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Predictors of Arterial Insufficiency in Revascularized and Replanted Digits
Michelle Frees, MD1, Sergey Toshinskiy, MD2; Christopher J Hillard, MD3
1University of Minnesota, Minneapolis, MN, 2The Cleveland Clinic, Cleveland, MN, 3Regions Hospital, St Paul, MN

Background Arterial insufficiency is common following digital revascularization and replantation. It can progress to digital ischemia, which can threaten survival of a digit in the immediate postoperative period. The aim of this study is to evaluate the predictors of arterial insufficiency in revascularized and replanted digits which can help inform the decision to replant the digit and manage patientsí expectations.
Methods A retrospective review was performed to identify patients with complete or incomplete digital amputations at a Level 1 Trauma Center who underwent digital replantation or revascularization from January 2005 to December 2020. Amputations proximal to the palmar arch or had perfusion on pre operative assessment were excluded. Arterial insufficiency was diagnosed based on the digitís color, turgor, capillary refill, and presence of bleeding after pinprick. All hands were kept warm, elevated, and splinted. The patients received a low dose aspirin, DVT chemoprophylaxis and antibiotics. Patient demographics, medical history, injury mechanism, extent and level of injury, operative details, and digitís ultimate survival were collected.
Results Of the 156 patients who underwent 213 digital revascularizations (n = 135) and replantations (n = 78), arterial insufficiency developed in 40 (19%) digits, all of which ultimately became nonviable. Replanted digits were more likely to exhibit arterial insufficiency than revascularized digits (p = 0.007, OR = 2.55; 95% CI 1.26 - 5.12). Hand fellowship training of the primary surgeon was protective against arterial insufficiency (p = 0.049). Avulsion injury mechanism was significantly associated with arterial insufficiency (OR 1.73; 95% CI 1.08-2.76) as was the use of the vein graft (OR 1.89; 95% CI 1.29-2.77). Repair of more than one artery or use of heparin was not protective against arterial insufficiency (p = 0.572 and p = 0.275, respectively). Within the revascularization cohort, presence of a circumferential laceration was predictive of arterial insufficiency (OR 3.09; 95% CI 1.76-5.46) as was tobacco use (OR 2.1; 95% CI 1.26-3.5).
Conclusion Arterial insufficiency was found to be a common complication in revascularized and replanted digits with low likelihood of digit survival. In our study, we found avulsion mechanisms, circumferential injury, use of vein graft, and tobacco usage to be predictors of digit failure whereas repair of more than one artery and use of heparin did not promote survival. Surgeon training was shown to be significant, supporting designated replant centers. These conclusions should help determine digit prognosis and can aid in the decision to salvage a dysvascular digit or proceed with revision amputation.


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