American Society of Hirudotherapy

The Use of Medicinal Leeches for the Treatment of Venous Congestion in Replanted or Revascularized Digits

Arami A, Gurevitz S, Palti R, Menachem S, Berelowitz M, Yaffe B (2018) · Journal of Hand Surgery (American Volume) · n=25

RCT evidence detailTrial reference
GRADE LowCohort / case series
Sample size of this trial compared with other venous-congestion-flap trialsMarquard JM 20251215Bishop JL 2023843Doğan S 2024570Troeltzsch M 2016330Kucur C 2015260Wang ZD 2022210Lehnhardt M 202196Kruer RM 201459Mozafari N 201056Arami A 201825
This trial (highlighted) by sample size alongside other indexed venous-congestion-flap trials. Larger trials generally carry more statistical weight.

Study Profile

Design
single-institution retrospective cohort study of patients with complete or incomplete digit amputation admitted to the Department of Hand Surgery at Sheba Medical Center (affiliated with Sackler School of Medicine, Tel Aviv University, Israel) between January 2008 and April 2014, evaluating salvage of venously congested digits replanted or revascularized proximal to the distal interphalangeal (DIP) joint and treated with medicinal leech therapy
Sample size (n)
25
Intervention
Medicinal leech therapy applied for venous congestion of replanted or revascularized digits proximal to the DIP joint; treatment initiation and duration based on clinical judgment (no fixed protocol); part of a larger replant cohort of 145 patients / 205 digits
Comparator
Within-cohort comparison of replanted (n=22) versus revascularized (n=3) digits; no randomized comparator
Primary endpoint
Digit salvage rate following medicinal leech therapy for proximal digit venous congestion
Primary result
Of 25 venously congested digits treated with medicinal leeches, 11 survived (44%); salvage was 8 of 22 (36%) for replanted digits and 3 of 3 (100%) for revascularized digits; in 24 of 25 digits venous congestion was diagnosed >48 hours after operation; one patient required blood transfusion for substantial blood loss; no other major complications reported
Follow-up duration
duration of hospitalization plus institutional postoperative follow-up (variable)
PMID
29602653

Key Findings

  • 44% overall digit salvage rate (11 of 25) — lower than distal-tip series (typical 60-80%) but consistent with the larger tissue volume of proximal digit congestion
  • 100% salvage for revascularized digits (3 of 3) versus 36% for replanted digits (8 of 22) suggests vascular reserve is a key prognostic factor
  • 24 of 25 digits had congestion diagnosed >48 hours postoperatively — emphasizes the importance of early detection
  • One transfusion-requiring blood loss event — bleeding is a real and clinically significant adverse event of multi-day leech protocols
  • Israeli academic-center experience adds Middle East/Mediterranean geographic representation to the K040187 evidence base

Limitations

  • Modest sample (n=25 leech-treated digits) — not powered to detect optimal protocol parameters
  • Retrospective design — selection bias toward digits with intermediate prognosis
  • Late diagnosis (>48 hr postoperatively in 96%) confounds salvage estimates and is a system-level finding rather than a leech-therapy efficacy finding
  • No standardized leech protocol (number, frequency, duration) - clinical-judgment basis varies between providers
  • Single-center single-country experience — generalizability untested

Clinical Implications

Arami 2018 is the principal published Israeli single-center series of medicinal leech therapy for proximal digit replantation and revascularization. For US clinicians, the trial provides a realistic salvage benchmark (44% overall, 100% for revascularization with preserved arterial inflow) and highlights that proximal-finger applications have lower success rates than distal-tip replants, likely reflecting the larger volume of congested tissue and the prevalence of late diagnosis. The trial supports the K040187 microsurgical-salvage indication while underlining the need for vigilant early postoperative monitoring of congestion and prompt initiation of leech therapy when indicated.

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Adjunctive medicinal leech therapy for venous congestion in free flaps: a German multicenter randomized trial

Lehnhardt M, Daigeler A, Behr B, Schmidt SV, Wallner C (2021)

Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review

Whitaker IS, Josty IC, Hawkins S, Azzopardi E, Naderi N, Graf J, Damaris L, Lineaweaver WC, Kon M (2011)

Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction

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This website provides educational information and does not constitute medical advice, diagnosis, or treatment recommendations. Medicinal leech therapy carries clinically meaningful risks and should be performed only by qualified clinicians under institutionally approved protocols. FDA 510(k) clearance for medicinal leeches is limited to specific indications; investigational and off-label discussions are labeled accordingly. For patient-specific guidance, consult a qualified healthcare provider.