flap reconstruction and history of dvt/pe?

Morwenna

flap reconstruction and history of dvt/pe?

Morwenna

Hi ladies,

I have Essential Thrombocythemia, a condition where my bone marrow over-produces platelets, which was diagnosed about the same time as my bc in 2012.

During my chemo treatments I developed large blood clots in my leg, which embolized to my lungs. My hematologist says it was probably a combination of having cancer, 2 surgeries, then chemotherapy, all of which are risk factors for clotting, quite apart from the high platelets! I had a few months on LMW heparin (Lovenox) injections, and am now still on warfarin.

So now I'm considering TRAM/DIEP flap reconstruction bilaterally, with a prophylactic right mastectomy. I saw the plastics surgeon last week, and he thinks it is a reasonable option, except he was concerned about my blood clot history, and said it was reasonable to assume my risk of flap failure (due to clots forming or lodging in the anastamosed vessels) would be higher than usual, although he was not able to quantify that. 

He wants to discuss my case with my hematologist, but did get me to sign a consent for the surgery. There's no rush to decide, as it seems unlikely to happen this year, but part of me is wondering what the flying f**k am I thinking!? I am adamant that I don't want to remain uni-boobed (rather large, and I am very mistrustful that rightie won't develop cancer too, if it's not there already!), but is it ridiculous to put myself through this huge a surgery, especially if there is a significant risk of failure? I think I could live with being flat if I had to.

Sorry for the long post. I just wondered if anyone out there has had flap surgery after a history of blood clotting?? 

Morwenna

Bumping, cos now it is morning in North America!

Ridley

Morwenna - no history, but a suggestion to post your question on the 2014 diep thread. It's very active and someone might be able to help from there.

Ridley

Morwenna

Thanks, I might do that.

nihahi

bumping this thread for mo....

tlbradyful

Morwenna - "Reasonable to assume" is not something on which I would base such a big decision. The surgeon you choose should have experience with patients with your condition. Clots are nothing to play around with. DIEP has a 98-99% success rate among leading surgeons. That level of success is one reason I chose DIEP over my local PS suggestion of TRAM. If the success rate was the same, why tamper with muscles I need in their current position?

You need more information before you can make any decision, but you are right to look into this option. Many of us have had prophylactic mastectomies on our non-cancer sides and bilateral reconstruction. I am not complete yet (finished stage1 DIEP), but know I feel more normal than I have in a year and a half. Keep searching for your answers. You will find the right person to do the right procedure. Never hesitate to question.

Morwenna

Thanks tlbradyful, for your reply, and Nihahi for bumping me

I've been searching and searching, and although it seems many articles indicate hypercoagulative history or disorders to be a contraindication, or at least a relative contraindication to microvascular surgery, there seems to be no real basis to this except, as my PS stated, it "being reasonable to assume a greater risk of failure". And doctors are reluctant to take that risk in this litigious age, I guess, particularly in North America!

I cannot find any clear evidence that this is the case, although I shall continue to enquire, and to consult fully with my health professionals, possibly seeking other opinions. One paper I did find, however concluded the following:

Conclusion: Pre-operatively diagnosed inherited or acquired hematological disorders are not a contraindication for microsurgery. Peri-operative medical management in close consultation with haematological specialists and meticulous surgical technique allows this patient population to undergo successful microvascular surgery.

http://aahs.asrm.aspn.confex.com/oasys_new/2009/te...

I think I'll go with this at the present time, as it pleases me, and go do something to change the subject for now. I have about four new songs to learn!!

MartyJ

morwenna - many Ps give their patients heparin while in patient and then have them take lovenox for at least 7 days after to prevent clots.  Although I do not have a clotting problem, I was in blood thinners for a total of 12 days.  I know of other PS that use the lovenox longer just to insure that no clots form in the tiny vessels until they are safely healed.  You might have to be more careful and less active for longer after surgery than many gals are.

Morwenna

Thanks MartyJ,

I would expect that .... at the very least in my case

Morwenna

Just an update:

My hematologist allowed me to discontinue Warfarin last summer, although he warned that I was at high risk for recurrence of thromboembolism, and if I clotted again I would have to stay on anticoagulant for life.

I had my PMx and bilateral MS TRAM flap reconstruction January 6 this year. My plastic surgeon discussed my clotting issues with the hematologist and the internist and anesthesiologist, and decided on what they were going to do with me.....

I had heparin injections for the 5 days I was in hospital, and also low dose aspirin, which I was to continue on discharge.

By four weeks post op I was concerned that I wasn't really making progress in my fatigue/activity levels and still couldn't walk near normal pace without breathlessness.

I mentioned it to my PT at the lymphedema clinic and she encouraged me to get checked out. I had no acute leg or chest symptoms.

Turns out I had clots throughout all lung fields as per CT scan. (Oops!)

So I'm back on anticoag for good. (Boo!)

But my flaps are fine!!! (Yay!)

My plastics guy was appropriately apologetic, and describes it as a "learning experience" that in the future (not MY future) might be avoided with more rigorous anticoagulation, and maybe I should have had a longer course of post op heparin .... although there is a distinct possibilty that the clots actually occurred on the operating table.

I guess we will never know, but maybe this experience will help someone on this board one day.