Applications of Thromboelastography (TEG) in Microsurgery: A Systemic Review and Meta-Analysis

Alireza Hamidian Jahromi, Sydney Horen Arnold, Petros Konofaos

Abstract


Viscoelastic testing including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has gained increasing popularity across many medical fields in recent years. As TEG/ROTEM testing usesawhole blood sample and evaluates interactions between cellular components i.e., platelets, red blood cells and the clotting factors, these evaluations are uniquely capable of assessing coagulation in an in-vitro environment, resembling native conditionsunlike those of conventual clotting tests (CCTs). While viscoelastic based protocols and applications are more commonplace in hepatic and cardiac surgery and trauma scenarios, results have attracted the attention of additional disciplines including microsurgery. TEG/ROTEM tests, with their ability to assess forreal-time risk of excessive bleeding or thrombosis, may be useful in the monitoring of microsurgery patients who may be at an increased risk for flap failure. The following review of TEG/ROTEM testing focuses on the most common applications of these coagulation tests and the evidence that does or does not support such uses. A systematic review and meta-analysis of the current application of TEG/ROTEM in microsurgery is reported along with an emphasis on the future that it might hold for the field.


Keywords


Microsurgery; Plastic Surgery; TEG; Thromboelastography; Implications; Thrombosis; Coagulation; Viscoelastic Testing, ROTEM

Full Text:

PDF

References


Hardy JF, De Moerloose P, Samama M; Groupe d'intérêtenHémostasePériopératoire. Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Can J Anaesth. 2004;51(4):293-310.

Nerurkar J, Wade WE, Martin BC. Cost/death averted with venous thromboembolism prophylaxis in patients undergoing total knee replacement or knee arthroplasty. Pharmacotherapy. 2002;22(8):990-1000.

Afshari A. Evidence based evaluation of immuno-coagulatory interventions in critical care. Dan Med Bull. 2011;58(9):B4316.

Benes J, Zatloukal J, Kletecka J. Viscoelastic Methods of Blood Clotting Assessment - A Multidisciplinary Review. Front Med (Lausanne). 2015;2:62. Published 2015 Sep 14.

McCrossin KE, Bramley DE, Hessian E, Hutcheon E, Imberger G. Viscoelastic testing for hepatic surgery: a systematic review with meta-analysis-a protocol. Syst Rev. 2016;5(1):151. Published 2016 Sep 6.

Deppe AC, Weber C, Zimmermann J, et al. Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients. J Surg Res. 2016;203(2):424-433.

Hunt H, Stanworth S, Curry N, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015;2015(2):CD010438. Published 2015 Feb 16.

Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J ThrombHaemost. 2020;18(8):1813-1838.

Gopal JP, Dor FJ, Crane JS, Herbert PE, Papalois VE, Muthusamy AS. Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?. World J Transplant. 2020;10(7):206-214.

Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109(7):2219-2230.

Masoomi H, Clark EG, Paydar KZ, et al. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery. 2014;34(8):589-594.

Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-2100.

Vanags I, Stepanovs J, Ozolina A, Mukans M, Bjertnaes LJ, Mamaja B. Thromboelastometry for Assessing Risks of Free Flap Thrombosis in Patients Undergoing Microvascular Surgery. Front Med (Lausanne). 2020;7:289. Published 2020 Jun 23.

HARTERT H. Blutgerinnungsstudienmit der Thrombelastographie; einemneuenUntersuchungsverfahren [Blood clotting studies with Thrombus stressography; a new Investigation procedure]. KlinWochenschr. 1948;26(37-38):577-583.

Mitchell DA, Gorton H. Thromboelastographic study of the effect of manipulation of central veins on coagulability of venous blood. Br J Oral Maxillofac Surg 2005;43(03):215–218.

Sankarankutty A, Nascimento B, Teodoro da Luz L, Rizoli S. TEG(R) and ROTEM(R) in trauma: similar test but different results? World J Emerg Surg. 2012;7(Suppl 1):S3.

Vaidya A, Muthusamy AS, Hadjianastassiou VG, et al. Simultaneous pancreas--kidney transplantation: to anticoagulate or not? Is that a question? Clin Transplant. 2007;21(4):554-557.

Luddington RJ. Thrombelastography/thromboelastometry. Clin Lab Haematol. 2005;27(2):81-90.

Gorlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J CardiothoracVascAnesth. 2013;27:S20eS34.

Haas T, Spielmann N, Mauch J, et al. Comparison of thromboelastometry (ROTEM!) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth. 2012;108:36e41.

Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. AnesthAnalg. 2008;106(5):1366–75.

Afshari A, Wikkelsø A, Brok J, Møller AM, Wetterslev J. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev. 2011;(3):CD007871. Published 2011 Mar 16.

Whiting P, Al M, Westwood M, et al. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(58):1-vi.

Sakai T. Viscoelastic testing in liver transplantation. Transfusion. 2020;60 Suppl 6:S61-S69.

Wang SC, Shieh JF, Chang KY, et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc. 2010;42(7):2590–2593.

Bonnet A, Gilquin N, Steer N, et al. The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation: a randomized controlled study. Eur J Anaesthesiol. 2019;36(11):825–833.

Mpaili E, Tsilimigras DI, Moris D, et al. Utility of viscoelastic coagulation testing in liver surgery: a systematic review [published online ahead of print, 2020 Nov 21]. HPB (Oxford). 2020;S1365-182X(20)31223-5.

Li C, Zhao Q, Yang K, Jiang L, Yu J. Thromboelastography or rotational thromboelastometry for bleeding management in adults undergoing cardiac surgery: a systematic review with meta-analysis and trial sequential analysis. J Thorac Dis. 2019;11(4):1170-1181.

Lodewyks C, Heinrichs J, Grocott HP, et al. Point-of-care viscoelastic hemostatic testing in cardiac surgery patients: a systematic review and meta-analysis. Tests hémostatiquesviscoélastiques au point de service des patients subissantunechirurgiecardiaque : revue systématique de la littérature et méta-analyse. Can J Anaesth. 2018;65(12):1333-1347.

Dias JD, Sauaia A, Achneck HE, Hartmann J, Moore EE. Thromboelastography-guided therapy improves patient blood management and certain clinical outcomes in elective cardiac and liver surgery and emergency resuscitation: A systematic review and analysis. J ThrombHaemost. 2019;17(6):984-994.

Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. CurrOpin Crit Care. 2007;13(6):680-685.

ACS TQIP Massive Transfusion in Trauma Guidelines. [(accessed on 17 December 2020)]; Available online: https://www.facs.org/-/media/files/quality-programs/trauma/tqip/transfusion_guildelines.ashx.

Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. Published 2019 Mar 27.

Cochrane C, Chinna S, Um JY, et al. Site-Of-Care Viscoelastic Assay in Major Trauma Improves Outcomes and Is Cost Neutral Compared with Standard Coagulation Tests. Diagnostics (Basel). 2020;10(7):486. Published 2020 Jul 17. doi:10.3390/diagnostics10070486

Gonzalez E, Moore EE, Moore HB, et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg. 2016;263(6):1051-1059.

Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion. 2020;60 Suppl 6:S33-S51.

Gary JL, Schneider PS, Galpin M, et al. Can thrombelastography predict venous thromboembolic events in patients with severe extremity trauma? J Orthop Trauma. 2016;30(6):294–298.

Chapman BC, Moore EE, Barnett C, et al. Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation. Am J Surg. 2013;206(6):913–917.

Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J ThrombHaemost. 2020;18(8):1813-1838.

Wang M, Hu Z, Cheng QX, Xu J, Liang C. The ability of throm- boelastography parameters to predict severe pre-eclampsia when measured during early pregnancy. Int J Gynecol Obstet. 2019;145(2):170-175.

Kettner SC, Pollak A, Zimpfer M, et al. Heparinase-modified thrombelastography in term and preterm neonates. AnesthAnalg. 2004;98(6):.

Burke GW 3rd, Ciancio G, Figueiro J, et al. Hypercoagulable state associated with kidney-pancreas transplantation. Thromboelastogram-directed anti-coagulation and implications for future therapy. Clin Transplant. 2004;18(4):423-428.

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. Published 2009 Jul 21.

Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-2100.

Parker RJ, Eley KA, Von Kier S, Pearson O, Watt-Smith SR. Functional fibrinogen to platelet ratio using thromboelastography as a predictive parameter for thrombotic complications following free tissue transfer surgery: a preliminary study. Microsurgery. 2012;32(7):512-519.

Kolbenschlag J, Daigeler A, Lauer S, et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery? Microsurgery. 2014;34(4):253-260.

Wikner J, Beck-Broichsitter BE, Schlesinger S, et al. Thromboelastometry: A contribution to perioperative free-flap management. J Craniomaxillofac Surg. 2015;43(7):1065-1071.

Zavlin D, Chegireddy V, Jubbal KT, Agrawal NA, Spiegel AJ. Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography. J ReconstrMicrosurg. 2019;35(3):198-208.

Ekin Y, Günüşen İ, Özdemir ÖY, Tiftikçioğlu YÖ. Effect of Coagulation Status and Co-Morbidity on Flap Success and Complications in Patients with Reconstructed Free Flap. Turk J AnaesthesiolReanim. 2019;47(2):98-106.


Refbacks

  • There are currently no refbacks.




 

Become a REVIEWER 

 

ISSN: 2346-8491 (online)