Outcome of rectus femoris muscle flaps performed by vascular surgeons for the management of complex groin wounds after femoral artery reconstructions

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications

BACKGROUND

Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis.

METHODS

We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared.

RESULTS

Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p = 0.03), especially deep incisional infection (4.9% vs. 2.4%; p = 0.04).

CONCLUSION

Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee

BACKGROUND

The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively.

METHODS

Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality.

RESULTS

In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups.

CONCLUSION

The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Human gelatin thrombin matrix with rifampin for the treatment of prosthetic vascular graft infections

We aim to describe and report on a novel graft preservation technique using a human gelatin thrombin matrix with rifampin for the treatment of vascular graft infections. Eight patients with vascular graft infections were included, one with bilateral infections, for a total of nine cases from January 2016 through June 2021. All the patients underwent wound exploration and placement of human gelatin thrombin matrix with rifampin. No deaths or allergic reactions had been reported at the 30-day follow-up, with only one major amputation. The graft and limb salvage rates were 77.8% at the 1-year follow-up. The mean time to a major amputation was 122 days, and the mean time to graft excision was 30 days.

Viability of the rectus femoris muscle flap for groin wound coverage after ligation of proximal inflow

Lower extremity revascularization via groin incisions can be complicated by wound dehiscence associated with infection, seroma and femoral vessel exposure. This may require additional surgical debridement and coverage of vascular structures and grafts. The pedicled rectus femoris muscle flap (RFF) has both bulk and a large arc of rotation, making it useful for reconstruction. Its main pedicle is the descending branch of the lateral femoral circumflex artery (DLFCA), a branch of the profunda femoris artery. One could anticipate that ligation of more proximal vasculature could lead to ischemia of the RFF. We present two patients who each underwent vascular surgery involving the common femoral artery and subsequent reconstruction utilizing a pedicled RFF. Both patients then required additional vascular procedures involving the ligation of inflow vessels proximal to the DLFCA. The flaps remained viable, demonstrating the rich collateralization of blood supply that occurs in vascular disease patients.

Flap management of groin wounds following vascular procedures: A review of 270 flaps for vascular salvage

BACKGROUND

Groin dehiscence following vascular procedures results in morbidity for patients with peripheral vascular disease. Controversy exists around the indications for flap coverage. We present an institutional experience with flap reconstruction of groin wounds after vascular procedures to identify predictors of beneficial outcomes.

PATIENTS AND METHODS

A retrospective review of patients who had flap coverage for infected/nonhealing groin wounds following a vascular procedure between 1998 and 2021 was performed. Demographics and clinical characteristics, including flap and vascular graft type, were collected along with major complications. Univariate and multivariable logistic regression analyses were performed to assess the associations between procedures and major complications.

RESULTS

A total of 270 flaps were transferred to 237 patients. Thirty-three patients had bilateral wounds. The mean age and BMI were 67 ± 11 years and 27.9 ± 6.3 kg/m², respectively. Flaps included rectus femoris (n = 142), sartorius (n = 118), rectus abdominis (n = 7), and gracilis (n = 3). Covered vascular grafts included prosthetic materials (n = 200) and autografts (n = 70). The median length of hospital stay after surgery was 10 days (interquartile range=12), and the mean follow-up was 29.1 ± 39.2 months. The major complication rate was 38.5% with wound infection being the most common. Flaps successfully prevented the infection-related removal of the grafts in 98.9% of cases. Multivariable analysis revealed no significant associations between variables and having a major complication.

CONCLUSIONS

Flap coverage of the inguinal vessels can be performed safely with favorable limb salvage. Wound complications were high, but graft salvage was excellent. Rectus femoris and sartorius muscle flaps were the most common flaps, yielding comparable outcomes.

Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Groin wound infections in vascular surgery are still a common complication and challenging problem. This systematic review aimed to establish a complete view of patient characteristics and clinical outcomes for infected groin wounds following vascular surgery reconstruction using muscle flaps and to evaluate the differences in outcomes between the sartorius muscle flap (SMF), rectus femoris muscle flap (RFF), and gracilis muscle flap (GMF).

METHODS

PubMed, Scopus, and Web of Science were systematically searched from inception to April 2021. Random-effects meta-analysis for comorbidities and outcomes and subgroup analyses for outcomes were performed.

RESULTS

Thirty studies were included in qualitative and quantitative syntheses. Overall pooled data showed the following outcome rates: 4.5% muscle flap necrosis (95% confidence interval [CI], -3.4-12.3%; I² = 0%), 21.8% overall complications (95% CI, 15.8-27.7%; I² = 0%), 8.0% limb loss (95% CI, 1.9-14.1%; I² = 0%), 15.4% graft loss (95% CI, 5.0-25.3%; I² = 37.9%), and 7.4% 30-day mortality (95% CI, -.9-15.6%; I² = 0%). The rates of overall complications were 20.3% (95% CI, 12.1-28.2%; I² = 0%), 23.2% (95% CI, 11.2-34.5%; I² = 10.2%), and 18.0% (95% CI, -3.537.8%; I² = 0%) for the SMF, RFF, and GMF, respectively. The rate of limb loss was highest for the GMF (17.2%; 95% CI, -4.237.2%; I² = 0%). The rate of graft loss for the RFF was the highest (20.7%; 95% CI, .6-39.1%; I² = 53.9%). The rate of 30-day mortality was the lowest for the SMF (5.3%; 95% CI, -6.1-16.6%; I² = 0%).

CONCLUSIONS

The effectiveness and safety of muscle flap reconstruction for infected groin wounds following vascular surgery are clearly positive. This review indicated a tendency for lower complication rates with the SMF than with other muscle flaps.

Salvage of Infected Prosthetic Grafts at the Groin or Thigh Using Muscle Flap Coverage

Objectives: This study aimed to evaluate early- and long-term outcomes in patients who undergo muscle flap coverage (MFC) for prosthetic graft infections (PGIs) at the groin or thigh.

Materials and Methods: We retrospectively retrieved and analyzed data on infected wound cures, recurrence, graft and limb salvage, and survival of patients who underwent MFC for PGI at the groin or thigh between 2000 and 2018.

Results: There were eight patients in our cohort: six had groin PGIs and two had thigh PGIs. Moreover, of these patients, seven were treated from sartorius muscles and one from a gracilis muscle. The indicated wounds healed in all eight patients, but two patients died during hospitalization. Three patients suffered recurrence within 8 months, one of which overcame the infection and achieved wound cure without graft removal, with negative pressure wound therapy. No patients lost their limbs during the follow-up term (mean, 24 months; range, 1–60 months). Finally, four patients (50%) survived without removal of the infected graft for longer than 2 years.

Conclusion: MFC can be a curative treatment for PGI, but there remains a possibility of a recurring infection thereafter.

Outcome of rectus femoris muscle flaps for groin coverage after vascular surgery

OBJECTIVE

The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage.

METHODS

All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay.

RESULTS

A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%).

CONCLUSIONS

This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.