Immediate Revascularisation of Borderline Ischemic Limbs Followed by Replantation

ABSTRACT

Introduction: Salvage of complex limb injuries is not onlydependent on the skill, experience and attitude of the surgeonbut also on the ischemia time. If the revascularisation isnot possible within the golden period then the outcomeis unfavourable. There are very few reports of delayedreplantation. We are presenting a case series of replantationbeyond the golden hours i.e. 6 hours of warm ischemia byimmediate revascularisation before undertaking definitivereplantation. The definitive sequence of replantation is carriedout after the limb gets revascularised and the viscious cycle ofischemia is broken. Study aimed to salvage amputated limbs inthe borderline ischemia time by immediate revascularisation.Material and methods: A study was conducted between April2013 to March 2018 at SBM Plastic Surgery Hospital, cuttackand included all patients with limb amputations of 6-10 hoursduration. In this study the artery was anastomosed first to haltthe sequence of prolonged ischaemia. Temporary stability tothe repair was provided by taking deep bites to the proximaland distal muscle group with 2.0 vicryl sutures adjacent tothe anastomosis. After the limb was adequately revascularisedand proper hemostasis was achieved then the proper sequenceof replantation was started.Result: out of 31 patients presenting during this period, 9patients were excluded for poor preservation of the limb andpresenting after 10 hours of warm ischamia. Total no of casesincluded in the study were 22 patients who presented between4 to 9 hours of cold ischemia time. The break up accordingto the nature of injury was, 19 patients had avulsion injuries,two had assault with heavy sharp weapons and one hadcrush injury. Out of 22 cases of replantation 2 cases requiredamputation at a later date due to complications.Conclusion: In our country majority of patient come tohospital after 6-8 hrs of warm ischemia which is the upperlimit of ishaemia. If the ideal sequence of replantation willbe followed these limbs will undergo irreversible ischaemicdamage due to further delay. So the concept of immediatearterialisation gives the best opportunity for limb survival.