- Email: [email protected]
Re: Novel oral anticoagulants in plastic surgery
Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) 69, 1151e1162
CORRESPONDENCE AND COMMUNICATIONS Re: Novel oral anticoagulants in plastic surgery* Dear Sir, We congratulate Munson and Reid for their detailed article “Novel oral anticoagulants and plastic surgery”.1 We are not aware of any published work highlighting the knowledge base of plastic surgeons regarding these drugs, although a more generic survey is available in the literature.2 To this end we would like to share the results of a survey conducted in 2014 at the three plastic surgery centres in the Southwest of England (Bristol, Exeter and Plymouth). Edoxaban was not licensed in the UK at the time of the survey, and thus only Dabigatran, Rivaroxaban and Apixaban were included. 52 respondents comprised 17 Consultants, 23 Registrars and 12 Senior House Officers. 27% either believed that novel oral anticoagulants (NOACs) required routine monitoring or had “no idea”, whilst 34% erroneously believed that specific antidotes may be available. There was no consensus regarding when to stop NOACs (Figure 1), and no awareness of the importance of renal function testing. Six surgeons (12%) reported bleeding complications that they felt were directly attributable to NOAC use. Although arguably less important than the clinical application, only 17% of respondents knew the mechanism of at least one NOAC, and none knew the action of all three drugs licensed in the UK at the time. The inappropriate use of bridging therapy in patients taking NOACs can result in increased perioperative bleeding complications.3 Our survey highlighted a further bleeding risk resulting from the fact that 31% of respondents believed that patients taking NOACs required additional pharmacological venous thrombo-embolism prophylaxis such as low molecular weight heparin, despite already being therapeutically anticoagulated by virtue of the NOAC. Indeed, a drug alert from the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK specified that concomitant treatment with any other anticoagulant is contra-indicated with NOAC use.4
* This work has previously been presented at the 2014 Summer Scientific Meeting of ESPRAS, 7e11th July 2014, Edinburgh.
Figure 1 surgery?
When should NOACs be stopped prior to elective
Following our survey we initiated local education sessions, and applaud Munson and Reid’s article for educating the wider plastic surgery community.
Conflict of interest statement None.
Funding N/A.
References 1. Munson CF, Reid AJ. Novel oral anticoagulants and plastic surgery. J PLast Reconstr Aesthet Surg 2016;69:585e93. 2. Faraoni D, Samama CM, Ranucci M, Dietrich W, Levy J. Perioperative management of new oral anticoagulants: an international survey. Clin Lab Med 2014;34:637e54. 3. Beyer-Westendorf J, Gelbricht V, Forster K, et al. Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry. Eur Heart J 2014;35:188e96. 4. MHRA drug safety update: new oral anticoagulants dabigatran, rivaroxaban and apixaban. 7 October 2013.
J. Warbrick-Smith Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, Wales, SA6 6NL, UK E-mail address: [email protected]
1152
Correspondence and communications D. Urriza Rodriguez Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
S. Gujral Department of Plastic Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK J. Smith Department of Plastic Surgery, Bradford Royal Infirmary, Duckworth Lane, BD9 6RJ, UK DOI of original article: http://dx.doi.org/10.1016/j.bjps.2016. 02.011 ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2016.05.025
Microsurgical venousbranch-plasty for approximating diameter and vessels’ Position in lymphatic supermicrosurgery
Figure 1 A schematic drawing of microsurgical venousbranch-plasty. A 2.0-mm vein was incised to raise a 1 10 mm venous wall flap (left). The both edges of the donor vein and the flap were sutured to create a neo-branch (right).
(Figure 1). The base of the flap was sutured to make the neobranch lumen narrow; the narrow branching point could act as a valve. The created neo-venous branch could be easily approximated and anastomosed to the lymphatic vessel in a
Dear Sir, Lymphatic supermicrosurgery, supermicrosurgical lymphaticovenular anastomosis (LVA), is becoming popular surgical treatment for compression-refractory lymphedema due to its effectiveness and minimal invasiveness.1,2 It is important to find a lymphatic vessel with abundant lymph flow and a vein with an intact valve to prevent post-anastomotic venous reflux and subsequent anastomosis site thrombosis.2,3 Finding lymphatic vessels suitable for LVA is significantly facilitated with the use of indocyanine green lymphography, but it is difficult to prevent venous reflux after anastomosis especially when there is only a large vein distant from a lymphatic vessel.4,5 Vein grafting can prevent venous reflux, but requires additional scar to harvest a vein. To address this challenge, we adopted a new technique, microsurgical venous-branch-plasty (MVP), in lymphatic supermicrosurgery. There was a large (2.0 mm) vein distant from a 0.5-mm lymphatic vessel. Since there was a significant distance between the vessels and a significant diameter discrepancy, it was impossible or inappropriate to anastomose them directly in a conventional manner such as end-to-end, endto-side, side-to-end, or side-to-side fashion. To approximate the vessels and to minimize the vessels’ size discrepancy, the vein was incised and split; 1 10 mm venous wall flap was raised, and the both edges of the donor vein and the flap were sutured using running10-0 nylon microsutures to create a neo-branch while preserving the native venous flow
Figure 2 Microsurgical venous-branch-plasty for supermicrosurgical lymphaticovenular anastomosis (asterisk) using a large vein (arrowhead) distant from a lymphatic vessel (arrow).
CORRESPONDENCE AND COMMUNICATIONS Re: Novel oral anticoagulants in plastic surgery* Dear Sir, We congratulate Munson and Reid for their detailed article “Novel oral anticoagulants and plastic surgery”.1 We are not aware of any published work highlighting the knowledge base of plastic surgeons regarding these drugs, although a more generic survey is available in the literature.2 To this end we would like to share the results of a survey conducted in 2014 at the three plastic surgery centres in the Southwest of England (Bristol, Exeter and Plymouth). Edoxaban was not licensed in the UK at the time of the survey, and thus only Dabigatran, Rivaroxaban and Apixaban were included. 52 respondents comprised 17 Consultants, 23 Registrars and 12 Senior House Officers. 27% either believed that novel oral anticoagulants (NOACs) required routine monitoring or had “no idea”, whilst 34% erroneously believed that specific antidotes may be available. There was no consensus regarding when to stop NOACs (Figure 1), and no awareness of the importance of renal function testing. Six surgeons (12%) reported bleeding complications that they felt were directly attributable to NOAC use. Although arguably less important than the clinical application, only 17% of respondents knew the mechanism of at least one NOAC, and none knew the action of all three drugs licensed in the UK at the time. The inappropriate use of bridging therapy in patients taking NOACs can result in increased perioperative bleeding complications.3 Our survey highlighted a further bleeding risk resulting from the fact that 31% of respondents believed that patients taking NOACs required additional pharmacological venous thrombo-embolism prophylaxis such as low molecular weight heparin, despite already being therapeutically anticoagulated by virtue of the NOAC. Indeed, a drug alert from the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK specified that concomitant treatment with any other anticoagulant is contra-indicated with NOAC use.4
* This work has previously been presented at the 2014 Summer Scientific Meeting of ESPRAS, 7e11th July 2014, Edinburgh.
Figure 1 surgery?
When should NOACs be stopped prior to elective
Following our survey we initiated local education sessions, and applaud Munson and Reid’s article for educating the wider plastic surgery community.
Conflict of interest statement None.
Funding N/A.
References 1. Munson CF, Reid AJ. Novel oral anticoagulants and plastic surgery. J PLast Reconstr Aesthet Surg 2016;69:585e93. 2. Faraoni D, Samama CM, Ranucci M, Dietrich W, Levy J. Perioperative management of new oral anticoagulants: an international survey. Clin Lab Med 2014;34:637e54. 3. Beyer-Westendorf J, Gelbricht V, Forster K, et al. Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry. Eur Heart J 2014;35:188e96. 4. MHRA drug safety update: new oral anticoagulants dabigatran, rivaroxaban and apixaban. 7 October 2013.
J. Warbrick-Smith Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, Wales, SA6 6NL, UK E-mail address: [email protected]
1152
Correspondence and communications D. Urriza Rodriguez Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
S. Gujral Department of Plastic Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK J. Smith Department of Plastic Surgery, Bradford Royal Infirmary, Duckworth Lane, BD9 6RJ, UK DOI of original article: http://dx.doi.org/10.1016/j.bjps.2016. 02.011 ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2016.05.025
Microsurgical venousbranch-plasty for approximating diameter and vessels’ Position in lymphatic supermicrosurgery
Figure 1 A schematic drawing of microsurgical venousbranch-plasty. A 2.0-mm vein was incised to raise a 1 10 mm venous wall flap (left). The both edges of the donor vein and the flap were sutured to create a neo-branch (right).
(Figure 1). The base of the flap was sutured to make the neobranch lumen narrow; the narrow branching point could act as a valve. The created neo-venous branch could be easily approximated and anastomosed to the lymphatic vessel in a
Dear Sir, Lymphatic supermicrosurgery, supermicrosurgical lymphaticovenular anastomosis (LVA), is becoming popular surgical treatment for compression-refractory lymphedema due to its effectiveness and minimal invasiveness.1,2 It is important to find a lymphatic vessel with abundant lymph flow and a vein with an intact valve to prevent post-anastomotic venous reflux and subsequent anastomosis site thrombosis.2,3 Finding lymphatic vessels suitable for LVA is significantly facilitated with the use of indocyanine green lymphography, but it is difficult to prevent venous reflux after anastomosis especially when there is only a large vein distant from a lymphatic vessel.4,5 Vein grafting can prevent venous reflux, but requires additional scar to harvest a vein. To address this challenge, we adopted a new technique, microsurgical venous-branch-plasty (MVP), in lymphatic supermicrosurgery. There was a large (2.0 mm) vein distant from a 0.5-mm lymphatic vessel. Since there was a significant distance between the vessels and a significant diameter discrepancy, it was impossible or inappropriate to anastomose them directly in a conventional manner such as end-to-end, endto-side, side-to-end, or side-to-side fashion. To approximate the vessels and to minimize the vessels’ size discrepancy, the vein was incised and split; 1 10 mm venous wall flap was raised, and the both edges of the donor vein and the flap were sutured using running10-0 nylon microsutures to create a neo-branch while preserving the native venous flow
Figure 2 Microsurgical venous-branch-plasty for supermicrosurgical lymphaticovenular anastomosis (asterisk) using a large vein (arrowhead) distant from a lymphatic vessel (arrow).