Increased Failure Rate of Leech Therapy in Revascularized and Replanted Digits with Venous Congestion after Seven Days
Sergey Toshinskiy, MD1, Michelle Frees, MD1, Pedram Zargari, MD1 and Christopher J Hillard, MD2, (1)University of Minnesota, Minneapolis, MN, (2)Regions Hospital, St Paul, MN
Purpose: Venous congestion following digital revascularization and replantation can threaten survival of the digit in the immediate postoperative period. Leech therapy is a well established treatment for venous congestion. Leeches facilitate venous egress while angiogenesis and neovascularization takes place, which can take up to a week. The aim of this study is to evaluate the efficacy of leech therapy in the revascularized and replanted digits and to determine a time point at which there is no survival benefit to continued leeching.
Methods: A retrospective review was performed to identify all patients with complete or incomplete digital amputations at an academic Level 1 Trauma Center who underwent digital replantation or revascularization from January 2005 to December 2020. Amputations proximal to the palmar arch as well as revascularized digits that showed any degree of perfusion on pre operative assessment were excluded. Leech therapy was initiated as soon as any signs of venous congestion appeared. Leech therapy commenced at a frequency of one leech every two hours, which was then titrated to clinical effect with frequent assessment of the digit's color, capillary refill, and the color of bleeding after pinprick. Leech therapy was discontinued once either venous congestion resolved or the digit became non viable.
Results: Of the 156 patients who underwent 213 digital revascularizations (n = 135) and replantations (n = 78), venous congestion requiring leech therapy developed in 27 digits in the revascularization group and in 26 in the replantation group. Of the digits that were leeched, 15 failed in the revascularization group (56% failure rate) and 17 failed in the replantation group (65% failure rate). Duration of leech therapy ranged from one to 15 days post operatively (median of five days in both revascularization and replantation groups). Success rate diminished with time such that leeching for 1-3, 4-7, >7 days had success rates of 69%, 42% and 8% respectively. The >7 day group had significantly higher risk of failure than 1-7 day group (OR = 11.6; 95% CI 1.36 - 98.5; p = 0.008).
Conclusion: Leech therapy has a modest success rate in treatment of vascular congestion in revascularized and replanted digits and its efficacy is further limited after seven days. These data can aid in determining the prognosis of a digit with venous congestion and help inform the decision of initiating or concluding leech therapy, exploring other ways of establishing venous outflow, or proceeding with revision amputation.
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