Prolongation of the Time Window From Traumatic Limb Amputation to Replantation From 6 to 33 Hours Using Ex Vivo Limb Perfusion

Author:

Zhang Lei12,Ipaktchi Ramin2,Ben Brahim Bilal1,Arenas Hoyos Isabel12,Jenni Hansjörg3,Dietrich Lena2,Despont Alain1,Shaw-Boden Jane1,Büttiker Svenja1,Siegrist David1,Gultom Mitra1,Parodi Chiara4,Garcia Casalta Luisana4,Petrucci Mariafrancesca4,Petruccione Ilaria4,Mirra Alessandro5,Nettelbeck Kay4,Wang Junhua1,de Brot Simone6,Voegelin Esther2,Casoni Daniela4,Rieben Robert1ORCID

Affiliation:

1. Department for BioMedical Research, DBMR, University of Bern , Bern 3008, Switzerland

2. Department of Plastic- and Hand Surgery, Inselspital, Bern University Hospital , Bern 3010, Switzerland

3. Department of Cardiovascular Surgery, Inselspital, Bern University Hospital , Bern 3010, Switzerland

4. Experimental Surgery Facility, EAC, University of Bern , Bern 3010, Switzerland

5. Section of Anaesthesiology and Pain Therapy, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern , Bern 3012, Switzerland

6. COMPATH, Institute of Animal Pathology, University of Bern , Bern 3012, Switzerland

Abstract

ABSTRACT Introduction Continuous extracorporeal perfusion (ECP), or machine perfusion, holds promise for prolonged skeletal muscle preservation in limb ischemia-reperfusion injury. This study aimed to extend the amputation-to-replantation time window from currently 6 hours to 33 hours using a 24-hour ECP approach. Materials and Methods Six large white pigs underwent surgical forelimb amputation under general anesthesia. After amputation, limbs were kept for 9 hours at room temperature and then perfused by 24-hour ECP with a modified histidine-tryptophan-ketoglutarate (HTK) solution. After ECP, limbs were orthotopically replanted and perfused in vivo for 12 hours. Clinical data, blood, and tissue samples were collected and analyzed. Results All 6 forelimbs could be successfully replanted and in vivo reperfused for 12 hours after 9 hours of room temperature ischemia followed by 24 hours ECP. Adequate limb perfusion was observed after replantation as shown by thermography and laser Doppler imaging. All pigs survived without severe organ failure, and no significant increase in inflammatory cytokines was found. Macroscopy and histology showed marked interstitial muscular edema of the limbs, whereas myofiber necrosis was not evident, implying the preservation of muscular integrity. Conclusions The use of a 24-hour ECP has successfully extended limb preservation to 33 hours. The modified histidine-tryptophan-ketoglutarate perfusate demonstrated its ability for muscle protection. This innovative approach not only facilitates limb replantation after combat injuries, surmounting geographical barriers, but also broadens the prospects for well-matched limb allotransplants across countries and continents.

Funder

U.S. Department of Defense

Publisher

Oxford University Press (OUP)

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