HAND SURGERY

AND

MICROSURGERY

Cross-Limb Vascular Shunting for Major Limb Replantation

Yao-Chou Lee, MD, and Jing-Wei Lee, MD
minutes, such that the ischemia insult is terminated almost instantaneously. In that previous report, however, the scenery was a near-total avulsion rather than a complete amputation. We did believe that such a strategy should be very useful in the treatment of total amputation. Eventually we had the opportunity to adopt such a concept in 2 clinical cases suffering complete limb avulsion. The very experience in these patients exemplied and validated the feasibility of the innovative method presented.

Abstract: In the management of traumatic major limb amputation, rapid re-establishment of circulation to the amputated part is imperative so as to prevent complications related to reperfusion injury, especially for those already suffering from prolonged ischemia. A temporary, extra-anatomic cross limb shunting with infusion lines can be used to perfuse the amputated part almost instantaneously. This allows the surgeon to carry out skeletal xation and other reparative works in an unhurried manner. The cannulation site is targeted at intact vessels far away from the injury zone, obviating the need to explore and handle traumatized vessels at the mangled stump ends, thus greatly simplifying and expediting the revascularization process. Such a method had been successfully applied in 2 young people suffering traumatic arm amputation and thigh amputation, respectively. We suggested that such a procedure could be a useful adjunct in the eld of major limb replantation. Key Words: cross-limb shunting, major limb replantation (Ann Plast Surg 2009;62: 139 143)

CASE REPORT Case 1

A 33-year-old male worker suffered from traction avulsion amputation of right arm during an industrial accident on September 22, 2005. He was sent to a nearby institute for rst aid and was then transferred to our hospital more than 4 hours after the accident. Upon arrival, the patient was still in clear consciousness and remained hemodynamically stable. The right arm was amputated completely at distal humeral level (Fig. 1A, B). Two long strips of nerve strings were seen trailing from the ragged cut end of the distal stump. The patient was taken to the operation theater right away for replantation attempt. The radial artery of the traumatized upper limb was connected to the radial artery on the unaffected side using a piece of arterial pressure tubing. And likewise, cephalic veins on both upper limbs were connected with a bridging conduit to allow for outow drainage (Fig. 1C, D). Rapid restoration of circulation was accomplished within 20 minutes. The tube was pre-lled with heparinized xylocaine solution to prevent intraluminal clot formation or air embolism. Profuse oozing from the wound edge and return of pinkish skin color was witnessed shortly after the maneuver. The humerus was shortened 5 cm in length and xed with compression plate. The brachial artery, 2 concomitant veins, and cephalic vein were then repaired with interpositional vein graft. The median nerve and ulnar nerve were repaired with antecubital nerve as bridging grafts. The radial nerve and the musculocutaneous nerve were coapted directly. The estimated intraoperative blood loss was around 500 mL. A total of 14 units of packed RBC and 4 units of fresh frozen plasma were given perioperatively. The patient received 4 sequential debridements and was discharged 76 days later. The 2 years follow-up demonstrated sensory return to the affected hand with positive Tinel sign. The motor functional recovery included active motion of elbow exion, pronation, and nger exion (Fig. 2AD).

eplantation or revascularization of an avulsed limb is a rigorous race against time. The detached limb of a high level amputation, with its signicant muscle content, is particularly vulnerable to ischemic insult. Rapid restoration of the blood ow to the amputated part is mandatory. However, such a serious trauma is often accompanied by other life-threatening injuries or critical systemic conditions that prohibit immediate limb replantation. In addition, it is not uncommon for the patients to travel through long distances or wander among hospitals before they nally reach an institute eligible for limb replantation. Therefore, signicant delay in denite replantation surgery is generally the rule rather than the exception. As such, the surgeons are pressed to re-establish the limb circulation promptly or even instantaneously so as to avoid the devastating reperfusion syndrome. Nunley et al1 suggested the use of a silicone tube as a temporary bridge between disrupted vessel ends to restore blood ow to the distal limb. However, to explore the traumatized vessels within the distorted tissue is sometimes difcult and time consuming, and the temporary shunt needs to be withdrawn during denite vascular repair, exposing the distal limb to ischemia insult for a second time. Lee et al proposed an innovative shunting method named as cross-limb vascular shunting for a mangled extremity.2 A segment of heparinized tube is used to connect the contralateral limb vessel with the distal vessel of the amputee to re-establish the circulation. It is easy to perform and the circulation could be restored within 20

Case 2
The 23-year-old male college student had his left thigh completely avulsed in a motorcycle accident while he was heading home in drunken condition at midnight April 2, 2007. The patient was sent to our emergency room later on by an ambulance. On arrival, his blood pressure measured only 84/60 mm Hg, with heart rate staying around 101 beats/minute. The Glasgow coma scale was recorded as E4V4M5. The left leg had been torn off through distal femoral level (Fig. 3A, B). Rapid infusion of 16 units of packed RBC and 6 units of fresh frozen plasma was administered in the emergency service. Bleeding control was achieved preliminarily through manual compression of the femoral artery root at groin 139

Received January 22, 2008 and accepted for publication, after revision, March 27, 2008. From the Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan. Reprints: Jing-Wei Lee, MD, Chief and Associate Professor,. Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Medical College and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan. E-mail: jwlee@mail.ncku.edu.tw. Copyright 2009 by Lippincott Williams & Wilkins ISSN: 0148-7043/09/6202-0139 DOI: 10.1097/SAP.0b013e3181776763

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Annals of Plastic Surgery Volume 62, Number 2, February 2009

FIGURE 1. A, B show right arm traumatic amputation at distal humeral level. C Cross-limb vascular shunting is established between both side radial arteries and cephalic veins. D Diagram of the cross-limb vascular shunting.

region, followed by arterial trapping with vascular tape tourniquet. As the surveillance results did not reveal any associated injuries, the patient was brought to the operation room for replantation procedure right away. In the meanwhile, total ischemic time had extended beyond 4 hours, therefore we quickly set up a cross-limb vascular shunting connecting both side dorsalis pedis arteries and greater saphenous veins (Fig. 3C, D). Our orthopedic colleagues then proceeded with the bony work. The femur was shortened by 8 cm and then immobilized with external skeletal xation. The estimated blood loss was around 1500 mL during the operative session. The intraoperative transfusion amounted to 24 units of packed RBC and 12 units of fresh frozen plasma. The popliteal artery and vein were anastomosed directly, followed by nerve coaptation and soft tissue repair. The patient was admitted to intensive care unit for close monitoring of probable manifestations of reperfusion syndrome. A total of 4 sessions of surgical intervention were conducted in the following period, either owing to postoperative bleeding, wound debridement, or eventual split thickness skin grafting. There was 1 episode of suspected osteomyelitis that occurred 5 months after the event, which was alleviated with immobilization, antibiotics administration, and hyperbaric oxygen therapy. At 8 months follow-up, the sensory return had reached to several centimeters below the suture line. The patient could stand up when wearing a custom-made iron shoe with knee-bracing harness. He could also move around with the help of a 4-pod walker (Fig. 4). 140

DISCUSSION
Since the rst successful arm replantation done by Malt and McKhann in 1962,3 a signicant number of encouraging reports about limb salvage were published thereafter. The successful rate seems to step up steadily with time, starting from 83.2% in Chens series4 (1978), reaching up to 89.8% in Waikakuls series5 (1998), and even progressing to 95% in Battistons recent series6 (2007). Despite the ever increasing successful rate, however, adverse outcome such as limb loss, local and systemic complications, or even death may still occur, which is mainly attributed to the disastrous reperfusion syndrome. The reperfusion syndrome is estimated to occur at the rate of 5.4%.5 To prevent such a dreadful complication, the surgeons are pressed to re-establish the circulation as soon as possible. Theoretically, vascular repair should be done before anything else. However, skeletal reconstruction after vascular anastomosis would be problematic, putting the anastomosis at risk. If the surgeon elects to proceed with the bony repair rst, then the ischemia time would be critically extended and the chance of replantation failure markedly increases. In light of this, Nunley et al1 advocated the use of a silicone tube to bridge across the separated ends of the vessels and reestablish the circulation to the distal limb. Such a notion seemed to be a straightforward and reasonable solution. It was, hence, adopted widely in clinical practice by many physicians, despite a couple of disadvantages. To begin with, it is technically challenging when the 2009 Lippincott Williams & Wilkins

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Cross-Limb Vascular Shunting

FIGURE 2. Motor function recovery included (A) elbow flexion and forearm supination, (B) forearm pronation, (C) finger in resting, and (D) finger flexion activities after 2 years follow up. amputation level is very high. And also, exploration of the traumatized vessels within the crushed tissue may be difcult and could induce further endothelium damage. Besides that, the temporary shunt may pose as an obstacle to the subsequent bony xation procedure. And furthermore, the temporary shunt must be withdrawn during denitive vascular repair, introducing an additional ischemic episode to the aficted limb. In view of these shortcomings, we then innovated a different approach using extra-anatomic cross-limb shunting as blood ow provider. The concept is somewhat similar to that of Nunley et al, but with several unique merits. First, the shunt is connected to intact vessels away from the injury zone, and is, therefore, much easier and faster to perform. Second, the target vessels are situated at a supercial and well known location, making the dissection simpler and more predictable. Third, when both limbs are tied up together at the palmar level, the risk of inadvertent dislodgement of connecting tube will be greatly reduced. Such a maneuver will not interfere with the bony xation work, because all the joints 2009 Lippincott Williams & Wilkins are still freely movable so that the unaffected limb acts as a crane-like carrier that can move the amputated stump around almost unrestrictedly. Fourth, the amputated vessel ends are left untouched and free from the risk of additional injury. Fifth, back ow from the ends of the disrupted vessels may assist in the judgment of the adequacy of vascular debridement. Sixth, if no reow phenomenon does occur, it would exhibit as cessation of muscular perfusion and alert the surgeon to the hazard of devastating reperfusion syndrome. A decision to abort the replantation efforts would then be made accordingly. Seventh, bony xation could be undertaken in an unhurried and undisturbed fashion because the circulation is re-established already and the shunt is not in the way. Eighth, tourniquet could be applied on both stump ends to diminish blood loss during debridement, which is not possible with orthotopic conventional shunt. Ninth, the crosslimb vascular shunt need not be removed while performing the denite vascular anastomosis and, thus, uninterrupted blood ow could be maintained throughout the entire course of the surgery. 141

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FIGURE 3. A, B show left thigh traumatic amputation at distal femoral level. C Photography of cross-limb vascular shunting. D Diagram of the cross-limb vascular shunting. A number of shortcomings in association with the use of such an approach need to be mentioned here. This technique eliminates the use of one of the limbs for a source of venous access and vascular and nerve grafts. Besides that, there is the additional risk of morbidity of the uninjured limb, such as infection, thromboembolism, vascular trauma, tissue intoxication because of toxic metabolites passage, or even some serious complications like compartment syndrome or distal limb devascularization. In the previous report, the feasibility of our innovation has been validated through clinical application, and yet the case had a near total rather than discretely separated amputation. In the present work, however, complete disruption of the extremities at rather proximal level in 2 cases serve as explicit examples to illustrate the efcacy of the shunting maneuver. In this group of patients, significant delay in surgical intervention is common because of the transportation process, resuscitation measures, and surveillance work-up, and thus the avoidance of further ischemic damage is of paramount importance.

CONCLUSION
Major limb amputation is a devastating insult from physical and psychosocial aspects, especially for productive young people. A quick move to restore the circulation of the distal stump is essential for a successful salvage. Cross-limb vascular shunting is a valuable adjunct in this respect, because it helps to re-establish the blood ow in less than 20 minutes. There would be time for an unhurried repair of bone, nerve, and the principal vessels of the extremity. The chance of limb survival, and even the quality of repair could be greatly improved with such a method.

ACKNOWLEDGMENTS
FIGURE 4. The patient could stand with weight bearing in the assistance of custom-made shoes after 8 months follow up. 142 The authors thank Dr. Kun-Lin Chuang for his kind help in preparing the artwork of illustrative diagrams. 2009 Lippincott Williams & Wilkins

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Cross-Limb Vascular Shunting

REFERENCES
1. Nunley JA, Koman LA, Urbaniak JR. Arterial shunting as an adjunct to major limb revascularization. Ann Surg. 1981;193:271273. 2. Lee JW, Pan SC, Lin YT, et al. Cross-limb vascular shunting as an auxiliary to major limb revascularisation. Br J Plast Surg. 2002;55:438 440. 3. Malt RA, McKhann C. Replantation of several arms. JAMA. 1964;189:716 722.

4. Chung-Wei C, Yun-Qing Q, Zhong-Jia Y. Extremity replantation. World J Surg. 1978;2:513524. 5. Waikakul S, Vanadurongwan V, Unnanuntana A. Prognostic factors for major limb re-implantation at both immediate and long-term follow-up. J Bone Joint Surg Br. 1998;80:1024 1030. 6. Battiston B, Tos P, Clemente A, et al. Actualities in big segments replantation surgery. J Plast Reconstr Aesthet Surg. 2007;60:849 855.

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