SCIENTIFIC ARTICLE Ischemic Toe Encountered During Harvesting: Report of 6 Cases Francisco del Piñal, MD, PhD, Francisco J. García-Bernal, MD, PhD, Higinio Ayala, MD, Leopoldo Cagigal, MD, Javier Regalado, MD, Alexis Studer, MD Local vessel disease causing lack of arterial inflow at the time of toe harvesting represents a surgical emergency. In a personal experience of 194 toe transfers to the hand, 6 cases (in 4 patients) were found to have diseased vessels at the first web to the point that acute ischemia of the toe occurred when the tourniquet was released at the lower limb. We report our experience in these 6 cases. (J Hand Surg 2008;33A:1820 –1825. Copyright © 2008 by the American Society for Surgery of the Hand. All rights reserved.) Key words Arterial damage, microvascular surgery, mutilating hand injuries, thrombosis, toe to hand. T OES CAN BE TRANSFERRED to the hand in busy microsurgical centers with a minimal risk of failure. Currently, 96% to 99% success rate is the norm. 1–4 Most failures in the early days were due to faulty technique and/or lack of understanding of the variable local anatomy. 1,5–7 Nowadays, systemic con- ditions, such as hypercoagulability, or unremitting spasm are the main causes when a microvascular case fails. 1,8 –11 It is frequent that the toe, once fully dissected and pedicled on the vessels, takes few minutes to reperfuse after the tourniquet is released at the lower limb. How- ever, the issue of the toe that does not show any capil- lary refill or only a sluggish circulation while still pedi- cled on the donor vessels is rare. We report our experience with ischemia of the harvested toe in 6 cases. CASE REPORTS From February 1995 to February 2008, the first author has carried out 194 toe-to-hand transfers with a success rate of 99%. All transfers were performed after ampu- tations, mainly after work-related injuries. Patient age ranged from 6 to 66 years. Six toes (in 4 patients) were found to have local arterial disease to the extent that the first web vessels did not provide arterial inflow to the toe. This group constitutes the body of this study (Table 1). Two additional toes from 2 of the patients had adequate arterial inflow to the harvested toe when transferred at subsequent operations. All 4 patients were manual workers and injured at work. They all suffered severe injuries: one an acute metacarpal hand, another 4 finger amputations, the only woman a massive burn injury with an avulsing compo- nent, and finally one patient, referred secondarily for reconstruction, who sustained bilateral mutilating inju- ries. Three of the patient, treated acutely by our team, had the reconstruction early. Patients were cleared by anesthesia and rated as minimal or no anesthetic risk. Average age was 53 years (range, 47 to 59 years). Two of the patients, however, had, apart from age, 12 comorbidities known to affect the blood vessels: both were former heavy smokers and one of these patients was obese with unknown arterial hypertension. All operations were car- ried out under continuous axillary and epidural blocks and proceeded uneventfully from an anesthesiology standpoint. Our 6 cases can be divided into 2 groups depending on whether they had or had not preserved a secondary arterial inflow pathway during the toe dissection (ie, whether they had another artery dissected as a backup). From the Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain. Received for publication March 13, 2008; accepted in revised form June 17, 2008. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Francisco del Piñal, MD, PhD, Calderón de la Barca 16-entlo, E-39002 Santander, Spain; e-mail: drpinal@drpinal.com. 0363-5023/08/33A10-0021$34.00/0 doi:10.1016/j.jhsa.2008.06.016 1820  ©  ASSH  Published by Elsevier, Inc. All rights reserved.