE VTE VTE Non-VTE Total
Total Flaps
Days to first Flap Procedure 28.6± ± ± 50.1
Mean Flap Size (cm2) ± ± ± 145.0
VTE
Non-VTE
*Would this be better presented in bullet points?
A total of 190 patients, 12 of which developed VTE (incidence 6.3%)
The mean age of all patients was 41 +/- 16
The Majority of Fractures were Gustilo 3B.
82% of patients had fractures of the tibia or fibula
Smaller percentages of patients suffered ankle and foot fractures
12.6% suffered open wounds without fractures.

11. Risk Factors for Development of VTE
Results
Risk Factors for Development of VTE
VTE Non-VTE P-Value OR CI
Significant Risk Factors (α ≤ 0.05)
Age ≥ % 28.1% *
Diabetes Mellitus 33.3% 57.9% *
Hypertension 41.6% 14.6% *
No Significant Risk (α > 0.05)
Pelvic Fracture 8.3% 6.2%
Polytrauma 16.7% %
Smoking % %
The risk factors found to be significantly associated with development of VTE were age greater than or equal to 50, diabetes and hypertension. Hypertension carried the highest risk for development of VTE of the three, but the odds ratios were all similar ranging from 3.6 to 4.2
Take out spinal cord injuries

12. Comparison of Complication Rates
Results
Comparison of Complication Rates
VTE Non-VTE Total P-Value
Amputation % % 1.0
Flap Loss % % 1.0
Hematoma % % % 0.08
Death % % 1.0
Stroke 8.3% % 1.0
Infection/Osteomyelitis 33.3% % % 0.32
Fat Necrosis 8.3% % % Seroma 8.3% % % 0.18
Flap Necrosis 8.3% % % 0.52
Flap Revision 16.7% % % 0.19
Any Flap-Related Complication 41.7% % % 0.33
The overall complication rate was not different between VTE and non-VTE groups. There was a greater rate of hematoma in patients with VTE, which approached statistical significance. There were no instances of flap loss patients with VTE events, and the limb salvage rate was 100% in this group.

13. Conclusions VTE rate was 6.3% in our study population.
Older age, diabetes and hypertension were associated with a greater rate of VTE.
VTE events caused significant morbidity and mortality.
In conclusion, lower extremity reconstruction resulted in an excellent limb salvage rate for patients with perioperative VTE
Patients with VTE, including ipsilateral DVT, did not have a significantly increased risk of flap failure or flap-related complications, although VTE events still caused significant morbidity and mortality.
It may be safe to perform soft tissue reconstruction on trauma patients with diagnosed VTE if appropriate standards of care for VTE management are followed.

14. Conclusions
Lower extremity salvage successful (100%) despite perioperative VTE.
May be safe to perform flap coverage on trauma patients with diagnosed VTE.
Standard anticoagulation prophylaxis and emergent VTE treatment are critical.

15. Thank you Thank you. -Add the statistical test that was used.
-Maybe add highlighting.

16. References
1. Raskob GE, Silverstein R, Bratzler DW, Heit JA, White RH. Surveillance for deep vein thrombosis and pulmonary embolism: recommendations from a national workshop. Am J Prev Med Apr;38(4 Suppl):S502–9.
2. Murray DJ, Neligan PC, Novak CB, Howley B, Wunder JS, Lipa JE. Free tissue transfer and deep vein thrombosis. J Plast Reconstr Aesthet Surg Jun;61(6):687–92.
3. Wang TY, Serletti JM, Cuker A, McGrath J, Low DW, Kovach SJ, et al. Free Tissue Transfer in the Hypercoagulable Patient: A Review of 58 Flaps. Plast Reconstr Surg Feb;129(2):443–53.
Thank you.

17. Type of Anticoagulation Therapy n (%)
Results
VTE Treatment
Type of Anticoagulation Therapy n (%)
Total Patients (100)
Therapeutic Anticoagulation
Dalteparin (50.0)
Enoxaparin 3 (25.0)
Warfarin (16.7)
PE Prophylaxis
IVC Filter Alone 1 (8.3)
All 12 patients received standard therapy for the diagnosed VTE. 50% received Dalteparin, 25% Enoxaparin, and 16.7% warfarin. One patient with an intracranial hemorrhage received an IVC filter alone, although some of the other patients with VTE events received an IVC filter during the course of care before transitioning to full anticoagulation on a chemical anticoagulant.
One patient (8.3%) with contraindication to anticoagulation due to concomitant ischemic cerebrovascular accident received an IVC filter alone

18. VTE (%) Non-VTE (%) Total (%)
Results
Fracture Information
VTE (%) Non-VTE (%) Total (%)
n (6.3) 178 (93.7) 190 (100)
Gustilo I 0 (0.0) 4 (2.3) 4 (2.1)
Gutilo II 2 (16.7) 37 (20.8) 39 (20.5)
Gustilo IIIA 1 (8.3) 3 (1.7) 4 (2.1)
Gustilo IIIB 4 (33.3) 61 (34.2) 65 (34.2)
Gustilo IIIC 2 ( (9.6) 19 (10.0)
% Closed Fracture 2 (16.7) 33 (18.5) 35 (18.4)
Tibia/Fibula Fracture 9 (75.0) 147 (82.6) 156 (82.1)
Ankle Fracture 3 (25.0) 22 (12.4) 25 (13.2)
Foot Fracture 1 (8.3) 24 (13.5) 22 (11.6)
Open Wound without Fracture 1 (8.3) 23 (12.9) 24 (12.6)
*Would this be better presented in bullet points?
A total of 190 patients, 12 of which developed VTE (incidence 6.3%)
The mean age of all patients was 41 +/- 16
The Majority of Fractures were Gustilo 3B.
82% of patients had fractures of the tibia or fibula
Smaller percentages of patients suffered ankle and foot fractures
12.6% suffered open wounds without fractures.

19. Results
Two patients with pulmonary embolis ultimately died as a result of the PE (PE-dependent mortality rate = 66%).
One patient experienced a middle cerebral artery stroke after a paradoxical embolism through a patent foramen ovale.
One patient experienced additional thrombotic events after anticoagulation therapy was initiated, including development of bilateral DVTs and thrombosis of IVC.
There were additional complications in patients with VTE that caused overall morbidity and mortality unrelated to limb salvage. One patient with a PE ultimately died of the condition, one patient developed additional thrombotic events after anticoagulation therapy was initiated, including development of bilateral DVTs that extended throughout the deep venous system, and a third patient experienced a middle cerebral artery stroke after a paradoxical embolism through a patent foramen ovale.