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Maruyama T, Imura H, Dohi M. Infected Aortic Aneurysm Secondary to Pyogenic Flexor Tenosynovitis from Streptococcus pyogenes. Intern Med 2024; 63:1505-1509. [PMID: 37813616 PMCID: PMC11157323 DOI: 10.2169/internalmedicine.2411-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/15/2023] [Indexed: 10/11/2023] Open
Abstract
Infected aortic aneurysms are rare, and have a high mortality rate. Although not a major pathogen, Streptococcus pyogenes has been reported to cause infected aortic aneurysms. In the present case, the patient was hospitalized for pyogenic flexor tenosynovitis with S. pyogenes bacteremia. Despite drainage of the abscess around the flexor tendon and effective antimicrobial therapy, infected aneurysms developed in the abdomen and ascending aorta. Because of their rapid enlargement, these aneurysms were treated with in situ reconstruction. Although rare, the possibility that S. pyogenes is the causative pathogen of infected aortic aneurysms should be considered.
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Affiliation(s)
- Takahiro Maruyama
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Japan
- Department of Intensive Care, Hyogo Prefectural Amagasaki General Medical Center, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Japan
| | - Masahiro Dohi
- Department of Cardiac Surgery, Rakuwakai Otowa Hospital, Japan
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2
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Isath A, Gregory V, Ohira S, Levine A, Dhand A, Laskowski I, Mateo R, Babu S, Spielvogel D, Kai M. Groin wound management after decannulation of veno-arterial extracorporeal membrane oxygenation in heart transplantation: Role of sartorius muscle flap. Clin Transplant 2023; 37:e15147. [PMID: 37755149 DOI: 10.1111/ctr.15147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND The management of complex groin wounds following VA-ECMO after heart transplant (HT) is uncertain due to limited experience. Sartorius muscle flaps (SMF) have been used in vascular surgery for groin wound complications. However, their use in HT recipients with perioperative VA-ECMO is unclear. This study aims to describe characteristics and outcomes of HT patients with groin complications after arterial decannulation for femoral VA-ECMO. METHODS We retrospectively reviewed HT patients who underwent peri-transplant femoral VA-ECMO at our institution from April 2011 to February 2023. Patients were categorized into two groups based on the presence of cannulation-related wound complications. RESULTS Among the 34 patients requiring VA-ECMO peri-transplant, 17 (50%) experienced complications at the cannulation site. Baseline characteristics including duration of VA-ECMO support were comparable in both groups. Patients with complications presented mostly with open wounds (41.1%) after a median duration of 22 days post-transplant. Concurrent groin infections were observed in 52.3% of patients, all caused by gram-negative bacteria. Wound complications were managed with 12 (70.6%) undergoing SMF treatment and 5 (31.2%) receiving conventional therapy. Four SMF recipients had preemptive procedures for wound dehiscence, while eight underwent SMF for groin infections. Among the SMF group, 11 patients had favorable outcomes without recurrent complications, except for one patient who developed a groin infection with pseudoaneurysm formation. Conventional therapy with vacuum assisted closure (VAC) and antibiotics were utilized in four patients without infection and one patient with infection. Three patients required additional surgeries with favorable healing of the wound. CONCLUSION Complications related to femoral VA-ECMO are common in HT patients, with infection being the most frequent complication. SMFs can be a useful tool to prevent progression of infection and improve local healing.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Abhay Dhand
- Transplant Infectious Disease, Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Igor Laskowski
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Romeo Mateo
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Sateesh Babu
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Basnayake O, Jayarajah U, Dissanayake D. Bilateral rectus femoris myocutaneous flaps to salvage exposed axillo-bifemoral graft of bilateral groins. SAGE Open Med Case Rep 2023; 11:2050313X231165631. [PMID: 37122425 PMCID: PMC10134173 DOI: 10.1177/2050313x231165631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/07/2023] [Indexed: 05/02/2023] Open
Abstract
Exposed prosthetic grafts are a challenge to vascular specialists. Groin dissections in vascular surgery can lead to local tissue breakdown, especially in patients who have multiple comorbidities and poor nutritional status. In this report, we describe a patient with exposed prosthetic bypass conduits in the groin region which was successfully covered with bilateral myocutaneous flaps. A 75-year-old Sri Lankan male with diabetes, hypertension and Parkinson's disease presented with bilateral non-healing wound and rest pain for 3 months. Since his premorbid status precluded the aortic cross-clamping and aorto-bifemoral graft, a decision was made to perform a right axillo-bifemoral bypass using a prosthetic graft. Re-operation was required for graft thrombectomy on the same day of surgery. His post-operative period was complicated with lymph leak and surgical site infection of bilateral groin wounds which ultimately led to exposed prosthetic graft which was fortunately patent. After optimizing his nutritional status and comorbidities, he underwent bilateral rectus femoris myocutaneous flaps to cover the soft-tissue defect over the exposed prosthetic grafts. His initial post-operative period was unremarkable except for a small area of skin breakdown. Myocutaneous flaps are preferred as they are more resilient to breakdown compared to facio-cutaneous flaps, especially in a patient with compromised blood supply. The type of loco-regional flap should be carefully selected in an individualized manner depending on the regional vascularity. The rectus femoris flap is a suitable option in terms of ease of surgical technique and durability. Comorbidities and local factors should be optimized prior to definitive reconstruction to maximize the chances for optimal wound healing.
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Affiliation(s)
- Oshan Basnayake
- Department of Anatomy, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- Plastic and Reconstructive Surgical Unit, The National Hospital of Sri Lanka, Colombo, Sri Lanka
- Oshan Basnayake, Department of Anatomy, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Western Province, Sri Lanka.
| | - Umesh Jayarajah
- Plastic and Reconstructive Surgical Unit, The National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Dammika Dissanayake
- Plastic and Reconstructive Surgical Unit, The National Hospital of Sri Lanka, Colombo, Sri Lanka
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4
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[Autologous tissue reconstruction of the lower extremity-indications and technique]. Chirurg 2022; 93:1007-1018. [PMID: 35089367 DOI: 10.1007/s00104-021-01566-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
Autologous tissue reconstruction for defect coverage of lower extremity wounds describes a broad interdisciplinary spectrum of conservative, surgical and interventional treatment options. The goals of reconstruction are a resilient and function-preserving but also esthetically acceptable wound closure, which should enable rehabilitation and the return to participation in social and working life for those affected. Depending on the wound conditions as well as on potentially occurring concomitant injuries and comorbidities, the timing and method of defect coverage is selected in an individualized approach for each patient. It is essential that the plastic surgeon is involved as early as possible in the preparation of a treatment plan and can then select the most appropriate and least invasive reconstructive procedure from the armamentarium, depending on the localization and etiology of the soft tissue defect. These vary from secondary wound closure to skin grafts up to local and free flaps.
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5
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Shimbo K, Kawamoto H, Koshima I. Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2022; 56:401-407. [PMID: 35050812 DOI: 10.1177/15385744211068342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan.,International Center for Lymphedema, 68272Hiroshima University Hospital, Hiroshima, Japan
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Lauer H, Goertz O, Landscheidt K, Hernekamp JF. [The proximally pedicled anterolateral thigh flap for reconstruction of complex soft tissue wounds of the hip and caudal trunk region]. Chirurg 2021; 93:388-394. [PMID: 34432070 DOI: 10.1007/s00104-021-01483-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Groin and lower trunk defects are common problems, especially for elderly patients. While groin defects are often due to prior vascular interventions, trochanteric defects are mainly caused by pressure sores. Plastic reconstructive methods are manifold; however, the pedicled anterolateral thigh (ALT) flap is supposed to be reliable with sustainable results. OBJECTIVE We present our experiences using the pedicled ALT flap for soft tissue reconstruction in patients with large wounds of the medial and lateral proximal thigh. MATERIALS AND METHODS A total of 16 patients with groin and lower trunk defects due to prior vascular surgery or pressure sores received locoregional soft tissue reconstruction using a proximal pedicled ALT flap. Patient characteristics, defect size, surgery time, clinical outcome and complication rate were assessed. RESULTS With the exception of two cases, sufficient soft tissue reconstruction was achieved. In all, 81,3% of patients were categorized as ASA (American Society of Anesthesiologists) 3. The average duration of surgery was 149 min. Length of stay was 18,3 days. A total of 31% needed revision surgery due to limited wound healing problems. Two patients died. All patients showed healed wound conditions when they were discharged. CONCLUSION The proximal pedicled ALT-flap is a reliable method for soft tissue reconstruction in groin and lower trunk defects. This reconstructive procedure enables reliable wound closure, especially in elderly patients with substantially reduced general health condition.
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Affiliation(s)
| | | | | | - J F Hernekamp
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar-Theyß-Straße 27, 14193, Berlin, Deutschland.
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O'Malley P, McDonnell C. Negative pressure wound therapy-two novel approaches to healing dehisced vascular bypass wounds. J Wound Care 2021; 30:449-453. [PMID: 34121434 DOI: 10.12968/jowc.2021.30.6.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The use of negative pressure wound therapy (NPWT) in surgical wound healing by secondary intention is well known. Its use in healing dehisced vascular bypass wounds is contraindicated by manufacturers due to exposed vasculature and risk of bleeding. There is an increasing body of knowledge to support the use of NPWT in vascular wounds in order to prevent graft excision and the need for flap closure. This paper reports the use of two different approaches using NPWT to heal dehisced, infected vascular groin bypass wounds in two patients. Both patients had lower limb bypass using Dacron (Vascutek Ltd., UK) grafts and subsequently became infected, dehisced and required debridement. Following debridement, graft was visible in the wound bed and NPWT was applied to facilitate healing. Case one had polyurethane (black) foam and a layer of petroleum-impregnated cellulose acetate mesh to prevent adherence to the graft. Case two had polyvinyl alcohol (white) (PVA) foam applied to the wound. The PVA foam was used in Case two due to pain at dressing changes. Negative pressure was initially -25mmHg but increased gradually to -125mmHg and -150mmHg, respectively, the therapeutic pressure for the respective foams. Dressings were changed every 48-72 hours and infection treated with antibiotics as appropriate. After eight days and 28 days of NPWT, respectively, graft was no longer visible. No significant bleeding was noted. These two case studies would suggest that, with precautions taken to protect the vasculature, the use of NPWT in healing dehisced vascular groin wounds is an appropriate treatment.
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8
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Tanaka K, Mii S, Ishida M, Guntani A, Kawakubo E, Tanaka S, Yoshiga R, Okazaki J. Salvage of Infected Prosthetic Grafts at the Groin or Thigh Using Muscle Flap Coverage. Ann Vasc Dis 2020; 13:404-409. [PMID: 33391558 PMCID: PMC7758575 DOI: 10.3400/avd.oa.20-00123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Kiyoshi Tanaka
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Fukuoka, Japan
| | - Masaru Ishida
- Department of Vascular Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Fukuoka, Japan
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Fukuoka, Japan
| | - Eisuke Kawakubo
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Fukuoka, Japan
| | - Shinichi Tanaka
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Ryosuke Yoshiga
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Fukuoka, Japan
| | - Jin Okazaki
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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Rasheed H, Diab K, Singh T, Chauhan Y, Haddad P, Zubair MM, Vowels T, Androas E, Rojo M, Auyang P, McFall R, Gomez LF, Mohamed A, Peden E, Rahimi M. Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery. Ann Vasc Surg 2020; 72:578-588. [PMID: 33157243 DOI: 10.1016/j.avsg.2020.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.
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Affiliation(s)
- Haroon Rasheed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Kaled Diab
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Tarundeep Singh
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Yusuf Chauhan
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Paul Haddad
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - M Mujeeb Zubair
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Travis Vowels
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Edward Androas
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Manuel Rojo
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Phillip Auyang
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ross McFall
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Luis Felipe Gomez
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ahmed Mohamed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Eric Peden
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Maham Rahimi
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX.
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Gwon JG, Han Y, Cho YP, Kwon TW. Obturator bypass using a ringed polytetrafluoroethylene graft for inguinal graft infection. Vascular 2020; 28:530-535. [PMID: 32366177 DOI: 10.1177/1708538120922112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Inguinal vascular graft infections are high-risk events that cannot be controlled medically but require surgical intervention. This study reviewed the long-term clinical outcomes of obturator bypass using a ringed polytetrafluoroethylene graft for inguinal graft infection. METHODS A total of eight consecutive patients who underwent obturator bypass using a ringed polytetrafluoroethylene graft for inguinal prosthetic graft infection at a single medical center between January 2006 and October 2017 were retrospectively analyzed. The demographics, clinical characteristics, surgical procedure, and clinical outcomes were evaluated. RESULTS There was no perioperative death; however, there were three operative complications. On the 1st and 9th postoperative day, two patients underwent hematoma evacuation in the pelvic cavity, and the other patient underwent suture reinforcement for partial dehiscence of the distal anastomosis on the 49th postoperative day. The median length of hospital stay was 14.5 (range, 7-29) days. Only one graft occlusion was observed at postoperative month 40; however, there were no ischemic symptoms. There were no limb amputations and postoperative deaths during the long-term follow-up period. There were no infections of the previous residual and obturator bypass grafts and inguinal infection during the follow-up period of 49 (range, 7-154) months. CONCLUSION Obturator bypass for inguinal graft infection is feasible and durable with excellent long-term outcomes. However, perioperative bleeding should be taken into consideration.
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Affiliation(s)
- Jun G Gwon
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul Republic of Korea
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11
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Wübbeke LF, Conings JZM, Elshof JW, Scheltinga MR, Daemen JWHC, Jacobs MJ, Mees BM. Outcome of rectus femoris muscle flaps for groin coverage after vascular surgery. J Vasc Surg 2020; 72:1050-1057.e2. [PMID: 32122734 DOI: 10.1016/j.jvs.2019.11.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/04/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Lina F Wübbeke
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jurek Z M Conings
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Marc R Scheltinga
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
| | - Jan-Willem H C Daemen
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michael J Jacobs
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Barend M Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; European Vascular Center Aachen-Maastricht, Aachen, Germany.
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12
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[Thigh muscle flaps for postoperative inguinal wound complications in vascular surgery : Sartorius muscle versus rectus femoris muscle]. Chirurg 2019; 91:337-344. [PMID: 31654105 DOI: 10.1007/s00104-019-01054-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Inguinal wound complications often cause postoperative morbidity and also mortality following vascular surgical interventions. The aim of this study was to report experiences and a comparison of the outcomes using rectus femoris muscle flaps (RFF) and sartorius muscle flaps (SMF). MATERIAL AND METHODS A retrospective study was performed at two locations of a cross-border vascular center and all muscle flap interventions performed at the two centers within the vascular surgery department were reviewed. Primary outcomes were muscle flap survival, graft salvage and major amputations. RESULTS A total of 44 RFFs were performed in 39 patients (mean age 67 years, 73% males) and 25 SMFs in 24 patients (mean age 64 years, 76% males). Wound infections were the most common indications for muscle flap reconstruction. At a mean follow-up of 24 months (±24) and 17 months (±20), respectively, comparable flap survival rates (91% vs. 84%), wound healing rates (72% vs. 83%), graft salvage (65% vs. 73%) and amputation rates (9% vs. 8%) were found. CONCLUSION Muscle flap reconstruction is an effective way to cover groin defects resulting from deep wound infections after vascular surgery, achieving good results in a high-risk group of patients. No differences were found between SMF and RFF regarding amputation and graft loss. Both techniques can be safely performed, depending on the preference and experience of the surgical team. The RFF technique should be preferentially used to cover large tissue defects, whereas the SMF procedure can be preferred to cover smaller defects in the groin.
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13
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Wübbeke LF, Elshof JW, Conings JZM, Scheltinga MR, Daemen JWHC, Mees BME. A systematic review on the use of muscle flaps for deep groin infection following vascular surgery. J Vasc Surg 2019; 71:693-700.e1. [PMID: 31630887 DOI: 10.1016/j.jvs.2019.07.073] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/15/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage. METHODS The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated. RESULTS A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences. CONCLUSIONS Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.
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Affiliation(s)
- Lina F Wübbeke
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Jurek Z M Conings
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc R Scheltinga
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
| | - Jan-Willem H C Daemen
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; European Vascular Center Aachen-Maastricht, Maastricht, The Netherlands.
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Batt M, Camou F, Coffy A, Feugier P, Senneville E, Caillon J, Calvet B, Chidiac C, Laurent F, Revest M, Daures JP. A meta-analysis of outcomes of in-situ reconstruction after total or partial removal of infected abdominal aortic graft. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:171-182. [PMID: 30698369 DOI: 10.23736/s0021-9509.19.10669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION There is currently a lack of evidence for the relative effectiveness of partial resection (PR) and total resection (TR) before managing abdominal aortic graft infection (AGI). Most authorities agree that TR is mandatory for intracavitary AGI in patients with favorable conditions but there is an increasing number of patients with severe comorbidities for whom this approach is not suitable, resulting in a prohibitive mortality rate. The purpose of this study was to determine the most appropriate indication for TR or PR. EVIDENCE ACQUISITION A meta-analysis was conducted on the rates of early/late mortality, amputations and reinfection. A meta-regression was performed with eight variables: patient age, male prevalence, presence of virulent or nonvirulent organisms, urgency, omentoplasty and follow-up. EVIDENCE SYNTHESIS Twenty-one studies and 1052 patients were included. For TR and PR, the rates of early mortality and reinfection were 16.8% and 10.5%, 11% and 27%, respectively. For TR urgency and male gender were associated with increased rate of early mortality and male gender, PDF and virulent organisms were associated with increased risk of reinfection. For PR no statistical correlation was analyzable except for PDF with increased risk of reinfection. CONCLUSIONS Early mortality rates are higher for TR and reinfection rates are higher for PR. For TR early mortality increases in urgent cases and it is suggested that alternative option must be discussed, reinfection decreases in the presence of nonvirulent organisms and TR seems optimal. For TR and PR reinfection increases in presence of PDF and alternative technique may be more appropriate.
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Affiliation(s)
- Michel Batt
- Department of Vascular Surgery, University Nice-Sophia Antipolis, Nice, France -
| | - Fabrice Camou
- Intensive Care Unit, Saint-Andre University Hospital, Bordeaux, France
| | - Amandine Coffy
- Laboratory of Biostatistics and Epidemiology, University Institute for Clinical Research, Montpellier, France
| | - Patrick Feugier
- Department of Vascular Surgery, University Claude Bernard Lyon 1, Hospices Civils de Lyon, Lyon, France
| | - Eric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Lille 2 University, Tourcoing, France
| | | | - Brigitte Calvet
- Anesthosiology Department, Béziers Hospital, Béziers, France
| | - Christian Chidiac
- Infectious Deseases Department, Hospices Civils de Lyon and International Center for Infectiology Research (CIRI), INSERM U1111, Lyon 1 University, Lyon, France.,Bacteriology Department, International Center for Infectiology Research (CIRI), INSERM U1111, Lyon 1 University, Lyon, France
| | - Frederic Laurent
- Infectious Diseases, and Intensive Care Unit, Pontchaillou University Hospital, CIC-INSERM 1414, Rennes 1 University, France
| | | | - Jean Pierre Daures
- Laboratory of Biostatistics and Epidemiology, University Institute for Clinical Research, Montpellier, France
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15
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The Marriage of Sartorius and Tensor Fasciae Latae in Treating Vascular Prosthetic Graft Infections. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1274. [PMID: 28507848 PMCID: PMC5426867 DOI: 10.1097/gox.0000000000001274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
Abstract
Background: Vascular prosthetic graft infection in the groin is associated with high morbidity and mortality. This article presents a case series on the use of 2 flaps in the treatment of this condition. Methods: Five patients, mean age 65 years (range, 49–74 years), with significant comorbidity were treated for an exposed and infected vascular prosthetic graft in the groin with a combination of sartorius muscle (SM) flap and tensor fascia lata (TFL) myocutaneous flap after debridement and start of microbiologic culture–guided antibiotic treatment. The SM flap was used to cover the exposed graft. To obtain stable wound coverage, the SM and remaining groin defect were closed with a pedicle TFL flap. Results: All flaps survived, with only 1 TFL flap suffering a small tip necrosis. All patients obtained stable wound coverage. Donor-site morbidity was minimal. During the follow-up, mean 46 months (range, 15–79 months), 1 patient had a recurrence after 15 months due to a kink in the elongated prosthetic graft that protruded through the skin alongside the SM and TFL flaps. Conclusions: The combination of SM and TFL flaps could be a new treatment option for patients who have an exposed and infected vascular prosthetic graft in the groin. This flap combination could also be used as a prophylactic procedure for those patients with a high risk to develop such a serious complication.
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Wilson WR, Bower TC, Creager MA, Amin-Hanjani S, O’Gara PT, Lockhart PB, Darouiche RO, Ramlawi B, Derdeyn CP, Bolger AF, Levison ME, Taubert KA, Baltimore RS, Baddour LM. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e412-e460. [DOI: 10.1161/cir.0000000000000457] [Citation(s) in RCA: 215] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Cerny M, Harder Y, Zimmermann A, Eckstein HH, Machens HG, Schantz JT, Schenck TL. [Locoregional solutions for groin defects : Coverage after vascular surgery]. Chirurg 2016; 88:43-49. [PMID: 27435247 DOI: 10.1007/s00104-016-0244-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Vascular surgery through a groin incision may be associated with severe wound healing disorders in this sensitive area. There are many options to reconstruct the defect surgically. The choice of surgical reconstruction depends mainly on the individual status of vasculature, which is most often compromised in these patients. There are random pattern flaps, as well as perforator, pedicled flaps or microvascular flaps to choose from. AIM We give an overview of plastic surgical solutions for groin defects, with a special focus on complex wounds after vascular surgical complications. We discuss advantages and disadvantages of different flaps with two case reports and also show alternatives. PATIENTS AND METHODS We demonstrate in two cases how the reconstruction of the groin defect was planned, taking into account the vascular status, and why we chose an innovative and seldom-used option in each case. RESULTS The selected flaps, a pedicled fasciocutaneous ALT propeller flap and a perforator-based, pedicled abdominal advancement flap reconstructed the defects successfully. DISCUSSION The surgical therapy for the reconstruction of groin defects should be chosen according to the individual vascular status to ensure safe and reliable blood supply. To guarantee the best possible reconstruction and avoid postoperative healing disorders and infections, less common flaps should also be considered.
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Affiliation(s)
- M Cerny
- Klinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland.
| | - Y Harder
- Abteilung für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano, Sede Italiano (OIL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz
| | - A Zimmermann
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - H-H Eckstein
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - H-G Machens
- Klinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - J-T Schantz
- Klinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - T L Schenck
- Abteilung für Handchirurgie, Plastische Chirurgie und Ästhetische Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
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Masaki H, Tabuchi A, Yunoki Y, Kuwata N, Tamura T, Honda T, Takiuchi H, Yamasawa T, Furukawa H, Kuinose M, Tanemoto K, Watanabe Y. Long-Term Results of Obturator Bypass. Ann Vasc Dis 2016; 9:80-4. [PMID: 27375799 DOI: 10.3400/avd.oa.15-00085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.
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Affiliation(s)
- Hisao Masaki
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Atsushi Tabuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yasuhiro Yunoki
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Noriaki Kuwata
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Taishi Tamura
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takeshi Honda
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroki Takiuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takahiko Yamasawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroshi Furukawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Masahiko Kuinose
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiko Watanabe
- Department of First Physiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Salvage of Exposed Groin Vascular Grafts with Early Intervention Using Local Muscle Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e514. [PMID: 26495227 PMCID: PMC4596439 DOI: 10.1097/gox.0000000000000480] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 07/13/2015] [Indexed: 11/25/2022]
Abstract
Background: Peripheral vascular surgery may be complicated by wound infection and potential graft exposure in the groin area. Muscle flap coverage of the graft has been promoted to address these wound complications. The authors present their findings regarding graft salvage rates and patient outcomes using local muscle flaps to address vascular graft complications of the groin. Methods: Data were obtained by retrospective cohort study of patients who underwent a local muscle flap procedure by a single surgeon following vascular graft complication in the groin. Results: Seventeen patients undergoing local muscle flap coverage of a vascular graft were reviewed. Six men and 9 women, 51–80 years old, were included in the study. Wound complications in the groin occurred anywhere from 3 days to 3.5 years following graft placement. Graft exposure was the most common presenting complication (14 of 17 patients). Muscle flap coverage occurred within 15 days of complication presentation in all patients (average, 6.4 days). Seven of the 15 patients experienced postoperative complications within 6 months of the procedure, most commonly wound dehiscence. However, analysis demonstrated that vascular grafts were successfully salvaged in 10 of the 17 patients (59%) over the course of follow-up (range, 104–1748 days). Average time to muscle flap coverage was 4.2 days in patients who retained the graft and 9.6 days in patients who ultimately lost their vascular graft. Conclusion: The authors demonstrate improved vascular graft salvage rate when local muscle flap procedure is performed early after initial wound complication presentation.
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20
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van der Slegt J, Kluytmans JAJW, de Groot HGW, van der Laan L. Treatment of surgical site infections (SSI) IN patients with peripheral arterial disease: an observational study. Int J Surg 2015; 14:85-9. [PMID: 25612852 DOI: 10.1016/j.ijsu.2015.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 01/10/2015] [Accepted: 01/14/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The management of surgical site infections (SSI's) in vascular surgery has been challenging over the years. To assess the outcomes associated with the various strategies, we performed a review of all SSI's after elective vascular procedures in patients with moderate to severe peripheral arterial disease in a single centre hospital. METHODS All patients with a SSI after peripheral vascular surgery were retrieved from a database on Surgical site infections (SSI)-surveillance after vascular surgery between March 2009 and January 2012. At admission, all patients were approached by microbiological wound sampling and empirical start of antibiotics. Further wound management was based on personal experience and preference of the attending vascular surgeon. Endpoints were treatment success (complete wound healing while staying alive and without major amputation), survival and major amputation during one year follow up. RESULTS A total of 40 patients with a SSI were identified (60% superficial SSI and 40% deep SSI). In 92% of the patients with a superficial SSI's were successfully treated with adjusted antibiotics and incisional drainages. In the contrast, 25% of the patients with deep-SSI's were successfully treated. No particular treatment was more successful than the others. CONCLUSION Adjusted antibiotic use and adequate wound drainage are sufficient strategies for superficial SSI management. The management of deep-SSI's is a challenging undertaking and future research on indications and timing of these wide arrays of treatment options is suggested.
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Affiliation(s)
| | - Jan A J W Kluytmans
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands; Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
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Thermann F, Wollert U. Continuous Irrigation as a Therapeutic Option for Graft Infections of the Groin. World J Surg 2014; 38:2589-96. [DOI: 10.1007/s00268-014-2650-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Verma H, Ktenidis K, George RK, Tripathi R. Vacuum-assisted closure therapy for vascular graft infection (Szilagyi grade III) in the groin-a 10-year multi-center experience. Int Wound J 2013; 12:317-21. [PMID: 23796163 DOI: 10.1111/iwj.12110] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 05/06/2013] [Indexed: 11/30/2022] Open
Abstract
The aim of the study was to evaluate the benefit of vacuum-assisted closure (VAC) therapy in the management of deep, alloplastic graft infections (Szilagyi grade III) in the groin. From 2000 to 2009, we identified and included in our study 72 deep inguinal infections in 68 patients, involving native as well as synthetic graft or patch material. There were 29 early graft infections (<30 days after implantation) and 43 late infections (≥30 days after implantation). Among these, 17 cases involved native grafts/patches (12 grafts and 5 patches), while 55 cases involved non-native grafts/patches [26 polytetrafluorethylene (PTFE) grafts and 24 Dacron grafts (Haemashield, Meadox Medical, Boston Scientific Corporation, Natick, NY; Gelsoft graft, Vascutek, Inchinnan, Renfrewshire, Scotland, UK; Intervascular, Mahwah, NJ); INVISTA, and 5 Vascu-Guard(™) bovine pericardial patches; Synovis Surgical Innovation]. All patients were treated with multiple wound debridements, graft salvage, sartorius myoplasty, intravenous antibiotics and VAC therapy until thorough surface healing was achieved. Exclusion criteria were an alloplastic graft infection with proximal expansion above the inguinal ligament, blood culture positive for septicaemia or septic anastomotic herald or overt bleeding. Nine months after initiation of therapy, overall, graft/patch salvage was achieved in 61 of 72 (84·7%) cases. Of the native graft/patch group, infected graft material was replaced with an autogenous great saphenous vein graft or patch in four patients (23·5%). In the non-native group, vein or synthetic graft preservation without revision was achieved in 48 of 55 (87·3%) patients. The mean duration of VAC therapy was 16 ± 7·7 days, and postoperative mean hospital stay was 25·3 ± 8·5 days. In 23 of 72 (31·9%) cases, a secondary closure of the wound was achieved; in the other 49 cases, wound healing was achieved by meshed split-thickness skin grafting. Mean wound healing time for all wounds was 24·3 ± 12·5 days. Specific complications during VAC therapy were wound fluid retention in 2 cases and an increased need for analgesics in 12 cases (16·66%). Negative pressure wound therapy (NPWT) has been reported to be useful in the treatment of severe wound infections. Even in the presence of synthetic vascular graft material, NPWT can greatly simplify challenging wound-healing problems leading to wound dehiscence and its sequelae. Our long-term experience demonstrates the safety and effectiveness of VAC therapy in the management of deep graft infections.
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Affiliation(s)
- Himanshu Verma
- Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bangalore, India
| | - Kiriakos Ktenidis
- Ist Surgical University Clinic, Department of Vascular Surgery, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robbie K George
- Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bangalore, India
| | - Ramesh Tripathi
- Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bangalore, India
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De Santis F, Chaves Brait CM, Caravelli G, Pompei S, Di Cintio V. Salvage of infected vascular graft via 'perivascular venous banding' technique coupled with rectus abdominis myocutaneous muscle flap transposition. Vascular 2012; 21:17-22. [PMID: 22375043 DOI: 10.1258/vasc.2011.cr0286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This is the case of a severe Pseudomonas aeruginosa biological vascular graft infection, completely involving the perianastomotic tract of a femoro - femoral crossover bypass and resulting in repeated bleeding from the offended vessel wall. After the failure of a sartorious rotational muscle flap transposition into the infected groin wound, this 'high-grade' vascular graft infection was finally treated successfully by wrapping a great saphenous vein patch reinforcement circumferentially around the damaged biological vascular conduit and filling the infected wound with a rectus abdominis myocutaneous muscle flap transposition. The aim of this report is to illustrate this novel, to our knowledge, 'perivascular venous banding' technique and to evaluate the prospective of future testing of this surgical procedure. Starting from this singular case, we will also review the role of the rotational muscle flaps in the conservative management of major vascular graft infections.
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Affiliation(s)
- F De Santis
- Department of Vascular Surgery, Sandro Pertini, Rome, Italy.
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Abstract
Infections in vascular surgery are usually of multifactorial nature resulting from a complex interplay of patient, surgical and environmental factors. Preventative measures initiated from the stage of pre-operative screening, maintenance of patient homeostasis and the use of organism-directed antibiotics can contribute to reduce infection rates. Graft preservation techniques are becoming increasingly popular as a method to treat established graft infections. In this article we report on the current trends and techniques on the management of infections in vascular surgery. Ongoing studies are required to continue to accumulate data on the effectiveness of these techniques.
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Affiliation(s)
- M R Tatterton
- Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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25
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Szeberin Z, Münch Z, Fehérvári M, Bíró G, Entz L, Acsády G. [Mid-term results of silver-coated Dacron graft implantation in aortic and lower extremity revascularization]. Magy Seb 2010; 63:369-73. [PMID: 21147670 DOI: 10.1556/maseb.63.2010.6.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prosthetic graft infection or the need for reconstructive arterial surgery in septic condition is a challenging situation in vascular surgery. Recent introduction of silver coated polyester graft has meant a new therapeutic option in selecting the type of graft for revascularization. In this study we analyzed the short and midterm outcome of using silver coated grafts in aortic and lower extremity arterial reconstructions (mortality, graft occlusion, graft infection, amputation). MATERIALS AND METHODS In a single center retrospective study we implanted 42 silver coated Dacron grafts (InterGard Silver Dacron prosthesis). The indication of silver graft implantation was graft infection in 17, aorto-duodenal fistula in 7, septic condition caused by gangrene in 16 cases and in 2 cases infection was not established. RESULTS Forty silver grafts were implanted in 40 patients with diagnosed infection. The mean age was 62 years (35-81 years), 70% were men. Long term follow-up data were available in 29 patients; the mean follow-up time was 36.76 months. Early (within 30 days of surgery) death occurred in 3 and late death in 11 cases (8 and 38%). Early graft occlusion was noticed in 8 and late occlusion in 2 cases (20 and 7%). Reinfection was diagnosed in 7% of the cases in the early and the midterm period as well. Eight amputations were indicated in the early postoperative period (5 major and 3 minor) and 28% of the patients required major amputation during the follow-up. CONCLUSIONS Silver coated Dacron graft means a valuable therapeutic option with good rate of infection control in the treatment of graft infection and septic condition in the lack of autologous graft material in this high risk population.
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Affiliation(s)
- Zoltán Szeberin
- Semmelweis Egyetem Érsebészeti Klinika 1122 Budapest Városmajor u. 68.
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26
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Geenen IL, Nyilas L, Stephen MS, Makeham V, White GH, Verran DJ. Prosthetic lower extremity hemodialysis access grafts have satisfactory patency despite a high incidence of infection. J Vasc Surg 2010; 52:1546-50. [DOI: 10.1016/j.jvs.2010.06.162] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 06/03/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
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Zetrenne E, Wirth GA, McIntosh BC, Evans GRD, Narayan D. Managing extracavitary prosthetic vascular graft infections: a pathway to success. Ann Plast Surg 2007; 57:677-82. [PMID: 17122558 DOI: 10.1097/01.sap.0000226928.10734.ae] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prosthetic vascular graft infections portend grave consequences if not treated expediently. Despite the low incidence of infection, the potential for limb loss or death greatly magnifies this complication. The surgical management of prosthetic graft infections has evolved over the last 2 decades. With the myriad therapeutic options now available, an algorithm is necessary to provide the optimal surgical treatment of Samson groups 1 through 5 extracavitary infected vascular prostheses. An extensive review of the literature was undertaken to evaluate the most effective management schemes. The authors found that 3 factors--Samson classification, bacteriology, and patient vascular anatomy--are vital to the surgical strategy. These 3 criteria were examined, and an algorithm was developed based on successful clinical and experimental results. This review provides a step-by-step rationale for the surgical management of extracavitary prosthetic graft infections according to the most successful reported outcomes.
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Affiliation(s)
- Eleonore Zetrenne
- Aesthetic and Plastic Surgery Institute, University of California, Irvine, Orange, CA, USA
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Atiyeh BS, Hayek SN, Skaf GS, Al Araj A, Chamoun RB. Baclofen pump pocket infection: a case report of successful salvage with muscle flap. Int Wound J 2006; 3:23-8. [PMID: 16650208 PMCID: PMC7951267 DOI: 10.1111/j.1742-4801.2006.00179.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.
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Affiliation(s)
- Bishara S Atiyeh
- Division Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Seify H, Moyer HR, Jones GE, Busquets A, Brown K, Salam A, Losken A, Culbertson J, Hester TR. The role of muscle flaps in wound salvage after vascular graft infections: the Emory experience. Plast Reconstr Surg 2006; 117:1325-33. [PMID: 16582808 DOI: 10.1097/01.prs.0000204961.32022.ab] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The incidence of prosthetic graft infection is 1 to 6 percent, and the mortality rate of infected aortoiliac or aortofemoral bypass is 25 to 75 percent. The goal of this study was to report the use of muscle flaps in the management of patients presenting with infected vascular grafts. METHODS A total of 22 patients required 26 muscle flaps to cover 24 infected vascular grafts. Muscle flaps were used for local wound control in all patients regardless of the fate of the graft. The vascular surgeons elected for graft salvage in eight of the 24 grafts. All of the muscle flaps survived. RESULTS The average time interval between the bypass and infection was 371 days. One-month follow-up revealed an 88 percent salvage rate, but this decreased to 50 percent during the mean follow-up of 23 months. None of the patients originally managed with a salvaged graft lost a limb, and overall, 14 of 22 limbs in this series remained viable (64.0 percent). The mortality rate during the index hospitalization was 9 percent. In this series, suprainguinal grafts had a higher mortality rate. In addition, infection occurring more than 1 month postoperatively, culture-positive Pseudomonas and methicillin-resistant species, and exposure of the arterial-graft anastomosis were poor prognostic indicators of graft preservation. CONCLUSIONS Management of infected vascular grafts remains a challenging problem. Muscle flap coverage should have a high priority, as the chance of a good outcome is highly favorable in early infections.
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Affiliation(s)
- Hisham Seify
- Division of Plastic and Vascular Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA 30327, USA.
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