Arteriovenous shunt in digit replantation From May 1958 to May 1987, 331 digits were replanted successfully with an overall survival rate of 86.2%. Complete success in replantation of amputated fingers requires an accurate anastomoses of both arteries and veins. However, anastomosis between arteries may not be possible in some patients. Since reports that a thumb amputated at the interphalangeal joint area could be successfully replanted by an arteriovenous shunt on the palmar side, we did arteriovenous shunts in four such cases. Two replantations were successful; necrosis developed In the other two patients. (J HAND SURG 1990j15A: 160-5.)
Akihiro Fukui, MD, Masarni Maeda, MD, Yuji Inada, MD, Susumu Tarnai, MD, and Takeo Sempuku, MD, Nara, Japan
From
May 1958 to May 1987 we successfully replanted 331 digits with an overall survival rate of 86.2%.1 Since Tsuchida and Ueki 2 reported that a thumb amputation could be successfully replanted by doing an arteriovenous (A-V) shunt on the palmar side, we did A-V shunt operations in 4 patients in which a normal anastomosis was impossible. The clinical course and findings of these four patients are reported.
Case reports Case 1. A 62-year-old man had his left thumb amputated completely by an electric saw on October 6, 1986. According to Tamai's category,J the amputation was in zone III (Fig. 1). After debridement under axillary block anesthesia, bonc fixation was done with two Kirschner wires. After suturing the flexor pollicis longus and the extensor pollicis longus tendons, anastomosis of the digital artery on ulnar side was attempted but it was discontinued because of serious damage of the vessels. Inasmuch as arterial anastomosis was impossible for the digital artery on the radial side, a skin incision on the radial side of the proximal end was made, and the digital artery was dissected proximally, moved to the dorsal side, and anastomosed to a dorsal vein on the amputated
From the Department of Orthopedic Surgery, Omiwa Hospital, Nara, Japan. Received for publication Nov. I, 1988; accepted in revised form Feb. 19, 1989. No benefits in any form have been It:ceived or will be received frorn a comrnercial party related directly or indirectly to the subject of this article. Reprint requests: Akihiro Fukui, MD, Department of Orthopedic Surgery, Omiwa Hospital, 136 Kanaya, Sakurai, Nara 633, Japan. 3/1/12501
160
THE JOURNAL OF HAND SURGERY
Fig. 1. A 62-year-old man cut off his left thumb with an electric saw.
thumb. The color of the pulp improved after providing the A- V shunt, and bleeding was also seen at the amputated end. One dorsal vein was anastomosed for returning venous blood. The operation lasted 4 hours. The color became poor 5 days later and exploration showed thrombus formation in the area of the A-V anastomosis (Fig. 2). A vein approximately 2 cm long was taken from the forearm and transplanted; but the color never returned to normal. Finally, a reversed radial forearm flap was provided 7 days after the operation. Case 2. A 20-year-old man had his index finger amputated completely by a car door. The injury was in zone I and showed an avulsed wound including the nail matrix (Fig. 3). Under axillary block anesthesia, the bone was fixed with a Kirschner wire, and arterial anastomosis attempted. Inasrnuch as only the proximal digital artery and the palmar digital vein in the amputated tip could be found, an A- V shunt was done between
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Fig. 2. The replanted thumb turned blue 5 days after operation. these vessels (Fig. 4). Fresh bleeding was seen when a fish-mouth incision was made on the pulp of the finger after the skin on the dorsal and palmar sides was roughly sutured. Heparinized gauze was replaced in the wound at I-hour intervals. Recovery from the operation was uneventful. The fish-mouth incision was sutured 10 days after the operation and the replantation was successful. The replanted finger showed marked atrophy (Fig. 5). This may be due to insufficient blood inflow through the A-V shunt, and outflow from the fish-mouth incision.' Digital subtraction angiography done after the operation clearly shows the anastomosed artery (Fig. 6). Case 3. A 48-year-old man was injured on May 19, 1988, when his long finger was caught in a machine. The injury was an incomplete amputation in zone Ill. The finger was severely crushed. Under axillary block anesthesia, the bone was fixed with two Kirschner wires, and an anastomosis of the palmar digital artery was attempted. The intima of the arteries in the amputated tip were separated from the tunica media and thrombus formation was seen. A defect approximately I cm long of the digital artery on the radial side was found; therefore, anastomosis was not attempted. Anastomosis of the ulnar digital artery was attempted twice, but blood flow in the vein did not return satisfactorily. Whcn the ulnar digital artery was separated proximally and cut at a place where favorable bleeding was seen, a defect about 2 cm long was made. A vein was taken from the palmar side of the forearm and transplanted. Blood flow from the end of the transplanted vein was good, but did not return from the dorsal vein even after the anastomosis. An A-V shunt between the grafted arterialized vein and the palmar digital vein of the tip was done. Because the radial digital artery was as severely damaged as on the ulnar side, we thought it is useless to graft a vein to the defect on the radial side. Fresh bleeding from the amputated end was seen. No venous anastomosis was
Fig. 3. A 20-year-old man pinched his index finger in the door of a car.
done, because the finger was incompletely amputated and it was not edematous. The finger made a good recovery after the operation (Fig. 7). Digital subtraction angiography clearly demonstrated the successfully anastomosed area. Case 4. A 60-year-Old man accidentally cut off his right thumb with an electric saw. The amputation was in zone III. Under axillary block anesthesia, thc bone was fixed with two Kirschner wircs, and arterial anastomosis was attempted. Aftcr end-to-end anastomosis of the ulnar digital artery with the amputated digital artery, the venous anastomosis was done. The color became poor and the arterial anastomosis was found to be thrombosed. After both ends of the artery were excised, a 2 ern long venous transplantation was interposed. However, arterial thrombosis again developed. The artery at this point ramified into three branches, so further anastomosis was not done. Since there was good blood flow from the 2 em long transplanted vein anastomosed with the proximal digital artery, it was anastomosed with the dorsal vein of the amputated finger. The color of the pulp turned pink after the operation, and bleeding was seen from the amputated end. A fish-mouth incision was made because no vein was found for anastomosis, and heparinized gauze was replaced at I-hour inter-
162
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If!
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The Journal of HAND SURGERY
Fig. 5. The finger made a good recovery.
Fig. 4. Arteriovenous shunt was done between a proximal artery and a distal vein (arrow: artery, double arrows: vein). vals. About 5 days after the operation, blood from the fish-mouth incision became dark red, and the area finally necrosed. An amputation was done, since the patient was not willing to undergo another major operation.
Discussion Few clinical cases have been reported in which amputated fingers have been replanted successfully using an A-V shunt. Tsuchida and UekF reported that a thumb amputated in the IP joint area could be successfully replanted by making an A-V shunt on the palmar side. As reasons for the successful replantation, they stated that nutrition could be supplied to distal tissues by an A-V shunt, and that the presence of valves in the peripheral vein might be of importance. Harveys demonstrated the presence of venous flow and valves. Timmonsl'i reported that venous valves would be controlled by the sympathetic nerve, and that blood would flow backwards through venous valves in the following situations: (I) The vein is denervated, for instance, by anesthetics and fragmentation of skin flaps; (2) Blood is present proximal and distal to the valves; and (3)
Pressure is higher proximal to the valves than in the periphery. At the same time, Timmons suggested that reflux would not occur when any of these conditions was found independently. From the facts that the vein is denervated when an amputated finger is successfully replanted and that arterial pressure is higher proximally it can be explained that an A-V shunt has a possibility of success in replantation of an amputated finger. A comparison was made between our sllccessful and unsuccessful cases. The successful cases were in index and long fingers with an A-V shunt on the palmar side and, in the case of the long finger, with venous transplantation. In contrast, the unsuccessful cases were of the thumb: in case 1, venous transplantation was done not at the operation soon after amputation, but in the later operation; and, in case 4, an A-V shunt was carried out after a vein graft had been added to the palmar digital artery. Both unsuccessful cases had an uncomplicated course for several days after the operation, but then circulatory disturbances developed. Two technical differences exist between the successful and unsuccessful cases, (l) The successful cases involved index and long fingers and the unsuccessful cases involved thumbs; and (2) In the successful cases, the A-V anastomosis was done on the palmar side. In the unsuccessful cases, the A-V anastomosis were done between
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Fig. 7. The finger made a good recovery.
Fig. 6. Digital subtraction angiography clearly demonstrated the area of anastomosis.
the palmar artery and a dorsal vein. From these differences, we reason that the venous valves on the dorsal side of the thumb blocked the inflow of arterial blood from the A-V shunt. However, Moss et al. 7 reported that the venous system of the thumb is similar to the
other digits. No successful cases of an A-V shunt between a proximal palmar digital artery with a dorsal vein on the amputated tip have been reported. Tsuchida and Ueki did succeed in restoring blood flow by endto-end anastomosis bctween a palmar digital artery with a palmar vein. In all of our failed cases, amputation was in zone IfI and an A-V shunt with the dorsal vein was carried out, which seems to have caused thrombosis. Moss et al. 7 studied the digital veins in nine cadavers and demonstrated that the dorsal and palmar veins had valves. They reported that when injection is done into the palmar system with a tourniquet placed at the level of the proximal interphalangeal (PIP) joint of the index finger, free flow occurs into the dorsal system through oblique communicating veins over the middle phalanx. The middle venous arch filled, but no distal reflex into the veins of the more distal dorsal system occurred because of the valves at the tributaries of this arch. The blood that passed through the palmar vein flowed backwards through the palmar valve and returned to the dorsal vein after passing through the oblique communicating vein. It is thought that in cases wherc pressure is high enough in an A-V shunt that blood could pass through the whole area of the amputated finger if it
164
The Journal of HAND SURGERY
Fukui et ai.
V_".~"~-~ V
A-V shunt
(A) Schema of Case 2
oblique communicating vein
Akihiro Fukui, MD, Masarni Maeda, MD, Yuji Inada, MD, Susumu Tarnai, MD, and Takeo Sempuku, MD, Nara, Japan
From
May 1958 to May 1987 we successfully replanted 331 digits with an overall survival rate of 86.2%.1 Since Tsuchida and Ueki 2 reported that a thumb amputation could be successfully replanted by doing an arteriovenous (A-V) shunt on the palmar side, we did A-V shunt operations in 4 patients in which a normal anastomosis was impossible. The clinical course and findings of these four patients are reported.
Case reports Case 1. A 62-year-old man had his left thumb amputated completely by an electric saw on October 6, 1986. According to Tamai's category,J the amputation was in zone III (Fig. 1). After debridement under axillary block anesthesia, bonc fixation was done with two Kirschner wires. After suturing the flexor pollicis longus and the extensor pollicis longus tendons, anastomosis of the digital artery on ulnar side was attempted but it was discontinued because of serious damage of the vessels. Inasmuch as arterial anastomosis was impossible for the digital artery on the radial side, a skin incision on the radial side of the proximal end was made, and the digital artery was dissected proximally, moved to the dorsal side, and anastomosed to a dorsal vein on the amputated
From the Department of Orthopedic Surgery, Omiwa Hospital, Nara, Japan. Received for publication Nov. I, 1988; accepted in revised form Feb. 19, 1989. No benefits in any form have been It:ceived or will be received frorn a comrnercial party related directly or indirectly to the subject of this article. Reprint requests: Akihiro Fukui, MD, Department of Orthopedic Surgery, Omiwa Hospital, 136 Kanaya, Sakurai, Nara 633, Japan. 3/1/12501
160
THE JOURNAL OF HAND SURGERY
Fig. 1. A 62-year-old man cut off his left thumb with an electric saw.
thumb. The color of the pulp improved after providing the A- V shunt, and bleeding was also seen at the amputated end. One dorsal vein was anastomosed for returning venous blood. The operation lasted 4 hours. The color became poor 5 days later and exploration showed thrombus formation in the area of the A-V anastomosis (Fig. 2). A vein approximately 2 cm long was taken from the forearm and transplanted; but the color never returned to normal. Finally, a reversed radial forearm flap was provided 7 days after the operation. Case 2. A 20-year-old man had his index finger amputated completely by a car door. The injury was in zone I and showed an avulsed wound including the nail matrix (Fig. 3). Under axillary block anesthesia, the bone was fixed with a Kirschner wire, and arterial anastomosis attempted. Inasrnuch as only the proximal digital artery and the palmar digital vein in the amputated tip could be found, an A- V shunt was done between
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Fig. 2. The replanted thumb turned blue 5 days after operation. these vessels (Fig. 4). Fresh bleeding was seen when a fish-mouth incision was made on the pulp of the finger after the skin on the dorsal and palmar sides was roughly sutured. Heparinized gauze was replaced in the wound at I-hour intervals. Recovery from the operation was uneventful. The fish-mouth incision was sutured 10 days after the operation and the replantation was successful. The replanted finger showed marked atrophy (Fig. 5). This may be due to insufficient blood inflow through the A-V shunt, and outflow from the fish-mouth incision.' Digital subtraction angiography done after the operation clearly shows the anastomosed artery (Fig. 6). Case 3. A 48-year-old man was injured on May 19, 1988, when his long finger was caught in a machine. The injury was an incomplete amputation in zone Ill. The finger was severely crushed. Under axillary block anesthesia, the bone was fixed with two Kirschner wires, and an anastomosis of the palmar digital artery was attempted. The intima of the arteries in the amputated tip were separated from the tunica media and thrombus formation was seen. A defect approximately I cm long of the digital artery on the radial side was found; therefore, anastomosis was not attempted. Anastomosis of the ulnar digital artery was attempted twice, but blood flow in the vein did not return satisfactorily. Whcn the ulnar digital artery was separated proximally and cut at a place where favorable bleeding was seen, a defect about 2 cm long was made. A vein was taken from the palmar side of the forearm and transplanted. Blood flow from the end of the transplanted vein was good, but did not return from the dorsal vein even after the anastomosis. An A-V shunt between the grafted arterialized vein and the palmar digital vein of the tip was done. Because the radial digital artery was as severely damaged as on the ulnar side, we thought it is useless to graft a vein to the defect on the radial side. Fresh bleeding from the amputated end was seen. No venous anastomosis was
Fig. 3. A 20-year-old man pinched his index finger in the door of a car.
done, because the finger was incompletely amputated and it was not edematous. The finger made a good recovery after the operation (Fig. 7). Digital subtraction angiography clearly demonstrated the successfully anastomosed area. Case 4. A 60-year-Old man accidentally cut off his right thumb with an electric saw. The amputation was in zone III. Under axillary block anesthesia, thc bone was fixed with two Kirschner wircs, and arterial anastomosis was attempted. Aftcr end-to-end anastomosis of the ulnar digital artery with the amputated digital artery, the venous anastomosis was done. The color became poor and the arterial anastomosis was found to be thrombosed. After both ends of the artery were excised, a 2 ern long venous transplantation was interposed. However, arterial thrombosis again developed. The artery at this point ramified into three branches, so further anastomosis was not done. Since there was good blood flow from the 2 em long transplanted vein anastomosed with the proximal digital artery, it was anastomosed with the dorsal vein of the amputated finger. The color of the pulp turned pink after the operation, and bleeding was seen from the amputated end. A fish-mouth incision was made because no vein was found for anastomosis, and heparinized gauze was replaced at I-hour inter-
162
Fukui
If!
{II.
The Journal of HAND SURGERY
Fig. 5. The finger made a good recovery.
Fig. 4. Arteriovenous shunt was done between a proximal artery and a distal vein (arrow: artery, double arrows: vein). vals. About 5 days after the operation, blood from the fish-mouth incision became dark red, and the area finally necrosed. An amputation was done, since the patient was not willing to undergo another major operation.
Discussion Few clinical cases have been reported in which amputated fingers have been replanted successfully using an A-V shunt. Tsuchida and UekF reported that a thumb amputated in the IP joint area could be successfully replanted by making an A-V shunt on the palmar side. As reasons for the successful replantation, they stated that nutrition could be supplied to distal tissues by an A-V shunt, and that the presence of valves in the peripheral vein might be of importance. Harveys demonstrated the presence of venous flow and valves. Timmonsl'i reported that venous valves would be controlled by the sympathetic nerve, and that blood would flow backwards through venous valves in the following situations: (I) The vein is denervated, for instance, by anesthetics and fragmentation of skin flaps; (2) Blood is present proximal and distal to the valves; and (3)
Pressure is higher proximal to the valves than in the periphery. At the same time, Timmons suggested that reflux would not occur when any of these conditions was found independently. From the facts that the vein is denervated when an amputated finger is successfully replanted and that arterial pressure is higher proximally it can be explained that an A-V shunt has a possibility of success in replantation of an amputated finger. A comparison was made between our sllccessful and unsuccessful cases. The successful cases were in index and long fingers with an A-V shunt on the palmar side and, in the case of the long finger, with venous transplantation. In contrast, the unsuccessful cases were of the thumb: in case 1, venous transplantation was done not at the operation soon after amputation, but in the later operation; and, in case 4, an A-V shunt was carried out after a vein graft had been added to the palmar digital artery. Both unsuccessful cases had an uncomplicated course for several days after the operation, but then circulatory disturbances developed. Two technical differences exist between the successful and unsuccessful cases, (l) The successful cases involved index and long fingers and the unsuccessful cases involved thumbs; and (2) In the successful cases, the A-V anastomosis was done on the palmar side. In the unsuccessful cases, the A-V anastomosis were done between
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Fig. 7. The finger made a good recovery.
Fig. 6. Digital subtraction angiography clearly demonstrated the area of anastomosis.
the palmar artery and a dorsal vein. From these differences, we reason that the venous valves on the dorsal side of the thumb blocked the inflow of arterial blood from the A-V shunt. However, Moss et al. 7 reported that the venous system of the thumb is similar to the
other digits. No successful cases of an A-V shunt between a proximal palmar digital artery with a dorsal vein on the amputated tip have been reported. Tsuchida and Ueki did succeed in restoring blood flow by endto-end anastomosis bctween a palmar digital artery with a palmar vein. In all of our failed cases, amputation was in zone IfI and an A-V shunt with the dorsal vein was carried out, which seems to have caused thrombosis. Moss et al. 7 studied the digital veins in nine cadavers and demonstrated that the dorsal and palmar veins had valves. They reported that when injection is done into the palmar system with a tourniquet placed at the level of the proximal interphalangeal (PIP) joint of the index finger, free flow occurs into the dorsal system through oblique communicating veins over the middle phalanx. The middle venous arch filled, but no distal reflex into the veins of the more distal dorsal system occurred because of the valves at the tributaries of this arch. The blood that passed through the palmar vein flowed backwards through the palmar valve and returned to the dorsal vein after passing through the oblique communicating vein. It is thought that in cases wherc pressure is high enough in an A-V shunt that blood could pass through the whole area of the amputated finger if it
164
The Journal of HAND SURGERY
Fukui et ai.
V_".~"~-~ V
A-V shunt
(A) Schema of Case 2
oblique communicating vein
