Local subcutaneous heparin as treatment for venous insufficiency in replanted digits

Abstract

In the treatment of venous insufficiency unsuitable for surgical correction in replanted digits, a small ungual window was surgically created to infiltrate subcutaneous heparin in the congested digit. The initial heparin dose was 1000 units. This dose made possible a continuous bleeding during 24 to 48 hours, solely through the ungual window. Further doses were applied based on the degree of congestion of the replanted digit, but usually it was necessary to infiltrate up to 500 units of heparin every 24 to 48 hours until vascular stability was achieved. Three patients were treated with this technique. One opted for quitting the treatment. A replanted thumb suffered venous congestion on the seventh postoperative day and was treated with local subcutaneous heparin for 3 days. A replanted fingertip suffered venous thrombosis 24 hours after surgery and was treated likewise for 18 days. In these two patients, success was attained. Blood transfusions were carried out in the latter two, and none had any systemic changes in partial thromboplastin or thrombin time. This treatment is based on the mechanism of action of heparin at high doses but applied only to the congested segment. Besides their anticoagulant effect through antithrombin, high doses of heparin slow platelet aggregation, may induce angiogenesis, and have a longer-than-normal half-life. With the above technique, heparin has been applied to the congested segment at an approximate dose of 33,000 to 40,000 units/kg, and continuous bleeding solely through the ungual window for 24 to 48 hours has been achieved, which has allowed us to save two replanted segments with no complications at all. This method may offer another alternative for the medical treatment of venous insufficiency in replanted segments.