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Botulinum Toxin-A as an Adjunct in Digital Replantation
Nicholas Bastidas, MD1, Zhi Yang, BA2, Daniel Ceradini, MD3, Pierre B. Saadeh, MD3.
1NYU/Bellevue Hosptial Center, New York, NY, USA, 2NYU, New York, NY, USA, 3NYU Langone Medical Center, New York, NY, USA.

PURPOSE:
Vasospasm of the digital arteries after replantation surgery is particularly problematic as it often leads to vessel thrombosis and subsequent loss of arterial inflow. Botuilinum Toxin-A (Botox) has been demonstrated in the literature to be an effective treatment for vasospastic disorders of the hand, including Raynaud’s phenomenon. We hypothesize that using a single dose of Botox intra-operatively may allow for a temporary, yet adequate, sympatholytic effect, and prevent the occurrence of vascular smooth muscle mediated vasospasm which often leads to replant failure (via vessel thrombosis).
Methods: An in vivo rodent vasospasm model was used to evaluate the timing of effect of a perivascular injection of Botox-A (20 units) into the pedicle of SIE flaps. Perfusion of the flaps was quantitatively assessed using color laser Doppler flow instrumentation (Moor Instruments). Vasospasm was induced using mechanical stimulation, intra-muscular epinephrine and topical epinephrine and flow was determined at 1hr, 24hrs, 48hrs, 72hrs, and one week post-injection.
An IRB/FDA approved randomized single blind clinical trial was initiated at Bellevue Hospital and informed consent obtained from participants in the trial.
Results:
Experimental: Rodent SIE flaps pre-treated with Botox maintained almost normal perfusion (82-100% of total flow) in response to vasospastic challenges when compared to controls (22-45% of total flow) with a significant effect on post-treatment day three. This effect was maintained up to at least one-week post-operative.
Clinical: One of seven revascularizations (14.3%) was taken back for exploration in the botox group (2hours post-injection). Upon exploration, the inflow returned without necessitating a revision of the anastomosis, confirming our suspicion for vasospasm. Two of eight (25%) revascularizations was taken back in the control group and found to have arterial thrombosis (POD #1 and POD #3), one of which was salvaged with a vein graft.
Conclusions: Botox-A significantly reduces vasospasm in response to challenges (mechanical stimulation and topical epinephrine) while maintaining flap perfusion in the rodent model, with a significant effect on post-operative day three. Preliminary results of the clinical trial suggest Botox to be a useful adjunct in reducing incidences of vasospasm and loss of the replanted part. More patients must be enrolled in the clinical trial to obtain statistical significance.


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