Ankara Hospital Protocol for Digital Replantations/Revascularizations: Review of Complications

Introduction: The success of digital replantation/revascularization is extremely dependent on the patency of the repaired vessel. However, treatment protocol in digital replantation/revascularization is still controversial and there is no consensus among surgeons after microvascular anastomosis. Previous studies revealed that hyperhomocysteinemia and activated protein C resistance/Factor V Leiden mutation prevalence were 10,9% and 1-15% among healthy people in European populations which may show us increased tendency toward coagulation and failure in surgery in case of excellent surgical technique. Antithrombotic agents, heparin, low molecular weight dextran are frequently used for preventing vascular occlusion. To increase the survival rate, we have been used a standard protocol since 2010. Herein, we report our routine treatment protocol and their side effects in digital replantation/revascularization of 4-year-experience.

Methodology and Material: 164 digits were treated from 2010 to 2013, including 114 revascularizations and 50 replantations. A retrospective analysis was performed. All patients after 2010, received the same treatment protocol of intravenous heparin 5000 IU administered at the time of arterial anastomosis and in postoperative period 20000 IU/day of systemic heparin infusion for 7 days. Additionally, 500 ml of low molecular weight dextran per day and 300 mg acetylcystein three times a day were given for 5 days by intravenous access. Acetylsalycilic acid was started 300 mg for first day and 100 mg a day for 4 weeks per oral. Younger than 13 year-old -age patients and proximal to wrist amputations/revascularizations were excluded from the study. Complications, liver and kidney biochemical function tests, blood count and coagulation parameters investigation and abdominal ultrasonography when needed were made. Given blood transfusion was also reviewed.

Results: Mean hospital stay was 13 days. Elevations in alanine aminotransferase and aspartate aminotransferase were seen as average maximum 5-fold in 62% of patients. However, by the ending of the protocol, the elevated levels tend to decrease. 5% of patients had headache which was symptomatic to discontinue intravenous dextran therapy. 11% of patients needed blood transfusion. No hypersensitivity or allergic reactions, heparin induced thrombocytopenia was observed.

Conclusions: The protocol described is both safe and reliable when those specific patients were monitored strictly. However, the surgeons should be alert for 7 days in postoperative period. The patient should also be informed that such replantation surgery attempts and postoperative period may result in the need for transfusions, extended hospital durations and may cause transient impaired liver function tests. Although surgical technique and type of injury remains the most important factors for success, other factors such as hypercoagulability cannot be denied in failure.