Lee Jun Yong, Kim Hak Soo, Heo Sang Taek, Kwon Ho, Jung Sung-No
aDepartment of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea bDepartment of Internal Medicine, School of Medicine, Jeju National University, Jeju, Republic of Korea.
Medicine (Baltimore). 2016 Jun;95(26):e3979. doi: 10.1097/MD.0000000000003979.
Replantation is a prime indication for distal digital amputation, as it helps restore hand aesthetics and functions; however, venous anastomosis is often not feasible. Previous studies used systemic anticoagulation in distal digital artery only anastomosis replantation surgery to improve replantation success rate, however, which yielded limited level of clinical evidence. This study aimed to compare controlled continuous heparinization (CCH) and intermittent bolus heparinization (IBH) for surgical outcome and clinical variables after single distal digital artery only anastomosis replantation surgery.A single-institution, retrospective cohort study was performed. Out of 324 patients who underwent digital replantation surgery, we focused the study for the Zone I and II single distal digital amputation patients excluding confounding factors. Sixty-one patients were included in this study and underwent artery-only anastomosis replantation surgery with postoperative CCH (34 patients) or IBH (27 patients) protocols. The CCH group targeted activated partial thromboplastin time (aPTT) at 51 to 70 seconds, monitoring aPTT levels every eight hours and administering 100 mg of aspirin per day. The IBH group received 300 mg of aspirin per day and underwent IBH (12,500 U). Both groups received intravenous prostaglandin E1 drips (10 μg). To verify the factors affecting the success rate of the heparin protocol, patient factors, clinical factors, and operative factors were extracted from the medical records. Statistical analysis with inverse probability of treatment weights propensity score methods compared treatment outcomes and clinical variables.The CCH group's replantation success rate was higher (91.17% vs 59.25%), and the transfusion rate was increased (P = 0.032). However, the significant decrease in hemoglobin levels (>15%) did not differ between the groups (P = 0.108). Multivariable logistic regression analysis with potent univariate variables (P < .10) revealed that CCH was a statistically significant variable in replantation success rate (P = 0.004). Neither the major bleeding complications nor the significant decrease in patients' platelet levels were observed in both groups.Our study suggests that CCH after artery-only anastomosis replantation surgery in Zone I and II distal digital replantation is a safe method to improve the replantation success rate and may provide a guideline for use of the anticoagulation method following artery-only anastomosis distal digital replantation surgery.
再植术是手指末节离断的主要治疗手段，因为它有助于恢复手部美观和功能；然而，静脉吻合往往不可行。以往的研究在手指末节动脉吻合再植手术中采用全身抗凝治疗以提高再植成功率，但其临床证据水平有限。本研究旨在比较单次手指末节单纯动脉吻合再植手术后持续控制性肝素化（CCH）和间歇性推注肝素化（IBH）的手术效果及临床变量。
本研究为单中心回顾性队列研究。在324例行断指再植手术的患者中，我们聚焦于排除混杂因素的Ⅰ区和Ⅱ区手指末节离断患者。本研究纳入61例患者，他们均接受了单纯动脉吻合再植手术，并采用术后CCH方案（34例患者）或IBH方案（27例患者）。CCH组将活化部分凝血活酶时间（aPTT）目标设定为51至70秒，每8小时监测aPTT水平，并每日给予100mg阿司匹林。IBH组每日接受300mg阿司匹林，并进行IBH（12500U）。两组均接受静脉滴注前列腺素E1（10μg）。为验证影响肝素方案成功率的因素，从病历中提取患者因素、临床因素和手术因素。采用治疗权重逆概率倾向评分法进行统计分析，比较治疗效果和临床变量。
CCH组的再植成功率更高（91.17%对59.25%），输血率增加（P = 0.032）。然而，两组间血红蛋白水平显著下降（>15%）并无差异（P = 0.108）。对具有显著单变量（P < 0.10）进行多变量逻辑回归分析显示，CCH在再植成功率方面是一个具有统计学意义的变量（P = 0.004）。两组均未观察到严重出血并发症或患者血小板水平显著下降。
我们的研究表明，Ⅰ区和Ⅱ区手指末节再植单纯动脉吻合再植手术后的CCH是提高再植成功率的一种安全方法，可能为手指末节单纯动脉吻合再植手术后抗凝方法的使用提供指导。
