Appropriate Use of Intravenous Unfractionated Heparin after Digital Replantation: A Randomized Controlled Trial Involving Three Groups.

BACKGROUND: The purpose of this study was to clarify the appropriate use of unfractionated heparin as an anticoagulation agent after digital replantation. METHODS: This study was a prospective, randomized, single-blind, blinded-endpoint method, three-arm, parallel-group, controlled clinical trial conducted at a single institution. A total of 88 patients (101 fingers) following digital amputation and subsequent repair by anastomosis of both arteries and veins were randomly allocated into three groups: (1) control group (no heparin dose), (2) low-dose heparin group (10,000 IU/day), and (3) high-dose heparin group (start at 15,000 IU/day, then adjust the dose to achieve an activated partial thromboplastin time of 1.5 to 2.5 times the baseline). The outcomes were assessed regarding the proportion of success at 2 weeks after replantation of amputated digits, total or partial necrosis, and occurrence of complications. RESULTS: No significant differences were found among the three groups, except for complications of congestion. The odds ratio of the heparin group compared with the control group for a success proportion was 5.40 (95 percent CI, 0.85 to 34.20; p = 0.027) in subjects aged 50 years or older. Significant elevations of activated partial thromboplastin time, aspartate transaminase, and alanine aminotransferase occurred in high-dose heparin groups on day 7. CONCLUSION: Unfractionated heparin administration is considered effective for patients aged 50 years or older, although the routine use of unfractionated heparin is not necessary after digital replantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Maggot debridement therapy with a direct dressing can cause compression injuries in patients with chronic limb ischemia.

While there are no reports regarding dressing-associated iatrogenic skin ulcer as an adverse event of maggot debridement therapy (MDT), MDT is clinically used on patients with critical limb ischaemia with dermal fragility. Herein we report causes and counter measures for a case of iatrogenic skin ulcer induced by MDT dressing.

Coronary Artery Disease in Patients with Critical Limb Ischemia Undergoing Major Amputation or Not.

BACKGROUND: Due to the increase of elderly and diabetes patients, surgeons encounter patients requiring treatment of critical limb ischemia (CLI) in the presence of systemic arteriosclerotic diseases. In this study, we retrospectively investigated the prevalence of coronary artery disease (CAD) in patients with CLI who underwent major (above-the-ankle) amputation or nonmajor amputation (below-the-ankle amputation or debridement of wound). METHODS: We retrospectively investigated 129 consecutive patients surgically managed for CLI in our institution between January 2013 and December 2015. The prevalence of CAD was defined as a cardiac treatment history or significant vascular stenosis (stenosis of > 75%). The outcomes were compared between patients who underwent major amputation (n = 36) and nonmajor amputation (n = 93). Additionally, archived record of 566 patients treated nonsurgically by percutaneous transluminal angioplasty in our institution was investigated to evaluate patients with milder peripheral artery disease. RESULTS: CAD was present in 83 patients (69%), including 82% of patients who underwent major amputation and 63% of nonmajor amputation group. The prevalence of CAD was significantly higher in the major amputation group (P = 0.042). Ejection fraction was not significantly different (P > 0.05). Among the 566 CLI patients treated by only percutaneous transluminal angioplasty, 227 (40%) had CAD, which was a significantly lower prevalence than those surgically treated (P < 0.001). CONCLUSIONS: The presence of CAD is more frequent in CLI patients who require extended surgical management of the limb than in those who do not. Evaluation of CAD and careful perioperative management are important for patients with CLI patients.

Maggot debridement therapy for a patient with critical limb ischaemia and severe cardiac dysfunction: possibility of limb salvage.

Ischaemic skin ulcer occurred on the foot of a 73-year-old man who had a history of fulminant myocarditis with severe cardiac dysfunction. We attempted wound bed preparation by maggot debridement therapy and salvaged his limb. It can be one of the adjuvant treatment strategies for critical limb ischaemia.