Venous Congestion

Venous congestion is a common complication of traumatic injuries and reconstructive surgery. Venous congestion occurs when arterial inflow is greater than venous outflow. When venous outflow is obstructed by clotting or disruption of veins, venous pressure increases. Prolonged elevated venous pressure results in distention, edema, stasis, ischemia and cellular death.

Postoperatively, this can occur when the reconstructive surgeon is simply unable to find and reconnect adequate venous circulation or when clots obstruct the venous outlet. Intraoperative anticoagulant therapy and microsurgical techniques are routinely employed to reduce the incidence of venous congestion, but it remains a significant risk. When surgical correction of venous congestion is not an option and arterial flow remains adequate, surgeons may choose to employ leech therapy to salvage the transferred flap.

Leeches increase tissue perfusion by actively withdrawing congesting fluids and passively by promoting bleeding. Leech therapy increases oxygenation of involved tissues, and allows time for neovascularization and thrombolysis.

Medical leeches are well adapted to treat venous congestion. They painlessly incise a triad shaped wound that closes slowly. They secrete saliva that: anesthetizes the skin, relaxes tissues and interferes with the clotting cascade. Finally, the leech can extract an average of 5 ml of blood and fluid while feeding and another 50 ml after detaching as the wound continues to ooze. Removing this volume allows the inflow of new blood. It is estimated that the leech increases surface perfusion in an area of approximately 1.6 cm. diameter around the leech head.

Before leech therapy is initiated it's very important to differentiate between arterial occlusion and venous congestion. This is because leech therapy is contraindicated with arterial occlusion. Insufficient arterial flow makes a wound much more susceptible to infection, including infection from the leech.

Characteristic

Arterial occlusion
Venous congestion

Color of skin

Pale, mottled blue

Dusky, cyanotic, blue

Capillary refill

Sluggish, >3 seconds

< or = to 3 seconds

Tissue turgor

Prune-like, then hollow

Tense, swollen, distended

Temperature

Cool

Cool

Dermal bleeding

Serum and/or scant amount of dark blood

Rapid bleeding, dark blood


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Leech therapy is contraindicated in the presence of arterial occlusion.
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