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Novel Oral Anticoagulants (NOACs) in Microsurgery: A Review
Amy Yao, BS1, Stav Brown, BS2, Peter J. Taub, MD1.
1Icahn School of Medicine at Mount Sinai, New York, NY, USA, 2Sackler School of Medicine, Tel Aviv University, New York, NY, USA.

BACKGROUND:
Thrombosis of the vascular anastomosis or distal flap microcirculation is the most common cause of microvascular free tissue transfer failure. The large volume of existing literature has not yet reached a consensus on the ideal anticoagulation regimen to prevent thrombosis following microsurgery. Dabigatran, rivaroxaban, and apixaban are novel oral anticoagulants (NOACs) with an efficacy and safety profile equivalent or superior to standard agents such as warfarin. However, published reports of the use of NOACs in microsurgery are limited. This review aims to summarize current knowledge regarding the use of NOACs in microsurgery and provide clinical recommendations based on each agent’s pharmacodynamics.
METHODS:
A systematic literature review was performed using the PubMed, Cochrane, and Google Scholar databases. Inclusion criteria were case reports and series of the use of NOACs in microsurgery.
RESULTS:
Five articles describing the use of NOACs in microsurgery were fully reviewed. A total of 32 patients undergoing 46 microsurgical procedures with either dabigatran or rivaroxaban were studied, with adverse effects occurring in 3 (6.5%). The most common adverse effect was hemorrhage, two of which were mild cases. No articles describing the use of apixaban were found. The risk of bleeding increased with concurrent administration of NSAIDs or other anticoagulants.
CONCLUSIONS:
Preoperative administration of NOACs in microsurgery is safe and has a low side-effect profile compared to standard anticoagulants. However, current administration protocols remain varied. Further research is warranted to elucidate the risks and benefits of NOACs in microsurgery, and to establish management guidelines for improved microsurgical outcomes.


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