Optimizing venous thromboembolism chemoprophylaxis in abdominal-based breast reconstruction: a narrative review of evidence and practice

Venous thromboembolism (VTE) remains a leading cause of preventable morbidity and mortality in surgical patients, with individuals undergoing abdominal-based free flap breast reconstruction representing a particularly high-risk group. Despite the widespread use of risk assessment tools such as the Caprini Risk Assessment Model (RAM), prophylaxis strategies remain inconsistent across institutions. This literature review aims to synthesize current literature on VTE incidence, risk stratification, and chemoprophylaxis in abdominal-based free flap breast reconstruction to identify best practices and areas for future research.

A narrative review of the literature was performed, focusing on studies evaluating VTE incidence, prevention strategies, and outcomes in patients undergoing abdominal-based autologous breast reconstruction. Emphasis was placed on risk stratification models, pharmacologic and mechanical prophylaxis, and the timing, dosing, and duration of anticoagulation regimens.

Validated tools such as the Caprini RAM effectively stratify surgical patients by VTE risk; however, specific recommendations for abdominal-based reconstruction are lacking. Extended-duration prophylaxis appears beneficial in high-risk patients, with recent studies supporting preoperative initiation. Despite concerns about flap loss or hematoma, evidence suggests that appropriately dosed chemoprophylaxis does not significantly increase complications. Oral agents like apixaban show promise for improving adherence without increased bleeding risk. The majority of VTE events occur after discharge, supporting the rationale for outpatient prophylaxis. Future directions include machine learning-enhanced risk prediction and multicenter trials to standardize prophylaxis.

Patients undergoing abdominal-based breast reconstruction face substantial VTE risk, and tailored chemoprophylaxis is essential. While current evidence supports individualized risk-based strategies, practice variability underscores the need for a standardized chemoprophylaxis algorithm. Future prospective studies are critical to establish optimal prophylaxis regimens, timing, and duration in this high-risk surgical population.