Avulsion of the Auricle in an Anticoagulated Patient: Is Leeching Contraindicated? A Review and a Case

Abstract

Amputation of the auricle is a periodic occurrence leading to disfigurement if not treated properly. Venous stasis is a common complication in reattachments and requires decongestant and anticoagulant treatment. Today, leech therapy is the treatment of choice. Common problems are that it is not available everywhere and that it is usually contraindicated in anticoagulated patients. The peculiarities of leech therapy and the various aspects of surgical management are reviewed. A case of a partial amputation of the auricle in a patient under concomitant anticoagulation therapy with warfarin is presented. The amputated part was reattached in another hospital without microvascular anastomosis. The patient presented to our department with early signs of venous congestion. Leech therapy was started 35 hours after trauma, and the patient continued his anticoagulation therapy. With this treatment, 90% of the amputated part was rescued. The anticoagulation therapy of the patient may have played an important role in the first hours after reattachment, preventing capillary thrombosis and in consequence facilitating the minimal oxygenation necessary. The claim that anticoagulation therapy is a contraindication to leeching should be questioned in cases of reattachments in well-controllable locations without arterial anastomosis.

The use of medical leeches for venous congestion

“…Modern clinical uses of medicinal leeching are found in microvascular surgeries (reimplantation), reconstructive surgeries (skin flaps), to decrease postoperative swelling from damaged venous structures, haematoma drainage, and even non-traditional uses such as treatment of osteoarthritis, otitis media, and compartment syndrome (1, 3, 4, 7-9, 12). In human medicine, leeches are most commonly used to aid in reimplantation of various body parts in human medicine but they are also employed frequently when the venous structures are too small or unsuitable for microvascular anastomosis (4)(5)(6)(7)(8)(9).…”

“…Venous congestion can occur any time there is an imbalance between arterial inflow and venous outflow which results in stasis of the blood. Decreases in venous outflow can occur with constrictive wounds, damage to venous structures during interventional radiology procedures, or in reconstruction and reimplantation because of the thin walls of the low capacit-ance veins which are easily collapsed or torn (6,9,12). This results in decreased tissue perfusion which causes hypoxia, acidosis, arterial thrombi formation, and tissue necrosis.…”

“…Removal of excessive blood reduces the capillary filling pressure and allows arterial capillary beds to reperfuse. Venous congestion is so common in surgical reattachment of auricles that it is considered by some an accompanying symptom rather than a complication (9). This technique is especially helpful with auricular reimplantation due to the challenging aspect of finding and reconnecting vessels of this size and the risk of damage to vessels during attempts at anastomosis.…”

“…Of those 10 cases, 60% were treated with leech therapy (13,14). Other types of bloodletting, such as chemical leeching (heparin injection) or pricking the ear and allowing it to bleed freely, have been performed with these procedures but have not gained near the support of medicinal leeching, especially when venous repairs cannot be performed (9,13,14).…”

“…In that case, leeches were successfully used when blood viscosity prevented successful phlebotomy. In human medicine, leeches are used extensively with reconstructive surgeries including skin flaps and reimplantations to aid in treatment of venous congestion that can occur postoperatively (3,(6)(7)(8)(9). The successful salvaging of a variety of free tissue grafts, axial pattern flaps, and treatment of damaging venous congestion from wounds by leech application is an exciting treatment modality and should be considered in our veterinary patients as a possible application.…”