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Temporary Extracorporeal Vascular Shunting To Assist Arm Replantation Following Blunt Traumatic Amputation
Rudra Pandya, MD, Stahs Pripotnev, MD, Abdel-Rahman Lawendy, MD, Audra Duncan, MD, John Landau, MD.
Western University, London, ON, Canada.
Demographics: A 27-year-old healthy female presented with a traumatic amputation of her left arm at the midshaft of the humerus.
History: Blunt amputation occurred secondary to an ATV rollover incident. The amputated arm was placed on ice by first responders and the patient presented to a level 1 trauma center 2.5 hours later. Considering the patient’s young age and lack of medical comorbidities, a multidisciplinary discussion took place, and a decision was made to attempt arm replantation.
Plan: We obtained percutaneous left femoral arterial and venous access with 6-French sheaths and explored the brachial bundle of the proximal amputated limb. Simultaneously, orthopedics team performed humeral foreshortening, reduction, and internal fixation. Distal dissection at antecubital fossa exposed traumatized brachial artery and vein; avulsed ends were debrided to healthy vessels, and lumens identified. Forearm arterial and venous thrombectomy retrieved no thrombus. A 5-French arterial sheath was inserted into the distal brachial artery and connected to the femoral arterial sheath; similarly, a brachial venous sheath was connected to femoral venous sheath, and satisfactory perfusion was confirmed with doppler interrogation (Figure 1). Forearm fasciotomies were performed. Proximally, the shortest possible length of injured brachial artery was resected to a healthy arterial end point and a thrombectomy retrieved clot on first pass. Hence, end-to-end brachial artery anastomosis was sufficient to restore pulses and triphasic Doppler at the radial artery. Venous outflow was reconstructed with end-to-end basilic and brachial anastomoses. Plastic surgery performed nerve and soft tissue repair. Perfusion was confirmed by Doppler signals at radial, ulnar, palmar arches, and digital arteries. The patient was stable and transferred to ICU. She underwent debridement at 2 days, skin grafting with vacuum dressing at 5 days. She currently has improved elbow, wrist, and finger motor function at 1-year post-replantation with ongoing rehabilitation.
Discussion: Patients with blunt extremity amputations are generally considered poor candidates for replantation. In this patient, collaborative efforts from surgical subspecialties and the use
of temporary intravascular shunting, nerve reconstruction, along with careful postoperative surveillance has resulted in acceptable motor function of the replanted arm.
Figure 1: Temporary intravascular shunting of the left arm.
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