(CS-030) Vasopressor Induced Foot Ischemia Salvage

Vasopressor induced digital ischemia is the consequence of decreased digital perfusion sometimes seen with vasopressor usage in critically ill patients.¹ Unfortunately, these ischemic changes are often irreversible and lead to amputation. The extent of soft tissue necrosis varies and can make surgical closure difficult to achieve. Piscine grafts offer a structure ideal for incorporating human fibroblasts within the matrix, allowing for fast incorporation.² Acellular fish skin also has antimicrobial, anti-inflammatory and analgesic effects³, which may be beneficial in the sensate immunocompromised patient. We illustrate a case where piscine graft was used to aid in salvage for vasopressor induced ischemia.

Methods:

We report a case where a piscine 2:1 pre-meshed graft was utilized for assistance in closure of a transmetatarsal amputation site following vasopressor induced ischemia with minimal viable soft tissue at the flap site. Initial amputation was performed, and the piscine graft was applied directly over the incision and surrounding full-thickness tissue deficits. A second debridement and application of the 2:1 pre-meshed graft was applied 10 days after initial application.

Results:

The amputation incision site healed without any dehiscence within 10 days after surgery. Epithelialization began of the surrounding full-thickness defects and lead to complete healing of the amputation site. The piscine graft appears to have aided in amputation site closure and with epithelialization of the surrounding soft tissue defects.

Discussion:

Amputation is often necessary following vasopressor induced ischemic changes of the digits. Amputation options are often limited due to the extent of surrounding soft tissue loss, necessitating a more proximal amputation.

The utilization of a piscine acellular dermal matrix appears to be a feasible option to provide soft tissue coverage when the surrounding skin has full-thickness loss. This allows for the most distal amputation possible to remove the necrotic digits, therefore, preventing the need for a more proximal amputation. This case report may hopefully guide surgeons in the future to prevent the need for a more proximal amputation.   

Trademarked Items:

References: 1. S. Jesani, S. Elkattawy, M. Noori, S. Ayad, S. Abuaita, K. Gergis, O. Elkattawy, V. Garg Vasopressor-induced digital ischemia Cureus, 13 (7) (2021), p. e16595, 10.7759/cureus.16595
2. S. Magnusson, et al. Regenerative and antibacterial properties of acellular fish skin grafts and human amnion/chorion membrane: implications for tissue preservation in combat casualty care
Mil. Med., 182 (suppl_1) (2017), pp. 383-388
3. S. Magnusson, et al. Acceleration of wound healing through utilization of fish skin containing omega-3 fatty acids
Today's Wound Clinic (2017)