title: Intra-arterial Thrombolysis for Postoperative Digital Ischemia: A Case Report.
abstract: OBJECTIVE
  Surgical repair of digital flexion deformities can result in vascular injuries threatening the viability of the affected digit. While uncommon, these injuries are reported to have a rate as high as 0.8% following palmo-digital fasciectomy for Dupuytren's disease. Late presentation of such vascular events pose a challenge, since taking the patient to the operating room does not guarantee success.
  
  
  METHODS
  We report a case of subacute digital ischemia that presented 10 days following correction of a boutonniere deformity treated with intra-arterial thrombolysis. There were no particular intraoperative complications. The thrombolytic regimen consisted of Alteplase (Roche, Mississauga, Canada) 2 mg bolus and 1 mg per hour (total 30 mg received over 28 hours) and intravenous heparin with a subtherapeutic target partial thromboplastin time of 40 to 50 seconds.
  
  
  RESULTS
  Thirty hours after the initiation of thrombolysis, an angiography confirmed complete reperfusion of the digital arteries at the distal interphalangeal joint that correlated with the clinical appearance of the digit. Thrombolysis was interrupted and therapeutic intravenous heparin was maintained. Bridging to warfarin was started 6 days postthrombolysis with a target international normalized ratio of 2 to 3. Unfortunately, she was weaned from the heparin while her international normalized ratio was not yet in the therapeutic range and the vessels rethrombosed. This was confirmed by angiography, and intra-arterial thrombolysis was performed with successful revascularization. The patient was restarted on therapeutic dose of heparin and carefully bridged to Coumadin.
  
  
  CONCLUSIONS
  For traction injuries, thrombolytic therapy can be a viable option although we should keep in mind that it could provoke severe adverse events.
authors.affiliation: Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.
authors.forename: Johnny I
authors.initials: JI
authors.lastname: Efanov
authors.affiliation: Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.
authors.forename: Andrei
authors.initials: A
authors.lastname: Odobescu
authors.affiliation: Division of Interventional Radiology, University of Montreal Hospital Center, Montreal, Quebec, Canada.
authors.forename: Marie-France
authors.initials: MF
authors.lastname: Giroux
authors.affiliation: Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.
authors.forename: Patrick G
authors.initials: PG
authors.lastname: Harris
authors.affiliation: Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.
authors.forename: Michel A
authors.initials: MA
authors.lastname: Danino
keywords: digital ischemia; iatrogenic; intimal injury; subacute; thrombolysis