Local Infections After Above-Knee Prosthetic Femoropopliteal Bypass for Intermittent Claudication

Treatment of Lymphatic Complications after Common Femoral Artery Endarterectomy

BACKGROUND

This study analyzes the outcome of lymphatic complications after a standard vascular procedure.

METHODS

This is a retrospective study including patients who had a lymphatic complication after endarterectomy and patch of the common femoral artery in our clinic between March 2007 and June 2018. Therapy of choice was selected according to wound situation and amount of lymphatic liquid. If signs of a wound infection occurred, a surgical therapy was performed; in all other cases a nonsurgical treatment (conservative treatment, radiotherapy) was chosen.

RESULTS

We performed 977 index operations, a lymphatic complication occurred in 112 cases (11.5%). In 69 cases the lymphatic complication presented as lymphatic fistula (Group 1), in 43 cases as lymphorrhea from the wound (Group 2). Nonsurgical treatment was done in 66 cases (Group 1: 76.8% vs. Group 2: 30.2%; P < 0.000), and a surgical treatment was necessary in 46 cases (Group 1: 23.2% vs. Group 2: 69.8%; P < 0.000). Indication for surgery was Szilagyi 1 infection in 25 cases, Szilagyi 2 infection in 11 cases, and Szilagyi 3 infection in 10 cases. Patients with Szilagyi 1 infections received negative wound pressure therapy (NWPT). A muscle flap in combination with an NWPT was performed in patients with Szilagyi 2 infections. In Szilagyi 3 infections, the patch was replaced; additionally, a muscle flap and an NWPT were performed. The median hospital stay was 13 days in the nonsurgical group and 22.5 days in the surgical group. We had no bleeding complications and no reinfection during follow-up. The median observation period was 23.0 months. Age ≥80 years was associated with an increased risk for lymphatic complications.

CONCLUSIONS

The therapy of lymphatic complications should be done in accordance with clinical symptoms. A nonsurgical treatment is often sufficient. However, in cases of a wound infection different surgical treatments are necessary.

A Changing Pattern of Infection After Major Vascular Reconstructions

Wound and graft infection can occur in more than 40% of patients undergoing vascular reconstructions for peripheral arterial disease (PAD). A recent increase in the frequency and severity of infections, as well as a change in the microorganisms recovered, led us to undertake a retrospective case-controlled study of wound/graft infections at this institution. The medical records of all patients undergoing vascular reconstruction for PAD during the previous 36 months were reviewed. Patient demographics, graft location and conduit, infection location, causative microorganisms, and factors potentially associated with development of infection were recorded. Infections were classified according to a modification of the CDC criteria into superficial incisional, deep incisional, or involving the graft (body only, anastomosis without disruption, or anastomosis with disruption). Univariate and multivariate regression analyses were used to identify factors associated with the development of infection. Four hundred ten (84 aortic, 41 extraanatomic, and 285 infrainguinal) revascularization procedures were performed in 217 men and 193 women with a mean age of 62 years (range 43–88). The infection rate for the entire group was 11.0% (45/410). Eighty percent (36/45) occurred after infrainguinal reconstructions and 64% (29/45) of the infections involved the groin incision. Direct involvement of the graft occurred in 67% (30/45), and 27% (12/45) presented with anastomotic disruption. Of the infrainguinal infections, in situ and prosthetic reconstructions were associated with a significantly higher rate of infection than reversed vein grafts tunneled anatomically (p <0.001, chi-square analysis). Patients with nonautogenous grafts (24 expanded polytetrafluoroethylene and 2 bovine) presented with more advanced infections involving the graft (20/26 procedures) and were more likely to present with anastomotic disruption (11/26). Staphylococcus aureus was isolated in the majority of infections (64%) and in all cases involving graft disruption. Multivariate regression analysis identified the following factors associated with development of infection: previous hospitalization (p = 0.03), a younger age (p = 0.047), and the presence of a groin incision (p = 0.04). Twenty-five percent of graft infections resulted in major amputation, and 11% of patients with graft infection died as a result. The incidence, morbidity, and mortality of infections in vascular reconstructions for PAD are increasing dramatically, particularly in infrainguinal reconstructions involving groin incisions. Perioperative antibiotic selection should be modified to include coverage for all Staphylococcal subspecies and hospitalization before surgical procedures should be avoided.

Prosthetic graft infections involving the femoral artery

BACKGROUND

Prosthetic graft infection is a major complication of peripheral vascular surgery. We investigated the experience of a single institution over 10 years with bypass grafts involving the femoral artery to determine the incidence and risk factors for prosthetic graft infection.

METHODS

A retrospective cohort single-institution review of prosthetic bypass grafts involving the femoral artery from 2001 to 2010 evaluated patient demographics, body mass index, comorbidities, indications, location of bypass, type of prosthetic material, case urgency, and previous ipsilateral bypass or percutaneous interventions and evaluated the incidence of graft infections, amputations, and mortality.

RESULTS

There were 496 prosthetic grafts identified with a graft infection rate of 3.8% (n = 19) at a mean follow-up of 27 months. Multivariable analysis showed that redo bypass (hazard ratio [HR], 5.8; 95% confidence interval [CI], 2.2-15.0), active infection at the time of bypass (HR, 5.2; 95% CI, 1.9-14.2), female gender (HR, 4.5; 95% CI, 1.6-12.7), and diabetes mellitus (HR, 4.6; 95% CI, 1.5-14.3) were significant predictors of graft infection. Graft infection was predictive of major lower extremity amputation (HR, 9.8; 95% CI, 3.5-27.1), as was preoperative tissue loss (HR, 4.7; 95% CI, 1.8-11.9). Graft infection did not predict long-term mortality; however, chronic renal insufficiency (HR, 2.3; 95% CI, 1.6-3.4), tissue loss (HR, 1.4; 95% CI, 1.0-1.9), and active infection (HR, 2.3; 95% CI, 1.6-3.4) did. Infected grafts were removed 79% of the time. Staphylococcus epidermidis (37%) and methicillin-sensitive Staphylococcus aureus (26%) were the most common pathogens isolated.

CONCLUSIONS

Redo bypass, female gender, diabetes, and active infection at the time of bypass are associated with a higher risk for prosthetic graft infection and major extremity amputation but do not confer an increased risk of mortality. Autologous vein for lower extremity bypass and endovascular interventions should be considered when feasible in high-risk patients.

Long-term quality of life and mobility after prosthetic above-the-knee bypass surgery

BACKGROUND

Multiple studies have addressed above-the-knee femoral artery bypass grafting; however, information on late quality of life (QoL) and mobility is scarce. We studied long-term QoL and mobility after above-the-knee bypass surgery.

METHODS

Consecutive patients presenting with claudication, ischemic rest pain, or gangrene who received above-the-knee prosthetic bypass grafting between December 1997 and January 2003 were included in this observational study. Data used were recorded in a prospectively collected database of patients receiving Dacron and polytetrafluoroethylene (PTFE) supragenicular bypasses for lower limb ischemia. Primary outcomes were QoL and mobility, and secondary outcomes were patency and patient survival. QoL was measured with the EuroQol questionnaire (EQ-5D/EQ-VAS). Mobility was assessed with the Walking Impairment Questionnaire (WIQ) and analyzed in univariate and multivariate models. Patency and survival were computed with Cox regression.

RESULTS

One hundred forty patients were treated during the study period. Sixty-nine patients (50%) died during follow-up, leaving 71 survivors who were asked (63 [89%] complied) to complete the EQ-5D/EQ-VAS and WIQ questionnaires. None of the primary outcome parameters (WIQ, EQ-5D, EQ-VAS) were affected by primary bypass occlusion (p = 0.34, p = 0.44, and p = 0.27, respectively) or long-term patency (p = 0.07, p = 0.54, and p = 0.36, respectively). Male sex was significantly associated with a better outcome on all primary outcome parameters. Patients with Dacron versus PTFE grafts had WIQ scores of 0.49 and 0.26, respectively (p = 0.01). EQ-5D scores of patients with Dacron and PTFE were 0.576 and 0.409 (p = 0.08) and EQ-VAS scores were 61 and 54, respectively (p = 0.24). Graft type was not independently associated with occlusion, but runoff was. The 5-year and 10-year patient survival rates were 58% and 51%, respectively.

CONCLUSIONS

In this study, long-term QoL and mobility did not seem to be associated with bypass patency, as assessed in a single late follow-up. Revision of bypasses did not contribute to long-term QoL and walking ability. Therefore, the necessity of graft surveillance and subsequent revision and/or thrombectomy in case of synthetic bypass failure in absence of critical limb ischemia seems to be questionable.

The safety and efficacy of a paclitaxel-eluting wrap for preventing peripheral bypass graft stenosis: a 2-year controlled randomized prospective clinical study

OBJECTIVES

To compare the safety and efficacy of a bioresorbable paclitaxel-eluting wrap implanted with a synthetic vascular graft (treatment) versus the graft implanted alone (control).

DESIGN

Prospective, randomized, controlled, multicentre, 2-year clinical study conducted in adults scheduled to undergo femoropopliteal peripheral bypass surgery with a polytetrafluoroethylene (PTFE) graft.

MATERIALS AND METHODS

Hundred and nine subjects were randomized 2:1 to treatment or control. All subjects were implanted with a 6mm expanded PTFE vascular graft; in addition, treated subjects had a 2.5 cm x 4 cm paclitaxel-eluting wrap (1.6 microg/mm(2)) placed around the distal graft anastomosis.

RESULTS

The overall incidence of adverse events was similar in both groups. Treated subjects required fewer limb amputations than controls (15.5% vs 18.4%) and time to amputation for those that required amputation was twice as long (153 days vs 76 days). Among diabetics, this effect was pronounced with 13.8% of treated subjects requiring limb amputations compared with 23.5% of controls. Over the course of study, the diameter at the distal graft anastomosis was greater in treated subjects than in controls (difference of 2.1mm at 2 yr, p=0.03).

CONCLUSIONS

The paclitaxel-eluting wrap maintained graft patency at the distal anastomosis and was safe to use in patients who had received a peripheral bypass PTFE graft.

Does the timing of reoperation influence the risk of graft infection?

OBJECTIVE

This study compared the incidence and characteristics of graft infection in patients who underwent early vs late revisional surgery of lower extremity arterial bypass grafts.

METHODS

Between 1992 and July 2005, 500 revisional procedures were performed on 198 lower extremity bypass grafts. Patients whose revisions were performed <30 days after the primary bypass were in the early revision (ER) group (n = 99), and those done >30 days after bypass were in the late revision (LR) group (n = 99). Infection was defined as cellulitis with graft exposure or purulence in continuity with a graft that required antibiotics and operation for infection control. Mean follow-up was 60 months (range, 2 to 60 months). Groups were compared using Student's t test.

RESULTS

The ER group included 66 autogenous and 33 prosthetic grafts. The LR group consisted of 53 autogenous and 46 prosthetic grafts. Of the 500 revisional procedures performed, 17 graft infections occurred (3.4%). Twelve (70.6%) were prosthetic grafts and five (29.4%) were autogenous grafts (P = .004). Defining the infection rate per graft rather than per revisional procedure, the ER group had a significantly higher graft infection rate at 11% (11/99) compared with 6.1% in the LR group (6/99; P = .012). The risk of infection for prosthetic grafts was significantly higher within the ER group at 27.3% (9/33) compared with autogenous grafts at 3.1% (2/66; P = .0001). Infection developed in three vein grafts and three prosthetic grafts in the LR group (P = NS). For prosthetic graft revisions only, infection risk was 27.3% (9/33) in the ER group and 6.5% (3/46) in the LR group (P = .005). The most common cultured pathogen was methicillin resistant Staphylococcus aureus (ER, 6/11 vs LR, 3/6; P = NS). Within the ER group, the prevalence of Pseudomonas aeruginosa was significantly higher at 27.3% (3/11) compared with 0% (0/6) in the LR group (P = .04).

CONCLUSIONS

Early revision of lower extremity arterial bypass grafts has a significantly higher risk of graft infection compared with revision >1 month after surgery. Infection will develop in approximately 25% (9/33) of prosthetic grafts that are reoperated on early. If feasible, reoperation should be delayed >1 month for prosthetic grafts needing revision. Endovascular or extra-anatomic interventions should be considered if early revision is mandated in this group.

Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency

BACKGROUND

In femoropopliteal bypass surgery, the use of saphenous vein grafts is preferable, but synthetic grafts are widely used above the knee. The objective of this meta-analysis was to assess the long-term patency of femoropopliteal bypass grafts classified as above-knee polytetrafluoroethylene, above-knee saphenous vein, or below-knee saphenous vein.

METHODS

Studies published from 1986 through 2004 were identified from electronic databases and reference lists; 73 articles contributed 1 or more series that used survival analysis, assessed femoropopliteal bypasses in one of the foregoing configurations, reported a 1-year graft patency rate, and included at least 30 bypasses. The series with a predominance of claudicant patients were included in meta-analysis C, and the series in which critical ischemia predominated were included in meta-analysis CI. Pooled survival curves of graft patency were constructed.

RESULTS

In meta-analysis C, the pooled primary graft patency was 57.4% for above-knee polytetrafluoroethylene, 77.2% for above-knee vein, and 64.8% for below-knee vein at 5 years; there was a significant difference between above-knee grafts at 3, 4, and 5 years (P < .05). The corresponding pooled secondary graft patency was 73.2%, 80.1%, and 79.7%, respectively (P > .05). In meta-analysis CI, the pooled primary graft patency was 48.3% for above-knee polytetrafluoroethylene, 69.4% for above-knee vein, and 68.9% for below-knee vein at 5 years; there was a significant difference between above-knee grafts until 4 years (P < .05). The corresponding pooled secondary graft patency was 54.0%, 71.9%, and 77.8%, respectively, with a significant difference between above-knee grafts at 2, 3, and 4 years (P < .05).

CONCLUSIONS

The great saphenous vein performs better than polytetrafluoroethylene in femoropopliteal bypass grafting and should be used whenever possible.