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Venous Thromboembolism After Pedicled TRAM Versus Free Flap Breast Reconstruction: A Propensity-Matched Analysis
Samuel A Knoedler1, Julius M Wirtz2, Giuseppe Sofo3
1Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Instituto Ivo Pitanguy, Rio de Janeiro, Brazil.
Background:
Venous thromboembolism (VTE) is a potentially life-threatening complication after autologous breast reconstruction, but comparative data between pedicled transverse rectus abdominis myocutaneous (TRAM) and free flap techniques remain limited.
Patients And Methods:
A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database (2013-2023). Female breast cancer patients undergoing immediate autologous breast reconstruction were included. Thirty-day deep vein thrombosis (DVT), pulmonary embolism (PE), and composite VTE were analyzed using multivariable regression and propensity score matching, with prespecified subgroup analysis by American Society of Anesthesiologists (ASA) classification.
Results:
A total of 8014 patients were included, of whom 21.3% underwent pedicled TRAM reconstruction, and 78.7% received free flaps. Overall, VTE incidence was 1.4%, including 0.9% DVT and 0.7% PE. No difference in overall VTE risk was observed between TRAM versus free flap reconstruction. However, patients who developed VTE were older (54.7 ± 9.3 vs 52.3 ± 9.3 years, P = .007), had higher body mass index (31.6 ± 6.4 vs. 29.3 ± 6.1 kg/m2, P < .001), and were more frequently obese (54.1% vs. 37.8%, P = .001). VTE was associated with significantly increased morbidity, including higher rates of reoperation (29.4% vs. 12.2%, P < .001), readmission (44.0% vs. 5.6%, P < .001), prolonged length of hospital stay (6.3 ± 9.3 vs. 3.9 ± 4.3 days, P = .006), and increased mortality (0.9% vs. <0.1%, P = .022). In patients with ASA ≥3, pedicled TRAM reconstruction was associated with significantly higher VTE risk (adjusted odds ratio 3.09, P = .039).
Conclusion:
While overall autologous VTE risk is modest, pedicled TRAM reconstruction carries a significantly higher thrombotic risk in frail patients. These findings support ASA-guided reconstructive decision-making and intensified VTE prophylaxis in high-risk patients.
