Appropriate Use of Intravenous Unfractionated Heparin after Digital Replantation: A Randomized Controlled Trial Involving Three Groups

Abstract

Background: The purpose of this study was to clarify the appropriate use of unfractionated heparin as an anticoagulation agent after digital replantation. Methods: This study was a prospective, randomized, single-blind, blinded-endpoint method, three-arm, parallel-group, controlled clinical trial conducted at a single institution. A total of 88 patients (101 fingers) following digital amputation and subsequent repair by anastomosis of both arteries and veins were randomly allocated into three groups: (1) control group (no heparin dose), (2) low-dose heparin group (10,000 IU/day), and (3) high-dose heparin group (start at 15,000 IU/day, then adjust the dose to achieve an activated partial thromboplastin time of 1.5 to 2.5 times the baseline). The outcomes were assessed regarding the proportion of success at 2 weeks after replantation of amputated digits, total or partial necrosis, and occurrence of complications. Results: No significant differences were found among the three groups, except for complications of congestion. The odds ratio of the heparin group compared with the control group for a success proportion was 5.40 (95 percent CI, 0.85 to 34.20; p = 0.027) in subjects aged 50 years or older. Significant elevations of activated partial thromboplastin time, aspartate transaminase, and alanine aminotransferase occurred in high-dose heparin groups on day 7. Conclusion: Unfractionated heparin administration is considered effective for patients aged 50 years or older, although the routine use of unfractionated heparin is not necessary after digital replantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Perioperative Thromboprophylaxis in Digital Replantation: A Systematic Review

“…However, Zhu et al 16 demonstrated no significant difference in digital survival among patients who received LMWH 4000 units compared with untreated controls (91% versus 89%, respectively; P > 0.05). Similarly, Nishijima et al 18 found no significant difference in digital survival among patients treated with 10,000 units intravenous heparin, 17,500 units intravenous heparin, and untreated controls (79% versus 89% versus 84%, respectively; P > 0.05). These findings are further supported by Veravuthipakorn and Veravuthipakorn, 21 who report a 91% digital survival rate without the routine use of perioperative thromboprophylaxis.…”

“…Lee et al 9 report that patients who received a continuous heparin infusion (target aPTT 51–70 seconds) had a significantly higher incidence of blood transfusion compared with patients who received 12,500 units intravenous bolus heparin. Nishijima et al 18 reported a significantly higher incidence of venous congestion in patients who received postoperative heparin (either 10,000 units or 17,500 units) versus controls.…”

“…One study reported the use of vein grafts in arterial (n = 11) and venous (n = 2) microanastomotic repair. 18 …”

“…Three studies reported a significantly higher incidence in postoperative complications in patients who received heparin infusions. 9 , 15 , 18 Nikolis et al 15 reported significantly higher rate of composite complications (including venous congestion, thrombosis, hematoma, and partial necrosis) in patients receiving continuous heparin infusions with a target aPTT between 70 and 90 seconds. Lee et al 9 report that patients who received a continuous heparin infusion (target aPTT 51–70 seconds) had a significantly higher incidence of blood transfusion compared with patients who received 12,500 units intravenous bolus heparin.…”

“…When compared with untreated controls, Nishijima et al 18 demonstrated a significantly higher rate of venous congestion in patients treated with systemic heparin (3% versus 21%; P = 0.02). Nikolis et al 15 demonstrated a significantly higher composite complication rate (comprising venous congestion, thrombosis, hematoma, and partial necrosis) in patients receiving systemic heparin infusions.…”