Temporary catheter perfusion and artery-last sequence of repair in macroreplantations

The sequence of repair of structures in macroreplantation surgery is important, since it has a direct influence on ischaemia time, blood loss and technical accuracy. Different sequences have been recommended in the literature. A uniform order of repair was used in a series of macroreplants, performing the arterial repair at the end of the procedure. A total of 341 parts were replanted in 249 patients. Of these, 28 cases (27 patients) were amputations proximal to the wrist. The sequence of repair was temporary catheter arterial shunt for 10-15 minutes, debridement, bone, musculotendons, veins and dorsal skin, nerves, arteries and volar skin. Fasciotomies were performed only if primary ischaemia time had been over 6 hours. A 100% survival rate was achieved. Primary ischaemia time was less than 6 hours in all cases but two. Fasciotomy was performed only in these two patients. Infection rate was 10% (three cases). Soft-tissue necrosis requiring free flap coverage occurred in four cases (14%). In these complicated cases (24%), salvage rate was 100%. Mean operative time was 240 minutes. Functional results according to Chen's criteria were grade I in six cases, grade II in nine, grade III in 13, and no patients with grade IV. Temporary catheter arterial perfusion reduces ischaemia time and permits an artery-last sequence. This may reduce blood loss, permits an accurate repair of non-vascular structures, and shortens operative time.