Selective preservation of infected prosthetic arterial grafts. Analysis of a 20-year experience with 120 extracavitary-infected grafts

Management of Popliteal Artery Interposition Graft Infection by Extra-anatomic Bypass

ObjectivesInfection of peripheral interposition grafts is a rare but devastating complication following aneurysm repair. Typically, graft infection necessitates explantation and, if possible, revascularization of the limb. However, treatment complexity varies substantially depending on the location and extent of infection. This case describes the management of a popliteal artery interposition graft infection.MethodsWe describe an 84 year old male with a history of left popliteal artery aneurysm repair with PTFE interposition graft (found on workup a year prior for a gangrenous great toe) who presented with four days of night sweats, chills, and a painful posterior left knee. Laboratory findings indicated leukocytosis, while ultrasound and CT imaging revealed complex fluid surrounding the graft without evidence of pseudo-aneurysm. Surgical management was conducted in two stages, the first with the patient supine for bypass from the superficial femoral artery to the posterior tibial artery using ipsilateral reversed great saphenous vein. The patient was then repositioned prone for the second stage of the procedure, and the infected popliteal fossa was entered posteriorly for debridement with caution to avoid injury to the tibial nerve and popliteal vein. The infected graft was removed, and antibiotic beads were placed in the infected region.ResultsFollowing this procedure and serial washouts one week later, the patient retained motor function, sensation, and palpable posterior tibial and dorsal pedal pulses. The patient was placed on IV cefazolin for 6 weeks following the procedure and discharged with 6 months of oral suppression to achieve long-term prevention of further infection.ConclusionsWhen managing popliteal artery graft infection, the presence of purulent material in the popliteal fossa can make anatomic bypasses high-risk for recurrent infection, and caution must be taken to avoid the nearby popliteal vein and tibial nerve during irrigation and debridement.

Fostering Collaborative Teamwork-A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery

Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision making for challenging presentations. This review will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.

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.

Surgical management of abdominal aortic graft infection: network meta-analysis

BACKGROUND

A paucity of evidence exists regarding the optimal management for abdominal aortic graft infection. The aim of this paper was to assess short- and long-term outcomes following different surgical options in aortic graft infection patients.

METHODS

Medline, Embase and the Cochrane Library were searched from inception to February 2023. Network meta-analysis was performed using a frequentist method. Patients were divided into four treatment groups: complete graft removal with in situ repair, complete graft removal with extra-anatomic repair, partial graft removal with in situ repair and partial graft removal with extra-anatomic repair. The mortality rate at 30-days and 1-year was the primary outcome. Secondary outcomes were longer-term mortality rate, primary patency and reinfections. For included RCTs, the Cochrane risk-of-bias tool was utilized to assess the risk of bias. The methodological quality of cohort studies was evaluated using the Newcastle-Ottawa scale.

RESULTS

Among 4559 retrieved studies, 22 studies with 1118 patients (11 multi-arm and 11 single-arm studies) were included. Patients received complete graft removal with in situ repair (N = 852), partial graft removal with in situ repair (N = 36), complete graft removal with extra-anatomic repair (N = 228) and partial graft removal with extra-anatomic repair (N = 2). Both network meta-analysis results and pooled results of multi- and single-arm cohorts indicated that partial graft removal with in situ repair has the lowest 30-day and 1-year mortality rates (0% and 6.1% respectively), followed by complete graft removal with in situ repair (11.9% and 23.8% respectively) and complete graft removal with extra-anatomic repair (16.6% and 41.4% respectively). In addition, complete graft removal with in situ repair had a lower 3-year (complete graft removal with in situ repair versus complete graft removal with extra-anatomic repair: 32.1% versus 90%) and 5-year (complete graft removal with in situ repair versus complete graft removal with extra-anatomic repair: 45.6% versus 67.9%) mortality rate when compared with complete graft removal with extra-anatomic repair. Patients in the complete graft removal with in situ repair group had the lowest reinfections (8%), followed by partial graft removal with in situ repair (9.3%) and complete graft removal with extra-anatomic repair (22.4%).

CONCLUSION

Partial graft removal with in situ repair was associated with lower 30-day and 1-year mortality rates when compared with complete graft removal with in situ repair and complete graft removal with extra-anatomic repair. Partial graft removal with in situ repair might be a feasible treatment for specific aortic graft infection patients.

Use of rifampicin and graft removal are associated with better outcomes in prosthetic vascular graft infection

OBJECTIVES

Prosthetic vascular graft infection (PVGI) is a very severe disease. We aimed to determine the factors associated with treatment failure.

METHODS

Patients admitted to two University Hospitals with PVGI were included in this retrospective study. PVGI was classified as possible, probable or proven according to an original set of diagnostic criteria. We defined treatment failure if one of the following events occurred within the first year after PVGI diagnosis: death and infection recurrence due to the same or another pathogen.

RESULTS

One hundred and twelve patients were diagnosed with possible (n = 26), probable (n = 22) and proven (n = 64) PVGI. Bacterial documentation was obtained for 81% of patients. The most frequently identified pathogen was Staphylococcus aureus (n = 39). Surgery was performed in 96 patients (86%). Antibiotics were administered for more than 6 weeks in 41% of patients. Treatment failure occurred in 30 patients (27.5%). The factors associated with a lower probability of treatment failure were total removal of the infected graft (OR = 0.2, 95% CI [0.1-0.6]), rifampicin administration (OR = 0.3 [0.1-0.9]) and possible PVGI according to the GRIP criteria (OR = 0.3 [0.1-0.9]).

CONCLUSIONS

Treatment failure occurred in 27.5% of patients with PVGI. Total removal of the infected graft and rifampicin administration were associated with better outcomes.

Results of the Proliferative Activity’s Analysis of Bifidobacterium Exometabolites in Regard to Hospital Isolates from Patients after Vascular Synthetic Prosthetics Implantation

Problems ofdevelopment of purulent septic complications in vascular surgery during the usage of synthetic prosthetics for shunting and arterial prosthetics are described in this work.Leading factors of development of prosthetic infection are described. Specialties of diagnostics and bacteriological researches wound discharge of wound’s discharge are shown. Tactics of complex treatment of patients with prosthetic infection are presented. This work is dedicated to the experimental researchof proliferative activityof the most encountered opportunistic microorganisms found from the patients of vascular surgery profile with purulent septical complications under the influence of bifidobacteriumbifidium’sexometabolites. Presented results proof the submission of proliferative activity of the most widespread antibiotic-resistant hospital’s isolates under the influence of bifidobacteriumbifidium’sexometabolites.Evaluation during the experiment in vitro of the influence of bifidobacteriumbifidium’sexometabolites on proliferative activityof opportunistic microorganisms.

Negative pressure wound therapy with intermittent instillation of rifampin for the treatment of an infected vascular bypass graft

Negative pressure wound therapy with intermittent instillation, especially with the addition of antibiotics in the case of infection, is a versatile treatment modality for the closure of wounds and can be used both primarily after débridement and secondarily after failure of muscle flap coverage. We present a case in which negative pressure wound therapy with intermittent instillation of rifampin was used to successfully close a groin wound secondary to an infected prosthetic vascular graft that initially failed to close with a muscle flap. Consideration of this approach to wound closure and graft salvage is important because of the seriousness and relatively common incidence of prosthetic vascular graft infection after infrainguinal arterial bypass revascularization.

Lateral femoral bypass for prosthetic arterial graft infections in the groin

OBJECTIVE

Prosthetic arterial graft infections (PAGIs) in the groin pose significant challenges in terms of revascularization options and risk of limb loss as well as associated morbidities. Although obturator canal bypass (OCB) has been suggested for revascularization of the extremity in these cases, moderate success rates and technical challenges have limited widespread use. Our study analyzed lateral femoral bypass (LFB) as an alternative approach for the treatment of groin PAGIs.

METHODS

This is a retrospective review of a prospectively maintained database of patients who underwent LFB for groin PAGIs at a single center from 2000 to 2017. Patients' data including demographics, comorbidities, perioperative complications, graft patency, and need for reintervention were used. Patients were observed after LFB with duplex ultrasound surveillance in an accredited noninvasive vascular laboratory every 3 months during the first year, followed by every 6 months for the second year and yearly thereafter. After isolation of the infected wound with sterile dressings, remote proximal and distal arterial exposure incisions were made. LFBs were tunneled under the inguinal ligament and lateral to the infected wound from an uninvolved inflow artery or bypass graft to an uninvolved outflow vessel.

RESULTS

A total of 19 LFBs were performed in 16 patients (mean age, 69 ± 12.6 years). Three LFBs were performed urgently for acute bleeding. Choice of conduit included 6 (31.6%) autogenous vein grafts, 10 (52.6%) cadaveric grafts, 2 (10.5%) rifampin-soaked Dacron grafts, and 1 (5.3%) polytetrafluoroethylene graft. Average follow-up was 33 months (range, 0-103 months). Major adverse events occurring within 30 days of the operation included one (5.3%) death and one (5.3%) graft excision for pseudoaneurysm. Primary patency and primary assisted patency at 12 and 24 months were 73% and 83%, respectively. One patient required an amputation 17 months after surgery after failure of repeated revascularization attempts. Overall limb salvage was 93.8% during this follow-up period.

CONCLUSIONS

In this series, LFB for management of groin PAGIs demonstrated higher patency and limb salvage rates compared with previous reports of OCB. Diligent postoperative duplex ultrasound surveillance is critical to the achievement of limb salvage and maintenance of graft patency. These results suggest that LFB, which is technically less complex than OCB, should be considered the first choice for revascularization in select cases of PAGIs involving the groin.

Complex treatment of vascular prostheses infections

Infections after vascular reconstructions are very rare; however, when they occur, they are associated with a high risk of morbidity. In order to obtain the best results possible, the treatment needs to be initiated as early as possible, from the very first signs of infection, and it needs to be carried out in centers specializing in vascular surgery. The aim of the present study was to assess the incidence of infections in a single university center.This retrospective analysis over a 2-year period is based on the medical reports of hospitalized patients who were diagnosed with infection following revascularization.From 2013 to 2014, a number of 151 open reconstructive surgical procedures were performed. 15 patients suffered from infection (10%) of the vascular reconstruction. Of these patients, 40% have had an aorto-bifemoral bypass, 53%-a femoro-popliteal bypass, and 7% (n = 1)-an axillo-femoral bypass. According to the Samson classification, the patients were categorized as follows: group 2: 6 cases, group 3: 2 cases, group 4: 4 cases, and group 5: 3 cases. The most frequent bacteria found were methicillin-resistant Staphylococcus aureus (MRSA) (n = 6, 40%), followed by S aureus (n = 5, 33%). The treatment options were: application of antibiotics alone without any invasive treatment in 3 patients, local irrigation and debridement in 6 patients, complete explantation of the prosthesis with a new extra-anatomic bypass in 6 cases, and partial excision of the prosthesis, which was replaced and covered with muscle flap, in 3 cases. The amputation rate in our study was 18%, which corresponds to the rates published in the literature.The treatment of infections in vascular surgery needs to be complex and adapted to each individual patient, because infections being in a permanent dynamic state. The treatment needs to be performed in specialized centers that have large experience in vascular surgery, in order for the patient to have the best chances of survival and protection from amputation.

Continuous betadine-bacitracin irrigation for vascular graft infections: A case series

The aim of the study was to conduct a retrospective chart review of patients who underwent betadine/bacitracin continuous irrigation (BBCI) for vascular graft infections (VGIs) to review its use as a treatment option. A retrospective chart review from 2013 to 2017 was conducted of patients with VGIs that were treated with BBCI postremoval of the infected graft. The BBCI is a continuous infusion of 0.25% betadine in normal saline at 0.3 mL/kg/h for 48 hours then followed by bacitracin infusion with a concentration of 50,000 units bacitracin/per liter normal saline at 0.3 mL/kg/h for 72 hours. Descriptive statistics were used to describe the sample. The nine adult patients who received postoperative BBCI had an age range of 30-81 years, with average age of 58.8 years. Five of the subjects were females with four males. A total of nine patients with groin infections were identified, with two aortobifemoral bypasses, two axillofemoral bypasses, three femoral-femoral bypasses, one femoral artery pseudoaneurysm repair with Dacron patch, and one common femoral endarterectomy with Dacron patch. VGIs were identified from 10 days up to 72 months from the original vascular procedure. Six patients had negative wound cultures, while two had wound cultures positive for methicillin-resistant Staphylococcus aureus and one patient had positive culture for Escherichia coli. The length of time of BBCI ranged from 48 to 84 hours with average of 57.6 hours (standard deviation [SD] = 12.7 hours). The length of time of the bacitracin irrigation ranged from 30 to 72 hours with average of 48.4 hours (SD = 14.9 hours). All patients healed their groin wounds except for an 81-year-old patient with aortobifemoral bypass graft who developed ischemic bowel and expired. Patients received at least 6 weeks of intravenous antibiotics followed by oral antibiotic suppression therapy for life. VGIs are a devastating complication associated with a high morbidity. BBCI provides an option for antiseptic irrigation of the vascular graft site postgraft removal to promote wound closure.

Femoral Artery to Prosthetic Graft Anastomotic Dehiscence Owing to Infection: Successful Treatment with Arterial Reconstruction and Limb Salvage

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances.

Infected Groin (Graft/Patch): Managed with Sartorious Muscle Flap

PURPOSE

The purpose of this study was to review the natural history, clinical outcome and safety in patients undergoing sartorius muscle flap (SMF) for groin infection, including lymphocele.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent SMF in a single center between 2000 and 2009.

RESULTS

Thirty patients (17 male, 13 female) underwent SMF for groin infection, which included infections of 22 artificial femoral bypass grafts (including 2 cryoveins) and 5 common femoral patch grafts, and 3 lymphocele infections (2 cardiac catheterizations and 1 penile cancer lymph node dissection). Wound isolates were most commonly Gram-positive organisms (n=22) with Gram-negative isolates and mixed infections accounting for 4 and 3 cases, respectively. In 9 patients there was no growth of organisms. Adjunctive wound vacuum-asssisted wound closure therapy was performed in 18 patients. Follow-up duration ranged from 8 days to 56 months (mean 14.1 months) after SMF. Reoperation was performed in 3 patients due to wound bleeding (n=1) and reinfection (n=1). One patient underwent graft excision with external bypass operation. There was 1 mortality case due to sepsis during the study period.

CONCLUSION

We found that muscle flap surgery provides successful single-intervention therapy for groin infections including lymphocele. Graft ligation or aggressive excision with bypass surgery should be reserved for patients requiring rapid control of sepsis for lifesaving.

Cost-Utility Analysis: Sartorius Flap versus Negative Pressure Therapy for Infected Vascular Groin Graft Managment

Background:

Sartorius flap coverage and adjunctive negative pressure wound therapy (NPWT) have been described in managing infected vascular groin grafts with varying cost and clinical success. We performed a cost–utility analysis comparing sartorius flap with NPWT in managing an infected vascular groin graft.

Methods:

A literature review compiling outcomes for sartorius flap and NPWT interventions was conducted from peer-reviewed journals in MEDLINE (PubMed) and EMBASE. Utility scores were derived from expert opinion and used to estimate quality-adjusted life years (QALYs). Medicare current procedure terminology and diagnosis-related groups codes were used to assess the costs for successful graft salvage with the associated complications. Incremental cost-effectiveness was assessed at $50,000/QALY, and both univariate and probabilistic sensitivity analyses were conducted to assess robustness of the conclusions.

Results:

Thirty-two studies were used pooling 384 patients (234 sartorius flaps and 150 NPWT). NPWT had better clinical outcomes (86.7% success rate, 0.9% minor complication rate, and 13.3% major complication rate) than sartorius flap (81.6% success rate, 8.0% minor complication rate, and 18.4% major complication rate). NPWT was less costly ($12,366 versus $23,516) and slightly more effective (12.06 QALY versus 12.05 QALY) compared with sartorius flap. Sensitivity analyses confirmed the robustness of the base case findings; NPWT was either cost-effective at $50,000/QALY or dominated sartorius flap in 81.6% of all probabilistic sensitivity analyses.

Conclusion:

In our cost–utility analysis, use of adjunctive NPWT, along with debridement and antibiotic treatment, for managing infected vascular groin graft wounds was found to be a more cost-effective option when compared with sartorius flaps.

Sartorius Muscle Flaps for Vascular Groin Wound Complications

Sartorius myoplasty (SM) has been used as an adjunct for soft tissue coverage in vascular groin wound complications. However, the reliability of SM as a primary muscle flap has been questioned. The purpose of this study is to determine the reliability of SM performed by vascular surgeons in the management of vascular groin wound complications. A retrospective review was performed on all patients who underwent SM from 1997 to 2012. The three indications for SM were prophylactic, infection, and noninfectious wound complication. Failure of SM was defined as operative reintervention for bleeding, persistent wound drainage, or infection. A total of 99 patients underwent 103 SM procedures. The patients were 43 per cent male and 57 per cent female; the mean age was 69 years. The indication for SM was infectious in 62 cases (60%), prophylactic in 21 cases (20%), and noninfectious in the remaining 20 cases. Failure of SM occurred in 11 cases (11%). Of these, salvage bypass and/or salvage muscle flap was required in eight cases (73%). When salvage bypass was required, extra-anatomic obturator bypass was performed in 80 per cent of cases. Salvage wound coverage included rectus abdominus flap (60%), rotational flap (20%), and skin grafting (20%). Seventy-three per cent of failures came from the infectious wound group. The most common reason for SM failure was hemorrhage (45%). In 82 per cent of the cases, the sartorius muscle was still viable at reoperation and was used for continued muscle coverage. SM performed by the vascular surgeon provides reliable soft tissue coverage for vascular groin wound complications and should be used as the primary muscle flap in the majority of patients. In cases of SM failure, the vascular surgeon should consider other more extensive muscle flap options.

Vascular complications and surgical interventions after world's largest Q fever outbreak

OBJECTIVE

Since chronic Q fever often develops insidiously, and symptoms are not always recognized at an early stage, complications are often present at the time of diagnosis. We describe complications associated with vascular chronic Q fever as found in the largest cohort of chronic Q fever patients so far.

METHODS

Patients with proven or probable chronic Q fever with a focus of infection in an aortic aneurysm or vascular graft were included in this study, using the Dutch national chronic Q fever database.

RESULTS

A total of 122 patients were diagnosed with vascular chronic Q fever between April 2008 and June 2012. The infection affected a vascular graft in 62 patients (50.8%) and an aneurysm in 53 patients (43.7%). Seven patients (5.7%) had a different vascular focus. Thirty-six patients (29.5%) presented with acute complications, and 35 of these patients (97.2%) underwent surgery. Following diagnosis and start of antibiotic treatment, 26 patients (21.3%) presented with a variety of complications requiring surgical treatment during a mean follow-up of 14.1 ± 9.1 months. The overall mortality rate was 23.7%. Among these patients, mortality was associated with chronic Q fever in 18 patients (62.1%).

CONCLUSIONS

The management of vascular infections with C. burnetii tends to be complicated. Diagnosis is often difficult due to asymptomatic presentation. Patients undergo challenging surgical corrections and long-term antibiotic treatment. Complication rates and mortality are high in this patient cohort.

Surgical and antimicrobial treatment of prosthetic vascular graft infections at different surgical sites: a retrospective study of treatment outcomes

Objective

Little is known about optimal management of prosthetic vascular graft infections, which are a rare but serious complication associated with graft implants. The goal of this study was to compare and characterize these infections with respect to the location of the graft and to identify factors associated with outcome.

Methods

This was a retrospective study over more than a decade at a tertiary care university hospital that has an established multidisciplinary approach to treating graft infections. Cases of possible prosthetic vascular graft infection were identified from the hospital's infectious diseases database and evaluated against strict diagnostic criteria. Patients were divided into groups according to the locations of their grafts: thoracic-aortic, abdominal-aortic, or peripheral-arterial. Statistical analyses included evaluation of patient and infection characteristics, time to treatment failure, and factors associated specifically with cure rates in aortic graft infections. The primary endpoint was cure at one year after diagnosis of the infection.

Results

Characterization of graft infections according to the graft location did show that these infections differ in terms of their characteristics and that the prognosis for treatment seems to be influenced by the location of the infection. Cure rate and all-cause mortality at one year were 87.5% and 12.5% in 24 patients with thoracic-aortic graft infections, 37.0% and 55.6% in 27 patients with abdominal-aortic graft infections, and 70.0% and 30.0% in 10 patients with peripheral-arterial graft infections. In uni- and multivariate analysis, the type of surgical intervention used in managing infections (graft retention versus graft replacement) did not affect primary outcome, whereas a rifampicin-based antimicrobial regimen was associated with a higher cure rate.

Conclusions

We recommend that future prospective studies differentiate prosthetic vascular graft infections according to the location of the grafts and that rifampicin-based antimicrobial regimens be evaluated in clinical trials involving vascular graft infections caused by staphylococci.

Will 1-stage implant salvage after periprosthetic breast infection ever be routine? A 6-year successful experience

BACKGROUND

Concomitant with the recent increase in breast augmentations has been an increase in periprosthetic infections necessitating further surgery. The conventional treatment of periprosthetic infections has been a multistage procedure involving explantation, control of infection, and reimplantation.

OBJECTIVES

The authors describe a 1-stage salvage procedure for the management of periprosthetic infections. This technique may become the standard for managing infection following cosmetic breast surgery.

METHODS

The authors performed a retrospective review of all patients who had periprosthetic infection following cosmetic breast augmentation. The treatment included explantation, sequential cleaning of the wound, and immediate insertion of a new prosthesis and drain. All patients received intravenous antibiotics postoperatively. Of 3012 patients undergoing primary breast augmentation, periprosthetic infection developed in 17 patients. These 17 patients underwent 1-stage implant salvage. Patients were monitored for ≤6 years.

RESULTS

All implants were retained; aesthetic results were satisfactory; and no significant adverse events were recorded after implant salvage.

CONCLUSIONS

One-stage implant salvage for periprosthetic infection has similar outcomes to conventional multistage procedures and may be preferred by patients.

LEVEL OF EVIDENCE

4.

Successful use of a gastrocnemius flap for an exposed PTFE femorodistal graft: a case report

Peripheral vascular disease (PVD) is a condition requiring aggressive management to minimise the associated increased morbidity and mortality. Femoro-distal bypass grafting is used in patients with extensive occlusion affecting the crural arteries and poor limb function, but is associated with infection, wound dehiscence and graft exposure. We report a case of a 73-year-old male with history of PVD and occluded ipsilateral femoro-distal bypass graft who underwent limb salvage surgery with a left 6 mm heparin-bonded polytetrafluoroethylene femoro-distal bypass graft in September 2011. He later presented with exposure of the graft over the lateral aspect of the knee following wound dehiscence. During surgery, the exposed portion of the graft was covered by a lateral gastrocnemius muscle flap with an overlying split thickness skin graft. Minor donor site healing problems were noted, but he otherwise made an excellent recovery. While gastrocnemius muscle flaps have been used to cover soft tissue tibial defects secondary to sarcoma and exposed knee joint prostheses, our case adds to the limited literature demonstrating successful salvage of an exposed synthetic graft as a viable alternative to amputation. We therefore recommend prompt referral to plastic services for the management of these complex wounds.

Surgical wound infections after peripheral vascular surgery

Surgical wound infection is one of the most common complications after peripheral vascular surgery. It increases the affected patient's risk for major amputation as well as mortality. Furthermore, surgical wound infection is an additional cost. Wound infections after vascular surgery are of multifactorial nature and generally result from the interplay of patient- and procedure-related factors. The use of systemic antibiotic prophylaxis may be the most important method in preventing surgical wound infections. In this review article, we report the current literature of surgical wound infections after peripheral vascular surgery.

The impact of surgical wound bacterial colonization on the incidence of surgical site infection after lower limb vascular surgery: a prospective observational study

OBJECTIVE

To study the relationship between surgical wound bacterial colonization and the development of surgical site infection (SSI) after lower limb vascular surgery. SSI is a major problem after lower limb vascular surgery. Most SSIs in vascular surgery are caused by Staphylococcal species that are part of normal skin flora. A prospective observational investigator blind study to examine quantitative and qualitative analysis of surgical wound bacterial colonization and the correlation with the development of SSI has been conducted.

METHODS

The study cohort comprised 94 consecutive patients with 100 surgical procedures. Swabs for microbiological analyses were taken from surgical wounds at four different time intervals: before surgery, just before the surgical area had been scrubbed, at the end of surgery, and on the first and second postoperative days. Postoperative complications were recorded.

RESULTS

Three hundred and eighty-seven skin bacterial samples from 100 surgical wounds were analyzed. The most common bacteria isolated were coagulase-negative staphylococci (80%), Corynebacterium species (25%), and Propionibacterium species (15%). In 13 (62%) cases, the same bacterial isolates were found in the perioperative study samples as in the infected wounds. The incidence of SSI was 21%. Multivariate analysis revealed that high bacterial load on the second postoperative day and diabetes independently increased the risk of SSI. Elective redo surgery was protective against the development of SSI.

CONCLUSIONS

A high bacterial load in the postoperative surgical wound independently increases the risk of the development of SSI after lower limb vascular surgery.

Vacuum-assisted closure therapy for salvaging a methicillin-resistant Staphylococcus aureus-infected prosthetic graft

Infection of a vascular prosthesis after a bypass surgery is relatively rare. However, once developed, serious complications can occur, such as bleeding, sepsis, and organ ischemia, occasionally resulting in leg amputation or even death in some cases. The treatment of a vascular prosthesis infection involves the necessary removal of the infected graft; subsequently, an extra-anatomical bypass surgery is often considered. We herein report a case in which postoperative methicillin-resistant Staphylococcus aureus infection caused dehiscence of the femoral vessels and exposure of the graft vessel and anastomosed area. The infected tissue was surgically removed (debridement), and the patient's condition was successfully treated by the application of a nonadherent dressing and vacuum-assisted closure therapy combined with the bridging technique.

Local application of gentamicin-containing collagen implant in the prophylaxis and treatment of surgical site infection following vascular surgery

BACKGROUND

The development of surgical site infection (SSI) following vascular surgery is an important issue for healthcare providers as it has serious implications for both patient morbidity and mortality.

METHODS

Five publications were identified using the PubMed online database and search terms 'gentamicin-containing collagen implant' plus 'surgical site infection', 'wound infection' and 'vascular surgery'.

RESULTS

The reviewed publications demonstrated that prophylactic use of GCCI in conjunction with standard treatment reduces the SSI rate in patients operated on for femeropopliteal bypass grafting. The prophylactic use of GCCI may also have a role to play in patients at high-risk of infection (e.g. in those with co-morbidities such as obesity) and in high-risk procedures (e.g. surgical revision to correct anastomotic aneurysm or dehiscence). GCCI in conjunction with systemic antibiotics may also be effective in the treatment of wound infections of the groin following vascular reconstruction.

CONCLUSION

This review demonstrates that GCCI have a role to play in preventing and treating SSI following vascular reconstruction when used in conjunction with standard treatment approaches. Additional randomised, controlled studies are required to further establish the efficacy and cost-effectiveness of GCCI in vascular surgery.

An interdisciplinary approach to the prevention and treatment of groin wound complications after lower extremity revascularization

BACKGROUND

If not effectively treated, groin wound infections following lower extremity revascularization (LER) may result in graft or limb loss.

METHODS

A retrospective review was performed of all patients who underwent muscle flap transposition by a single surgeon after LER between 2006 and 2010.

RESULTS

Twenty-nine muscle transposition flaps were performed in 24 patients (21 sartorius, 6 rectus femoris, and 2 gracilis). Nineteen were for treatment of groin wound infections, two for treatment of lymphocele, one for coverage of exposed graft in the setting of pyoderma gangrenosum, and seven for infection prophylaxis. Two graft losses followed flap placement. The limb loss rate was 4%. When performed for therapeutic purposes, graft salvage rates were 100% for autogenous and 92% for synthetic grafts.

CONCLUSIONS

Muscle transposition flaps are an effective means of graft salvage in the setting of groin wound complications following LER and should be considered for infection prophylaxis in high-risk patients.

Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta

Infection of a vascular prosthesis or endovascular stent-graft is probably the most serious complication that may occur after implantation and dramatically affects the patient's outcome. Surgical treatment is almost always required but even after surgery, morbidity can be significant. Several approaches have been described with some advantages and/or some limitations. Complete resection of the infected foreign material with debridement of the surrounding tissue gives most probably the better results. Orthotopic reconstruction is the best option for all thoracic and thoraco-abdominal pathologies and the use of coated prostheses, homografts or self-made vascular tubes from xenopericardial tissue has to be discussed from case to case. In some exceptional situations, endovascular stent-graft can be performed as bridging to a more complete treatment if general condition of the patient has to be stabilized.

Surgical Wound Infections after Vascular Surgery: Prospective Multicenter Observational Study

Background and Aims:

This multicenter prospective observational study defined the incidence and risk factors of surgical wound infections (SWI) after infrarenal aortic and lower limb vascular surgery procedures and evaluated the severity and costs of these infections.

Methods:

The study cohort comprised of 184 consecutive patients. Postoperative complications were recorded. The additional costs attributable to SWI were calculated.

Results:

Eighty-four (46%) patients had critical ischaemia, 81 (45%) patients underwent infrainguinal bypass surgery and 64 (35%) received vascular prosthesis or prosthetic patch. Forty-nine (27%) patients developed SWI. Staphylococcus aureus was the leading pathogen cultured from the wound. Forty-seven of the 49 infected wounds responded to and healed with the treatment. SWI was the cause of one major amputation. Independent predictors for SWI were infrainguinal surgery (OR 7.2, 95% Cl 2.92–17.65, p < 0.001), obesity (OR 6.1, 95% Cl 2.44–15.16, p < 0.001) and arteriography injection site within the operative area (OR 2.5, 95% Cl 1.13–5.48, p = 0.02). The average cost attributable to SWI was 3320 €.

Conclusion:

The incidence of SWI after vascular surgery is high. The risk factors for SWI are infrainguinal surgery, obesity and arteriography injection site within the operative area. SWI increases morbidity and costs of operative treatment.

Role of negative pressure wound therapy in treating peripheral vascular graft infections

Wound complications involving large subcutaneous vessels can cause significant challenges for surgeons. Negative pressure wound therapy (NPWT) has been increasingly used for treating complex wounds in vascular surgery, including groin infections, either as a bridge to surgical closure or as a primary wound treatment modality. Although a growing body of evidence exists for managing various problematic wounds, such as diabetic foot ulcers and open abdominal wounds, the role of NPWT in wounds involving large blood vessels or wounds complicating infected vascular grafts has not been well defined. A multidisciplinary advisory panel reviewed the literature relevant to wounds related to vascular surgical procedures and complications, focusing on large subcutaneous or infected vascular conduits. The results supported by the literature and the clinical practice of the consensus panel suggested that NPWT can be a useful adjunct to the management of vascular groin infections and dehiscences but must be used with caution.

Evolving Microbiology and Treatment of Extracavitary Prosthetic Graft Infections

The authors report the microbiology and outcomes following an individualized treatment algorithm for extracavitary (EC) prosthetic graft infection, including the use of graft preservation and in situ graft replacement techniques. A retrospective 8-year review of 87 patients treated for EC prosthetic graft infections was carried out. The treatment algorithm included culture-specific antibiotic therapy, surgical site debridement with antibiotic bead placement, selected graft preservation with muscle flap coverage, or graft excision with in situ conduit replacement. Outcomes measured included death, limb loss, and recurrent infection. It was found that present-day management of EC prosthetic graft infections is associated with lower mortality and morbidity despite changes in microbiology and the increased application of graft preservation and in situ grafting treatments.

Use of Cryopreserved Femoral Vein for In Situ Replacement of Infected Femorofemoral Prosthetic Artery Bypass

Isolated groin infection following crossover femoral bypass is not uncommon, and its management may be challenging, especially in medically high-risk patients. When an in situ replacement is appropriate, using an autologous vein (femoral or saphenous) would be the preferred method; however, this may not always be feasible. The authors used cryopreserved femoral vein grafts for in situ replacement of femorofemoral bypass grafts with excellent results in 3 high-risk patients who developed early graft infections and failed graft preservation attempts. In situ replacement of infected femorofemoral grafts using a cryopreserved femoral vein graft can be considered as a second-line intervention when an adequately sized autologous vein is unavailable or unusable or is not feasible in high-risk patients.

Prosthetic vascular graft infection: a multi-center review of surgical management

A multi-center retrospective review of major prosthetic graft infection outcomes was undertaken to determine graft preservation and limb salvage rates. The management of infected prosthetic vascular grafts continues to be controversial. The purpose of this study was to review the surgical management of major extracavitary prosthetic vascular graft infections and to correlate the outcomes on the basis of bacteriology and grade. The change in patient population seen by vascular surgeons and the recent emergence of more virulent bacterial strains should influence surgical management. Bacteriology and severity of infection based on grade must play a greater role in the selection criteria for graft salvage. Despite advancement in the understanding of these interactions and the emergence of new management algorithms, we are continuing to operate without a uniform standard in managing this difficult and rapidly evolving clinical problem.

Infección asociada a prótesis vascular: manejo exitoso sin retirada de prótesis

INTRODUCTION

Removal of graft with intravenous antibiotics is traditionally considered the most effective treatment of vascular graft-associated infections. However, an increasing number of reports suggests that this complication can be effectively treated without graft removal.

METHODS

A prospective study to evaluate the outcome of conservative management of vascular graft-associated infection seen in our center was performed. The diagnosis of graft-associated infection was based on microbiological tests, and imaging studies. In our study, patients were hemodynamically stable with functioning vascular graft as per clinical and imaging evaluations. Conservative management included antibiotic treatment and local debridement without removal of vascular graft.

RESULTS

Fourteen patients with vascular graft-associated infection were enrolled in our study. Eleven out of 14 patients (78.6%) responded successfully to conservative management. Treatment failure was reported in 3 patients, 2 of whom required graft removal. After a two-year follow-up, these 14 patients were clinically stable without recurrence of infection.

CONCLUSIONS

Our study has revealed that conservative management of vascular graft-associated infection seems to be effective and should be considered in hemodynamically stable patients with functioning vascular graft.

Managing extracavitary prosthetic vascular graft infections: a pathway to success

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.

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.

Use of antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections

PURPOSE

This study was conducted to assess the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the management of lower extremity extracavitary prosthetic arterial graft infection.

METHODS

This was a retrospective review of 34 patients treated for vascular surgical site (VSS) infections involving 36 prosthetic lower extremity arterial bypasses using antibiotic-loaded PMMA beads and culture-specific parenteral antibiotics for 4 to 6 weeks. Sites of graft infection were explored, debrided, and cultured. As determined from the results of Gram's stains of VSS purulence, PMMA powder was polymerized with an antibiotic (vancomycin, daptomycin, or tobramycin/gentamicin, or a combination), molded into a chain of beads, and implanted adjacent to the infected graft after debridement and pulsed-spray antibacterial lavage. All wounds were closed primarily with planned exploration to verify sterilization before a graft preservation or in situ replacement procedure. Treatment outcomes, including wound sterilization, were analyzed based on tissue culture isolates, procedures for persistent infection, and freedom from graft infection.

RESULTS

Cultures isolated 42 pathogens, (32 gram-positive, 9 gram-negative, 1 Candida albicans) with methicillin-resistant Staphylococcus aureus (MRSA) cultured from 16 (44%) of 36 surgical site infections. As determined from the initial operative Gram's stain or a prior culture result, vancomycin PMMA beads were implanted in 29 of 36 VSS infections at the first procedure; daptomycin (n = 4) or tobramycin (n = 3) beads were implanted in the rest. Repeat VSS exploration and culture results led to an average of 2.5 antibiotic bead replacements before definitive treatment. A sterile (no growth on tissue culture) VSS was achieved in 87% of cases before a graft preservation (n = 16) or in-situ replacement of an infected graft (n = 20) procedure. No patient deaths occurred. Early and late limb salvage was 100%. Infection recurred in 4 (11%) VSSs during a mean 23-month follow-up period, one within 3 months owing to unrecognized bowel injury associated with in situ replacement of an aortofemoral graft limb.

CONCLUSION

Antibiotic-loaded PMMA beads may be a useful adjunct in the contemporary surgical management of VSS infection involving a prosthetic graft. Wound sterilization was achieved in most VSSs before graft preservation or an in-situ replacement procedure, including infections caused by MRSA, a pathogen isolated in half of the extracavitary prosthetic graft infections. This preliminary trial shows the potential benefit of this new technique, but further study is required to prove efficacy.

The role of muscle flaps in wound salvage after vascular graft infections: the Emory experience

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.

Proximal Vascular Pedicle Preservation for Sartorius Muscle Flap Transposition

BACKGROUND

A variety of muscle flaps have been described to treat complex groin wounds associated with infected and/or exposed femoral vessels or vascular grafts and persistent lymphatic leaks, and for prophylaxis against wound breakdown following inguinal lymphadenectomy. The sartorius muscle flap has several advantages over other muscle flaps: it is immediately adjacent to the groin, it is easy to prepare, and the harvest causes no functional morbidity. Despite these advantages, the flap's reliability has been questioned because of the segmental blood supply to the muscle and the flap's limited arc of rotation. To improve the reliability of the flap, the authors defined the proximal vascular anatomy of the sartorius muscle in 20 human cadavers and assessed the correlation with 20 clinical cases. They describe a technique for the harvest of the sartorius muscle transposition flap that preserves the most proximal pedicle.

METHODS

From July of 2000 to January of 2004, 40 sartorius muscles were dissected in 20 human preserved cadavers. During the same time period, 21 sartorius muscle transposition flap procedures were performed in 19 patients for a variety of complex groin wound complications, including infection (n = 10), lymphadenectomy (n = 4), lymphatic leak (n = 3), exposed femoral vessels (n = 3), and high-risk wound (n = 1). The location of the most proximal vascular pedicle with respect to the anterior superior iliac spine was measured in each cadaveric dissection as well as in each clinical case. Outcomes were assessed in the clinical cases with respect to wound healing.

RESULTS

The distance between the anterior superior iliac spine and the proximal vessels in the cadaver specimens was 6.6 +/- 1.3 cm (range, 5.0 to 9.5 cm). The distance between the anterior superior iliac spine and the proximal vessels in the clinical patients was 6.2 +/- 0.6 cm (range, 5.5 to 7.5 cm). Patients were followed for an average period of 30 months (range, 5 to 45 months). There were no incidences of partial or total flap necrosis. All wounds healed to completion.

CONCLUSIONS

The proximal pedicle of the sartorius muscle is consistently located at 6.5 cm from the anterior superior iliac spine. Preservation of the proximal pedicle during dissection ensures the viability of the sartorius muscle transposition flap for the treatment of complex groin wounds.

Preservation of infected and exposed vascular grafts using vacuum assisted closure without muscle flap coverage

The most widely used techniques for graft preservation after localized graft infections are muscle flap closure or antibacterial dressings and irrigations after débridement. Vacuum assisted closure (VAC) has been increasingly used for complex wounds in vascular surgery, including groin infections, but not directly on exposed bypass grafts as a stand-alone technique. We used the VAC system after wound débridement in four patients with fully exposed synthetic bypass grafts who were too unstable or risky for further operative interventions. Mean duration of VAC use was 22.8 days (range, 6 to 53 days), with time to total wound closure of 30 to 63 days (mean, 41 days). There were no reinfections with 11 to 25 months' follow-up (mean, 18.3 months). For high-risk surgical patients with a fully exposed infected prosthetic vascular graft, VAC therapy along with aggressive débridement and antibiotic therapy may be an effective alternative to current management strategies.

Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study

OBJECTIVE

To evaluate whether hyperglycaemia in the first 48 h after infrainguinal vascular surgery is a risk factor for post-operative infection, independent from factors associated with insulin resistance and surgical stress.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

Patients who underwent infrainguinal vascular surgery in our hospital between March 1998 and March 2003 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Post-operative infections, treated with antibiotics, during hospital stay were scored until 30 days after surgery. Data were analysed with univariate and multivariate logistic regression analyses.

RESULTS

At least one post-operative glucose value was retrieved for 211/275 (77%) patients. The incidence of post-operative infections was 84/275 (31%). When corrected for factors associated with insulin resistance and surgical stress, post-operative glucose levels were found to be an independent risk factor for post-operative infections (odds ratio top quartile versus lowest quartile: 5.1; 95% confidence interval: 1.6-17.1; P=0.007).

CONCLUSION

Post-operative glucose levels appear to be an independent risk factor for infections after infrainguinal vascular surgery. This finding requires confirmation in a prospective study.

Rotational muscle flap closure for acute groin wound infections following vascular surgery

Since 1996, 41 patients have presented to our institution with deep but localized groin infection following bypass (30) or isolated femoral artery surgery (11). These patients were treated with antibiotics, debridement, and rotational muscle flap coverage either immediately or within a few days. Patients had one of three patterns: serous leak from a groin incision within a few days of operation (Acute, n = 10), early serous leak that later became grossly infected (Acute-observed, n = 8), or obvious purulent drainage following an initially normal, healed wound (Delayed, n = 23). Patients with early leak had nearly uniformly polymicrobial infections with a preponderance of gram-negative organisms, whereas most of those with late purulence had monobacterial infection with Staphylococcus aureus. At exploration, 26 of 41 suture lines were exposed. Rectus femoris flaps were used in 35 patients (85% of cases) for coverage, and graft preservation was attempted in all 8 vein grafts and 16 of 23 prosthetic grafts. Only one flap failed and there were no instances of anastomotic bleeding. There were no deaths directly attributable to reexploration and flap coverage, although 10 patients died during the index hospitalization. Durable coverage with no long-term evidence of infection was achieved in 24 patients with mean follow-up of 23 (range 10-66) months and another 12 had no evidence of local problems despite shorter follow-up; only 5 patients (12%) overall had evidence of persistent graft infection or unexplained bacteremia. In patients with attempted graft salvage, limb salvage was 97% at 6 months and 85% at 1 year. Although early mortality is high, deaths are not related to the flap procedure itself, local outcome is excellent, and graft and limb salvage are good; results are much worse if an initially draining wound is treated too late. Local rotational muscle flap closure is an excellent solution for acute infections involving the groin following vascular procedures.