Multiple Anastomotic Thrombus Due to Decreased Anti-Thrombin Activity during Microvascular Anastomosis - Case Report

Introduction

With recent advances in microsurgical instruments and technique, microvascular anastomosis has become a universal surgical technique however, thrombosis still presents in a number of cases. Tension, twisting and compression to the anastomotic site are the main causes of thrombus however disorder of the coagulation fibrinolysis system also need to be considered. To date, only few reports exist regarding thrombosis caused by disorder of coagulant system in microvascular anastomosis. Here we report our three cases in which multiple thrombus formation occurred intraoperatively caused by decrease of anti-thrombin (AT) activity.  

Case Reports

Case 1: A 70-year-old male presenting with an esophageal and intestinal fistula after gastric tube cancer were subjected to jejunal pull-up through ante-thoracic route and vascular augmentation to the jejunal artery and vein with the internal thoracic artery and vein was performed. During the operation, arterial thromboses occurred three time and venous thromboses occurred four time. Intraoperative examination showed AT activity decrease (50 %) and AT transfusion was performed. After transfusion, arterial or venous thrombosis was not observed. The intraoperative bleeding volume was 1100ml and the operation time was 12 hours 20 minutes.

Case 2: A 77-year-old man presenting with a right hepatic artery injury during hepatectomy for hilar cholangiocarcinoma. Resection of injured artery followed by vascular anastomosis were performed however thrombosis was observed 3 times. Intraoperative blood test showed marked decreaseof AT activity (25 %) and AT transfusion was performed. Fourth arterial anastomosis was performed after AT transfusion and no further thrombosis was observed thereafter. Intraoperative bleeding volume was 403ml and operation time was 13 hours 23 minutes.

Case 3: A 78-year-old man presenting with extensive left maxillary sinus carcinoma underwent left total maxillectomy, anterior and middle skull base resection, and subsequent free rectus abdominis myocutaneous flap reconstruction. During the operation, arterial thrombosis was observed 3 times in the microvascular anastomotic site. Intraoperative examination showed AT activity decrease (37 %) and AT transfusion was performed. Fourth arterial anastomosis was performed after AT transfusion and no further thrombosis was observed. Intraoperative bleeding volume was 1480ml and operation time was 18 hours 20 minutes.

Results

Thrombosis was not observed in any of three patients intraoperatively after the transfusion or postoperatively and no other complications were observed. 

Discussion

AT deficiency was thought to be a main reason for the thromboses observed during the operation in all three cases. AT is synthesized in the liver and inhibits thrombus formation. It accounts for about 80 % of the thrombin inactivation in the blood, and is greatly related to the balance of the coagulation-fibrinolytic system. Various factors are thought to explain the decrease of AT activity observed in the cases presented; including hereditary AT deficiency, severe intraoperative blood loss, highly invasive operation, malnutrition and impaired liver function. It is necessary to consider AT deficiency in case repeated thrombosis developed intraoperatively.