Heparin Irrigation Research Articles

Utility of the intraflap perfusion procedure for abdominal free flap in unilateral breast reconstruction

Heparin prophylaxis for venous thromboembolism can be used in microsurgery. If vein anastomosis is performed before the artery, heparin irrigation into the artery can be performed locally without systematic effect. This study aimed to introduce this "intraflap perfusion procedure" in autologous breast reconstruction. Among the 220 patients with unilateral breast cancer who had received the free abdominal flap, we retrospectively compared those that had undergone the intraflap perfusion procedure (n = 108) and those who did not (n = 112). A 10 mL injection of heparinized physiological saline solution (100 units/mL) was administered into the deep inferior epigastric artery. Intraflap perfusion was performed before, during, and after vein anastomosis, without the vessel clip of the vein. Artery anastomosis was performed without the use of a vein clamp. Further, vein anastomosis was performed tightly to prevent leakage from the vein anastomosis site during artery anastomosis. The rates of superficial inferior epigastric vein (SIEV) superdrainage (18.5% vs. 42.0%, P < 0.001), and intraoperative flap congestion (0.9% vs. 8.0%, P = 0.01) were significantly lower in patients undergoing this procedure. There were no significant differences regarding other factors (age, BMI, laterality, comorbidities, and other operative details). Intraflap perfusion prevented long-term stasis at the venous anastomosis site and capillary level. It could reduce flap congestion. SIEV superdrainage was performed to manage flap congestion, particularly in patients who did not undergo this procedure. Consequently, it can be inferred that this procedure reduces the rate of superdrainage.

A Rare Case of Obstructive Jaundice After Endoscopic Sphincterotomy

Obstructive jaundice due to formation of a biliary clot is exceedingly rare with less than 8 documented cases reported in literature to date. The pathogenic mechanism underlying these cases are biliary hemorrhaging due to endoscopic manipulation. We present a case of obstructive jaundice after endoscopic sphincterotomy due to biliary hemorrhaging and subsequent clot formation. An 87 year old female with past medical history of atrial fibrillation on Coumadin and past surgical history of cholecystectomy presented to the hospital with nausea, vomiting, fever, and RUQ pain. Labs revealed abnormal liver function and leukocytosis. CT abdomen/pelvis revealed multiple stones in the distal common bile duct, which was dilated at 1.6 cm. ERCP with sphincterotomy was performed and multiple stones were removed via balloon extraction. No post-sphincterotomy bleeding was noted at the time of the procedure. Three days later the patient developed worsening liver function, jaundice, and RUQ pain. Repeat CT abdomen/pelvis showed a small filling defect measuring 5x5 mm in the distal common bile duct. Repeat ERCP was performed and revealed an ulcerated papilla with a large, protruding blood clot. The clot was partially removed with a snare during attempted cannulation. A wire was then passed into the biliary tree through the blood clot and injection of contrast revealed a dilated common bile duct with no filling defects. A 12 mm balloon sweep of the common bile duct was performed and the blood clot was removed.1293.tif Figure 1: Blood clot seen during ERCP at the papillaPatients experiencing post-sphincterotomy hemobilia present with clinical findings indicative of hemorrhage such as fatigue, hypotension, low hemoglobin, and hematochezia. Subsequent clot formation as seen in this case can obscure the diagnosis due to signs of obstructive jaundice mimicking choledocolithiasis. Standardizing treatment for blood clots induced by endoscopic instrumentation in the setting of hemobilia has been difficult due to lack of consensus on diagnostic classification, variability in presentation, and infrequency of incidence. As suggested in literature, most cases arise within the first 10 days following biliary manipulation. Treatment modalities for clot extraction vary but typically include: nasobiliary catheter placement, balloon catheter retrieval, Dormia basket, heparin irrigation. The literature suggests improved outcomes with ERCP and endoscopic catheter retrieval, but further comparative studies of treatment modalities need to be conducted.

The Untold Story of the First Hand Transplant: Dedicated to the Memory of one of the Great Minds of the Ecuadorian Medical Community and the World.

In 1964, faced with the challenge of traumatic amputation, a team of surgeons at Clinica Guayaquil was convinced that the transplantation of a hand could significantly improve function and quality of life for the recipient. With a current but basic understanding of immunosuppression, the surgeons identified a recipient and waited for the correct donor. A human hand transplant had never been performed to date. The surgeons' criteria for the recipient included a young healthy individual who had sustained a traumatic amputation at the distal forearm level with full motion of the proximal joints. Communication with receiving hospitals and military facilities identified what they perceived to be a feasible donor for an allograft transplantation. Consent was obtained from the family in conjunction with the local military medical authorities and the clergy. Iced saline solution and Heparin irrigation were to be used to prepare the donor extremity. The immunosuppression regimen, limited at the time, consisted only of intravenous cortisone, Imuran, and a single dose of radiation. A member of the Ecuadorian marine sustained a limited blast injury that amputated his dominant hand but spared the forearm. He was transferred to the emergency department of Clinica Guayaquil. A donor who had recently died in a nearby hospital was identified not long after. A successful technical surgical transplantation was achieved. Consultants from major hospitals around the world (including Peter Bent Brigham Hospital) convened at the patient's bedside to observe the results. Despite all efforts, the patient suffered an irreversible rejection at 21 days post-transplant. This was the first allograft transplantation of a hand. The surgeons embarked on an intervention never tried before, firmly believing that better function and quality of life would result. The bravery of this surgical team was commendable. This early surgical endeavor opened the way for future successes in transplant surgery today.

Role of Heparin Irrigation in the Management of Superficial Burns with Special Reference to Pain Relief and Wound Healing: A Pilot Study

IntroductionThe objective of this study was to assess the effect of heparin irrigation in the management of superficial first and second degree burns with special reference to pain relief and wound healing.Materials and methodsThis pilot study was carried out over a period of 12 months in a tertiary care centre in South India. The study patients were divided into two groups: the heparin group and the saline control group. In the control group, the burn wound was irrigated with 100 mL of normal saline before the conventional dressing with silver sulfadiazine. In the heparin irrigation group, the wound was irrigated with heparin solution before the conventional dressing. Wound healing was assessed in terms of necrotic tissue score and granulation tissue score. Patient satisfaction in terms of patient satisfaction score, visual analogue scale (VAS) score, and length of hospitalization were compared between the two groups.ResultsA total of 40 patients were analysed in the study, 20 patients in each group. Both the groups were comparable with respect to age, gender, co-morbidities, body mass index (BMI), and degree of burns. Wound healing parameters like necrotic tissue score of six [40% vs. 50%; p = 0.024] and granulation tissue score of four [85% vs. 65%; p= 0.06] were significant in the heparin group compared to the control group. However, the difference was not statistically significant. The mean length of hospitalization between the two groups [10.5 days vs. 12.6 days; p = 0.74] were not statistically significant. Similarly, there was no statistically significant difference between the two groups with respect to the VAS pain score on the seventh dressing day [6.9 vs. 7.3; p= 0.321].ConclusionIn comparison to saline irrigation, heparin irrigation would result in better wound healing in superficial first and second-degree burns. The length of hospital stay in days and VAS pain score on the seventh dressing day were not statistically significant between the two groups.

Heparin irrigation solution accidentally administered intravenously

Heparin irrigation solution accidentally administered intravenously

A systematic approach to emergent breast free flap takeback: Clinical outcomes, algorithm, and review of the literature

Few evidence-based and detailed algorithms exist on the management of failing breast free flaps, including use of the numerous salvage tools that are available. The purpose of this study was to analyze our outcomes with an algorithmic approach to breast free flap salvage after vascular compromise. A review of the literature is also presented. A retrospective review of all breast free flaps performed at our institution between 2007 and 2012 was performed. Flaps with intraoperative and postoperative vascular complications were analyzed. A total of 612 microsurgical breast reconstructions in 442 patients were reviewed. Of these, 72 (11.8%) flaps had intraoperative vascular complications, and 36 (5.9%) had postoperative vascular complications. The total flap loss rate was 2.8%. The most commonly used salvage modalities were anastomotic revision (72%), heparin irrigation (72%), systemic heparin (37%), Fogarty catheter thrombectomy (17.6%), thrombolytics (13%), and indocyanine green angiography (10.2%). In 53 (49.1%) cases, flap salvage involved use of 1 modality, whereas in 55 (50.9%) cases multiple modalities were used. Factors associated with failure of these flap salvage tools included intraoperative arterial rather than postoperative arterial compromise (P = 0.01), and situations requiring use of a greater number of salvage modalities (P < 0.001). We found that intraoperative compromise had significantly better prognosis than postoperative compromise. By organizing the numerous salvage modalities available to microsurgeons into a well-defined algorithm that is supported by the literature, we have established a best practices protocol that has achieved flap salvage rates that compare favorably to the published literature.

Comparisons of medicinal leech therapy with venous catheterization in the treatment of venous congestion of the sural flap

The originally described distally based sural flap technique has a risk of partial or total flap necrosis as high as 25%. The purpose of this study was to compare the medicinal leech therapy (MLT) with venous catheterization (VC) for blood volume removal, infection, wound dehiscence, and flap necrosis in the distally based sural flap with venous congestion. Fifty-six conventional distally based sural flaps with venous congestion during reconstructive surgeries were randomly divided into two groups, MLT group and VC group. The results of comparisons were analyzed using SPSS software (SPSS for Windows Ver.11.5). There were significant differences in terms of the average volume of removed blood (53.6cc vs.172.2cc), infection (10.7% vs. 34.6%), wound dehiscence (10.7% vs. 42.3%), flap necrosis (3.6% vs. 19.2%), and nursing (7.8 vs. 5.19) and patient's satisfaction (8.03 vs. 5.6) in the VC group and MLT group, respectively. Although local heparin irrigation was performed in the VC group, the catheter was exchanged in 10 patients due to obstruction by clot. It is recommended that the VC be used for congested pedicled flaps instead of leech therapy, as VC is more effective, easy, and safe in blood removal, and it has less complication.

A Large Animal Survival Model (Sus Scrofa) of Extremity Ischemia/Reperfusion and Neuromuscular Outcomes Assessment: A Pilot Study

Extremity ischemia/reperfusion has been studied mostly in small-animal models with limited characterization of neuromuscular or functional outcome. The objective of this experiment was to report a large-animal survival model of extremity ischemia/reperfusion using circulating, electromyographic (EMG), gate, and histologic measures of injury and limb recovery. Sus scrofa swine (n = 6; mean, 83 kg) were randomized to iliac artery occlusion for 0 (control), 1 (1 HR), 3 (3 HR), or 6 (6 HR) hours. Restoration of flow after a standard large-vessel reconstructive technique (thrombectomy, heparin irrigation, and patch angioplasty) was performed in each of the control, 1HR, 3HR, and 6HR animals, whereas one animal had iliac artery segment excision with no restoration (NR) of axial flow. One animal had operative exposure but no intervention on the iliac artery (sham). Animals were recovered and closely monitored for 2 weeks. Indicators of ischemia/reperfusion and functional recovery, including circulating markers, EMG measures (complex motor action potential), and Tarlov gate scoring (0-4; 0, insensate/paralyzed to 4, normal posture and no gait abnormality) were measured at 24 hours and 72 hours and 7 days and 14 days. Muscle (peroneus) and nerve (peroneal) were collected during necropsy at 14 days to assess gross and histologic changes. Duplex ultrasound was performed serially during the recovery period to confirm patency of vascular reconstruction. There were no deaths or failures of vascular reconstruction. Control had a Tarlov score of 4 and normal EMG measures at each point during recovery (same as sham). Tarlov scores at 1, 3, and 14 days recovery in each of the animals were as follows: 1HR: 3, 3, and 4; 3HR: 1, 2, and 4; 6HR: 1, 2, and 3; and NR: 1, 2, and 4. Complex motor action potential as a percentage of baseline at 1, 2, and 14 days recovery was as follows: 1HR: 56%, 55%, and 84%; 3HR: 9%, 8%, and 57%; 6HR: 5%, 5%, and 16%; and NR: 22%, 28%, and 33%. Muscle and nerve histology was the same in sham, control, and 1HR animals. Moderate degeneration and necrosis was observed in peroneus muscle of the 3HR animals. The peroneal nerve in 3HR demonstrated minimal Wallerian degeneration. Severe necrosis was present, as was minimal regeneration, and peroneal nerve demonstrated moderate Wallerian degeneration in 6HR. This study reports a new large-animal survival model of extremity ischemia/reperfusion using circulating, functional, and histologic markers of neuromuscular recovery. Findings provide insight into an extremity ischemic threshold after which functional neuromuscular recovery is lost. Additional study is necessary to define this threshold and factors that may move it to a more or less favorable position in the setting of extremity injury.

Management of vascular defects in digital replantation

207 cases of digital amputation (261 digits) with vascular defects were replantated during the past two decades. The vascular defect was managed with various methods. 240 digits (92%) survived with good post-operative circulation and recovery of function. The methods of management of arterial defects were as follows: 1) Digital artery transfer from adjacent digits in 25 thumbs and three index fingers. All had survived. 2) Arterial transplantation: in 12 digits, arteries from the contralateral side or from the digits that were unsuitable for replantation were grafted to fill the arterial defects. All of these fingers survived. 3) Vein graft: superficial veins were taken to reconstruct the defects of the digital arteries in 59 digits, with 55 digits surviving and four failing. 4) Ulnar digital arterial flap of the ring finger. This technique was used in four digits with composite artery and soft tissue loss. All the cases survived. 5) Implantation of the arteries into the distal amputation parts. This was done in two digits with no arteries for anastomosis in the distal parts. The management of venous defects was as follows: 1) Transfer of veins from the adjacent digits. Five digits treated with this technique survived well. 2) Vein graft. Six digits survived but one failed. 3) A venous flap was done in six digits and all the digits survived after this procedure. 4) Arterio-venous anastomosis: this was used in 20 digits without suitable veins for anastomosis in replantation of the digit distal to the DIP joint level. 5) Replantation without venous return: a fish-mouth incision and heparin irrigation was used for venous drainage in 19 digits, with survival of 14. 6) The palmar venous system was anastomosed in 84 digits without dorsal veins for suture. 77 digits survived. 7) Venous fascial flap transfer: A composite venous fascial flap was harvested from the adjacent fingers. The flap was turned over on the side close to the injured finger to make an anastomosis of the veins with those in the distal amputated part. A skin graft was placed over the flap without a tie-over dressing. The pedicle was divided 3 weeks later. All the 16 digits with this technique survived well.

Evaluation of the thrombogenecity of microvascular prosthesis by in vivo microscopy.

Expanded polytetrafluoroethylene(ePTFE) grafts 4mm long and 1mm in diameter were implanted into the iliac artery of 100-150g male rats using standard microvascular technique. Prior to clamp removal, the cremaster muscle was isolated as an island flap based on the iliac artery and observed using intravital fluorescence microscopy. Fields which contained a bifurcation of a first order arteriole(80-100 microns diameter) into second order arteriole(50-80 microns) were chosen for observation. Platelets were labeled in vivo with acridine red to visualize and quantify the aggregates. Images of microemboli were counted manually and the area was measured by computerized planimetry. Six control grafts were implanted with no further processing, six were irrigated with heparin, and six were coated with tridodecylmethylammonium chloride(TDMAC) and heparin. Most thrombi appeared within the first five minutes after implantation in all groups. The total number of emboli observed in the control group was 91 pr animal, in the heparin irrigation group it was 84, and in the TDMAC-heparin group it was 22. The total thrombus area observed per animal was 137,660 +/- 29,467 microns 2 in the control group, 79,040 +/- 10,893 microns 2 in the heparin irrigation group, and 17,498 +/- 6,059 microns 2 in the TDMAC-heparin group (p < .01 vs control or heparin irrigation group). With this results we could find that heparin irrigation and TDMAC-heparin coating appear to reduce the number, size, and total amount of microemboli generated by ePTFE graft implantation and apparent thromboresistant property of TDMAC-heparin coating may have widespread application in many clinical and research areas and this experimental model can be used for evaluation of other graft matrials.

Prevention of Thrombosis by Topical Application of Tissue Factor Pathway Inhibitor in a Rabbit Model of Vascular Trauma

The extrinsic pathway of coagulation is initiated when tissue factor complexes with factor VII. A naturally occurring protein inhibitor of this complex, tissue factor pathway inhibitor (TFPI), has recently been isolated and the cDNA coding for this protein cloned. We used a rabbit ear artery model of crush/avulsion injury and microvascular repair to investigate the efficacy of TFPI as a topically applied antithrombotic agent. Traumatized arteries treated through lumenal irrigation with normal saline vehicle (controls) achieved patency rates of 8% and 0% at 1 and 7 postoperative days, respectively. Heparin irrigation (10 U/ml) resulted in patencies of 40% at both evaluation times. In contrast, TFPI at a dose of 20 micrograms/ml (0.2 ml total volume; 10 minute exposure) yielded a 91% patency rate at 1 day and 73% at 7 days postoperatively (p < 0.0005 vs controls). Prothrombin time and activated partial thromboplastin time values were not altered after topical treatment with TFPI. Scanning electron microscopy revealed dramatically inhibited thrombogenesis upon the injured surfaces of TFPI-treated vessels. These results suggest that TFPI used as a topically applied antithrombotic agent is effective for the prevention of thrombosis in microvascular anastomoses.

Thrombus formation and endothelial alterations in microarterial anastomoses.

The sequential hematological and endothelial responses in the postoperative period after end-to-side arterial anastomosis in 1- to 1.3-mm vessels were assessed by scanning electron microscopy. Two minutes after restoration of flow, an amorphous coating covered the vessel lumen around the suture line, and oozing of blood from the suture line ceased. Within 15 minutes, a partially occluding thrombus was present, which was maximal at the anastomotic bifurcation point. The thrombus underwent partial lysis or embolization within 30 minutes, and gross intraluminal thrombi did not recur. The initial thrombi that formed within 2 minutes were composed of platelets and erythrocytes in a loose reticular fibrin network, but the intraluminal thrombi present at the branch point 15 minutes after flow restoration appeared to be composed solely of platelets. Thrombi that did not undergo complete dissolution had a loss of distinct cellular elements at later time intervals. The fibrin-platelet matrix coating the lumen remained unchanged during the initial 24 hours. When examined at 9 days, normal endothelium was present throughout the vessel with the exception of the suture line, which remained covered by a smooth coagulum. This sequence of events suggest that if surgical manipulation is to result in complete occlusion of the anastomosis, it will likely occur in the initial 30 minutes after resumption of blood flow. Anticoagulant regimens were evaluated. Pretreatment with aspirin and intraoperative heparin irrigation of the vessel lumen were not beneficial in altering the quantity of thrombus. All systemic heparin regimes tested resulted in a quantitative decrease of thrombotic material. Five minutes of intravenous heparin therapy after resumption of blood flow was as effective as long-term heparin in decreasing the transient intraluminal thrombotic response.