[Salvage of digits replantations by direct arterial antithrombotic infusion].
Institut Aquitain de Chirurgie Plastique, Reconstructrice et Esthétique, Chirurgie de la Main et Microchirurgie, 56, allée des Tulipes, 33600 Pessac, Bordeaux, France.Annales de Chirurgie Plastique Esthétique (Impact Factor: 0.31). 01/2007; 51(6):471-81.
At the end of the seventy, we saw the reconstructive microsurgery developed to such an extent that it became a new and an independent surgical specialty. The development of the microsurgical instrumentation and the description of the surgical anatomy allowed the application of this technology to the most complex plastic reconstructions and particularly to the replantation of the amputated digits, especially the very distal digital amputations. Nowadays, the indications of digital replantation are well-defined according to numerous parameters conditioning the anatomical result and the functional outcome. It is well-known that the replantation of the amputated digit should be realized as soon as possible with optimal conditions of digital hibernation during the patient transport. In spite of that technical progress, the failure rate is still relatively important. The causes are sometimes recognizable and connected to technical defection, such as a non permeable vascular anastomosis, bad hemodynamics conditions or an insufficient anticoagulation, while in certain cases, the digital ischemia occurs in spite of permeable and technically successful arterial anastomosis. We then consider a "no reflow phenomenon". It corresponds to the constitution of vascular microthrombi which will block the arteriolar network. Those microthrombi are inaccessible to the microsurgical techniques and their treatment remains medical by intra-arterial infusion of antithrombotic agents. Through our series of fifteen digital replantations, having suffered a "no reflow phenomenon", we are going to present the fibrinolytic protocol we used and the promising results we obtained. All our patients were victims of traumatisms associating avulsions and crush injuries mechanisms. The conditions of preservation of the amputated digits were all quite unfavourable: 1) the amputated digit soaked in water in 5 cases; 2) the amputated fingers underwent a long-term "warm ischemia" in three cases, going up to 13 hours for one of them; 3) the amputated digits were completely frozen in six cases; 4) and one amputated finger was correctly hibernated but for too long a period (8 hours). The signs of ischemia appeared very prematurely in the first minutes after the microvascular revascularisation in ten cases, and in average within three hours postoperatively in the other five cases, with extreme cases going from 2 up to 6 hours. As soon as the diagnosis of "no reflow phenomenon" was confirmed, an intra-arterial catheter was fixed. The radial axis was chosen as the arterial infusion way and approached at the level of the pulse groove. The antithrombotic protocol included a flash of 50,000 UI of urokinase, 36 ml of lidocaïne 1% and 40 mg of enoxaparine, followed by an electric syringe infusion the first six hours with 150,000 UI of urokinase, 36 ml of lidocaïne 1% and 40 mg of enoxaparine at 6 cc/h speed. The urokinase was then interrupted but the intra-arterial infusion maintained with 72 ml of lidocaïne 1% and 80 mg of enoxaparine for 24 hours, at a 3 cc/h speed, and this for ten days. In 12 cases, the "no reflow phenomenon" was able to be raised and the digital vascularization restored. The success rate is very encouraging (80%) and it turns this protocol into a precious ally of the digit replantation microsurgery and an effective therapeutic means way against the "no reflow phenomenon".
Article: Digital Replantation[Show abstract] [Hide abstract]
ABSTRACT: The final judgment of whether to replant may not be determined until after microscopic inspection of vessels and nerves is complete. Once committed, it is ultimately the attention to detail that will determine function; bone shortening and rigid fixation, multiple strand flexor tendon repair, and quality, meticulous repair of the extensor mechanism to permit early movement, periosteal approximation to aid gliding, radical debridement of damaged vessels and primary skin closure.
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ABSTRACT: Nowadays, It is easy to define optimal conditions (cryoprotective agent, speed and steps of freezing, speed of warming) for the cryopreservation of a homogeneous cell population or a one cell-layer tissue. Meanwhile, It is still hard to obtain cryopreservation of composite organs. Each tissue has its own requirements and its own reactivity to the cryopreservation process. The challenge consists of, on the one hand, to select the ideal combination of cryoprotective agents that can fit the needs of the different tissues, and the definition of adequate technical parameters, on the other hand. All the experimental trials have studied the survival rate of non-vascularized cryopreserved tissues. The aim of our experimental work is to demonstrate the feasibility of cryopreserving a composite organ with its nutrient vessels "artery and veins" in order after thawing to revitalize it by reestablishing the blood irrigation by microsurgical vascular anastomosis. We report our experimental results on the cryopreservation of composite organs-amputated digits-xenotransplanted in the rabbit. Digital segments were cryopreserved, then revitalized after warming using vascular microsurgical techniques. Preliminary results are encouraging and may pave the way in the future to the microvascular allotransplantation of cryopreserved composite organs.
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ABSTRACT: No consensus exists among microsurgeons regarding the role of intravenous (IV) heparin in digital replantation/revascularization. The current experience of the Provincial Replantation Center in Quebec was reviewed over a 4-year period. An initial retrospective review of all revascularized or reimplanted digits at our Replantation Center from April 2004 to April 2006 was conducted. Then, data of all patients treated at our center from January 08 to September 08 were prospectively collected. The two cohorts were compared with regards to demographics, injury characteristics, postoperative thromboprophylaxis medication as well as complication and success rates. Proportions were compared using χ(2) tests/Fisher's exact tests. Multivariate analysis was conducted with logistic regression. 175 digits were treated from April 2004 to April 2006, including 104 revascularizations and 71 amputations. IV heparin was used in 35.1% of the cases and was associated with a 3.59-fold (95% CI, 1.55-8.31) increase risk of developing a complication compared with cases where heparin was not used (P = 0.001). In 2008, 106 digits were treated. IV heparin was used in 14.6% of the cases and was not significantly associated with a higher complication rate compared with cases where heparin was not used (P = 0.612). Both cohorts' success rates were very similar (P = 0.557). The number of complications decreased from the first period (20.5%) to the second one (12.8%). Routine use of IV heparin following digital replantation and revascularization is not warranted. Surgical technique and type of injury remains the most important predictors for success in these complex procedures.
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