Arterial and Venous Revascularization with Bifurcation of a Single Central Artery

Sir: We have read the article entitled “Arterial and Venous Revascularization with Bifurcation of a Single Central Artery: A Reliable Strategy for Tamai Zone I Replantation” by Hsu et al.1 with great interest. First, the authors should be applauded for their novel idea of solving the venous drainage problem in distal phalanx replantation. We agree with the authors that this method indeed is an available option for distal phalanx replantation. However, instead of this technique, we are more inclined to the application of artery-only replantation technique, as we all know that the greatest challenge in fingertip replantation is reestablishment of adequate venous flow. When there is no vein or other artery available in the amputated parts, the artery-only replantation technique and the revascularization technique are the two main options.2,3 In this article, arterial and venous revascularization with bifurcation of a single central terminal branch of the digital artery is adopted with the combination of a vein graft. The average number of anastomosis sites for each digit was four, the average operative time was 245 minutes, and the average length of hospital stay was 5 days. We performed the artery-only replantation technique in 22 patients, and all of the patients subsequently received chemical leech management. Only one artery of the amputated part was anastomosed, with a mean operative time and length of hospital stay of 160 minutes and 6 days for each digit, respectively. All anastomoses were performed without the use of an interpositional vein graft. All fingertips survived completely, without evidence of postoperative insufficiency of the blood supply (Figs. 1 and 2).Fig. 1: A 23-year-old man suffered left index fingertip guillotine amputation (left). The patient had smooth fingertip contour and nearly normal nail regeneration at the 8-month follow-up (center and right).Fig. 2: A 37-year-old woman presented with right index fingertip avulsion amputation (left). A left ATF with two perforators was made to fit the defect (left). The patient had smooth fingertip contour with good finger function at the 6-month follow-up (center and right).Although there is no significant difference between two and four sites of vessel anastomosis for an experienced surgeon in confirming anastomotic patency, we believe that the increase in the number of vessel anastomosis sites will indeed increase the risk of vascular insufficiency. In addition, the operative time is another issue to consider. These are the reasons why we are more inclined to use the artery-only replantation technique with chemical leech management for fingertip amputation.2,3 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Shi-Ming Feng, M.D. Hand and Foot Microsurgery Department The Xuzhou Central Hospital Xuzhou, Jiangsu, People’s Republic of China Jia-Xiang Gu, M.D., Ph.D. Nai-Chen Zhang, M.D. Hong-Jun Liu, M.D. Jing-Cheng Wang, M.D., Ph.D.