The impact of MRSA on vascular surgery.

OBJECTIVES: To investigate the prevalence of MRSA infection in patients treated in a major vascular unit and examine its consequences. DESIGN AND METHODS: A retrospective case-note review was performed. RESULTS: During the period 1993 to 2000, a total of 172 patients (4.4% of total) were positive for MRSA. Of these 97 were colonised and 75 were infected by MRSA. The proportion of wound or graft infections caused by MRSA has increased (4% in 1994 to 63% in 2000). Three patients developed native artery infection (one following aortic stent insertion and 2 following embolectomy). All patients with aortic graft infection died. All patients with infected prosthetic infrainguinal bypass ended up with an amputation. CONCLUSION: The prevalence of MRSA infection is increasing. Infection of aortic grafts appears to be uniformly fatal and lower limb graft infection is associated with high limb loss.     

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

OBJECTIVE: The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts. METHODS: When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years). RESULTS: This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases). CONCLUSION: Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision.     

Infected femorodistal bypass: is graft removal mandatory?

Infected lower extremity bypass grafts have been associated with high rates of limb loss. Traditionally treatment has included graft excision. To compare aggressive local treatment, without graft removal, with more conventional graft excision, we reviewed 38 consecutive patients with 39 infected lower extremity bypasses treated during the last 10 years. The grafts used were prosthetic in 33 cases, vein in 4, and composite in 2. Median follow-up was 2.7 years. Twenty-eight infected grafts were treated with either complete (14) or partial (14) graft removal. Nine new grafts were placed. Recurrent infection developed in five cases, and two patients died of complications of graft infection. Ten of 20 limbs at risk were lost. Eleven patients with patent bypasses (4 vein, 2 composite, 5 prosthetic) were treated without graft excision. Treatment of five patients in this group included muscle transposition. Five patients were treated with incision and drainage of abscesses, and one had excision of a persistent sinus tract. One patient underwent major amputation 6.3 years after treatment of graft infection. Limb salvage was significantly higher (p = 0.012, log-rank test) than in patients treated with graft excision. One patient died, and no recurrent infections developed; these were not significant differences compared with those having graft excision. We conclude that aggressive local treatment of infected lower extremity bypass grafts, including drainage, debridement, and muscle transposition may treat infection in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy.     

Prosthetic patch remnants to treat infected arterial grafts

PURPOSE: Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants. METHODS: During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months). RESULTS: No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible. CONCLUSION: Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.     

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.     

Intra-abdominal aortic graft infection: complete or partial graft preservation in patients at very high risk

BACKGROUND: Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. METHODS: Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. RESULTS: One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). CONCLUSIONS: Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.     

Infrainguinal anastomotic arterial graft infections treated by selective graft preservation.

The purpose of this study was to determine whether the type of graft material and bacteria involved in an infrainguinal arterial anastomotic infection can be used as guidelines for graft preservation. Between 1972 and 1990, the authors treated 35 anastomotic infections involving a common femoral or distal artery. The graft material was Dacron in 14 patients, polytetrafluoroethylene (PTFE) in 14, and vein in 7. Of the 14 Dacron grafts, immediate graft excision was required for overwhelming infection in eight patients (bleeding in five, sepsis in three) and for an occluded graft in one patient. Three of five patients failed attempted graft preservation because of nonhealing wounds. Thus, 12 of the 14 Dacron grafts ultimately required graft excision. Of the 21 "smooth-walled" vein and PTFE grafts, 10 required immediate graft excision for occluded grafts (five PTFE, one vein) or bleeding (three PTFE, one vein). Ten of the remaining 11 (91%) patients with patent "smooth-walled" grafts, intact anastomoses, and absence of sepsis managed by graft preservation healed their wounds and maintained distal arterial perfusion. Wound cultures grew pure gram-positive cocci in 17 of 21 "smooth-walled" graft infections versus 8 of 14 Dacron graft infections. In the absence of systemic sepsis, graft preservation is the treatment of choice for gram-positive infections involving an intact anastomosis of patent PTFE and vein grafts. Regardless of the bacterial cause, the authors recommend that any infrainguinal anastomotic infection of a Dacron graft be treated by immediate excision of all infected graft material.     

Outcome After Occlusion of Infrainguinal Bypasses in the Dutch BOA Study: Comparison of Amputation Rate in Venous and Prosthetic Grafts

OBJECTIVE: To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. METHODS: In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. RESULTS: The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). CONCLUSION: The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.     

Long-term results of catheter-directed thrombolysis to treat infrainguinal bypass graft occlusion: the urokinase era

PURPOSE: This study was undertaken to review the long-term results of catheter-directed thrombolysis in treatment of infrainguinal bypass graft occlusion. METHODS: From January 1987 to December 1998, 67 patients with 69 acutely occluded infrainguinal arterial bypass grafts (48 vein grafts, 21 prosthetic grafts) underwent treatment with catheter-directed thrombolysis with urokinase. Long-term results were assessed with Kaplan-Meier life-table analysis, and factors predictive of success were determined with multivariate analysis. RESULTS: Thrombolysis was aborted in 7 patients (10%) because of major complications or technical failure and was unsuccessful in restoring graft patency (相似文献   

Infected femoral artery false aneurysms in drug addicts: evolution of selective vascular reconstruction

Fifty-four infected femoral artery false aneurysms resulting from chronic drug addiction were managed surgically with an 11% amputation rate and no mortality. Angiography localized the arterial segment involved, which in turn influenced the type of operation performed. Twenty-six aneurysms of anatomically isolated femoral artery segments were ligated and excised without resultant amputation. However, of the 28 aneurysms involving the common femoral bifurcation, 18 required triple ligation and excision that led to six amputations. Six of the 28 aneurysms were reconstructed with autogenous saphenous vein grafts, three by prosthetic grafts, and one by primary anastomosis. No amputations followed vascular reconstruction. However, all synthetic grafts eventually developed septic complications that required graft removal. On the basis of this experience we recommend ligation and excision for single artery segment aneurysms and immediate autogenous reconstruction for selected common femoral bifurcation lesions. This approach has proved safe and has reduced our amputation and graft complication rates. Extensive uncontrollable wound sepsis may contraindicate revascularization. Under these circumstances we estimate a 33% risk of amputation when the common femoral bifurcation is excised.     

Management of infection of major amputation stumps after failed femorodistal grafts

A retrospective review was performed of 174 patients who underwent 199 lower-extremity amputations for unreconstructable vascular insufficiency from 1976 to 1983 at the Northwestern University Medical Center. This study was initiated to identify the cause of amputation wound healing complications and secondary ascending prosthetic graft infection, as well as to propose a plan of management for the failed prosthetic grafts at the time of major limb amputation. Ninety-eight amputations were performed primarily, 12 were performed secondary to graft infection, and 89 were performed in patients who had previously undergone infrainguinal arterial bypass procedures. At the time of amputation, graft management consisted of high transection and suture ligation, allowing the graft to retract into the substance of the stump and away from the skin suture line and weight-bearing area of the limb. Delayed stump healing was noted to occur more commonly in the group who had undergone previous bypasses as opposed to those who had undergone primary amputation (34.8% versus 14.3%). Fourteen graft infections developed in 89 patients after amputation (15.7%), which is significantly higher than the overall 1.4% incidence of lower-extremity bypass infections that occurred during the same interval in patients with intact extremities. In addition, it was found that when infected grafts in amputated limbs were completely removed, stump healing without recurrent wound and graft sepsis was better than when treated locally or with partial graft removal. We therefore recommend removal of a thrombosed graft with an infected wound or an infected graft at the time of major limb amputation to decrease the incidence of wound complications and graft infection.     

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.     

Treatment strategies for aortic and peripheral prosthetic graft infection

Purpose

The aim of this study was to investigate the outcomes correlated with our treatment strategy for prosthetic graft infection.

Methods

Seventeen patients were treated for prosthetic graft infections between 1997 and 2009. Initially, total graft excision was applied in five cases, partial graft excision was applied in six cases and graft preservation with drainage and irrigation was applied in six cases. Among the graft-preserved cases, four patients were infected with methicillin-resistant Staphylococcus aureus (MRSA) and treated with gentian violet (GV).

Results

The overall survival rate was 88 % at 30 days and 82 % at 1 year in this series. Of the excised cases, nine patients survived; however, two patients died. Among the cases in which MRSA-infected grafts were preserved, three patients survived; however, one patient died under a septicemic state. Infected graft preservation was applied at a high rate of 36 %, and the mortality rate remained at 16 %, without any signs of graft reinfection.

Conclusions

In the treatment of infected grafts, the patient’s condition should be considered in order to select the appropriate treatment in each case. Graft preservation should be considered as an alternative treatment option, especially in high-risk patients, and GV can be effective for conservative treatment of prosthetic graft infections, including MRSA infections.     

Expanded application of in situ replacement for prosthetic graft infection

PURPOSE: The purpose of this study was to analyze the outcome of an individualized treatment algorithm for prosthetic graft infection, including the application of in situ graft replacement, based on clinical presentation, extent of graft infection, and microbiology. METHODS: There was a retrospective review (1991-2000) of 119 patients with 68 aortoiliofemoral or 51 extracavitary (infrainguinal, 19; axillofemoral, 16; femorofemoral, 16) prosthetic graft infections presenting more than 3 months (range, 3-136 months) after implantation/revision. The treatment algorithm consisted of graft excision with or without ex situ bypass grafts for patients presenting with sepsis or graft-enteric erosion, whereas in situ replacement (autogenous vein, rifampin-bonded polyester, polytetrafluoroethylene [PTFE]) was used in patients with less virulent gram-positive graft infection, in particular infections caused by Staphylococcus epidermidis. Outcomes (death, limb loss, recurrent infection) were correlated with treatment type and infecting organism. RESULTS: In situ replacement was used in 52% of aortoiliofemoral (autogenous vein, 10; rifampin-bonded polyester, 6; PTFE, 9) and 80% of extracavitary (autogenous vein, 26; PTFE, 9; rifampin, 6) graft infections. Total graft excision with ex situ bypass was performed in 34 patients, including 21 patients with graft-enteric erosion/fistula, with a 21% operative mortality and 9% amputation rate. In situ graft replacement was used to treat 76 graft infections with a 30-day operative mortality rate of 4% and an amputation rate of 2%. Graft excision alone was performed in nine patients with one 30-day death. Gram-positive cocci were the prevalent infecting organisms of both intracavitary (59% of isolates) and extracavitary (76% of isolates) graft infections. S epidermidis was the infecting organism in 40% of patients, accounting for the expanded application of in situ prosthetic replacement using a rifampin-bonded polyester or PTFE prosthesis. During the mean follow-up interval of 26 months, recurrent graft infection developed in 3% (1 of 34) of patients after conventional treatment, 3% (1 of 36) patients after in situ vein replacement, and 10% (4 of 40) patients after in situ prosthetic graft replacement (P >.05). Failure of in situ replacement procedures was the result of virulent and antibiotic-resistant bacterial strains. CONCLUSIONS: In situ replacement was a safe and durable option in most (64%) patients presenting with prosthetic graft infection. In situ replacement with a rifampin-bonded graft was effective for S epidermidis graft infection, but when the entire prosthesis is involved with either a biofilm or invasive perigraft infection, in situ autogenous vein replacement is preferred. Virulent graft infections presenting with sepsis, anastomotic dehiscence, or graft enteric fistula should continue to be treated with total graft excision, and if feasible, staged ex situ bypass graft.     

Low-dose thrombolytic therapy for infrainguinal graft occlusions: An idea whose time has passed?

Despite the growing enthusiasm for low-dose intra-arterial thrombolytic therapy, the efficacy and risks in specific clinical situations have not been defined. During the past 13 months, 10 infrainguinal bypass graft occlusions occurred in nine patients 2 to 48 months postoperatively and were treated with local infusions of either streptokinase or urokinase. The grafts treated included two saphenous vein femoropopliteal grafts, two expanded polytetrafluoroethylene (PTFE) femoropopliteal grafts, four saphenous vein femoro-anterior tibial grafts, one saphenous vein-PTFE composite femoro-anterior tibial graft, and one saphenous vein-PTFE composite femoroperoneal graft. The graft occlusions occurred 2 to 14 days prior to initiation of treatment. The infusion failed to restore flow completely in seven grafts; and of the three successes, two patients required surgical treatment of complications. All successful recanalizations occurred within 48 hours of the initiation of thrombolytic therapy. Of the seven failures, two patients had viable limbs and were discharged, whereas two required amputation (one above and one below knee). Three patients underwent surgical thrombectomy and revisions that were successful in two and resulted in a below-knee amputation in the other. Despite all precautions, complications occurred in five patients. Low-dose intra-arterial thrombolytic therapy is a poorly efficacious, risky method of infrainguinal graft occlusion management.     

Complete versus partial excision of infected arteriovenous grafts: Does remnant graft material impact outcomes?

ObjectiveInfected arteriovenous grafts necessitate intervention to obtain source control. However, excising the graft material can be challenging and can lead to complications. Leaving a cuff of graft at the sites of anastomosis allows for the avoidance of potential risks. However, it is unclear whether doing so places patients at risk of recurrent graft infection. The purpose of the present study was to investigate the effect of complete vs partial excision of infected arteriovenous prosthetic dialysis access grafts.MethodsThe data from all patients who had undergone surgical intervention for infected arteriovenous grafts at a single institution were retrospectively reviewed. The patients were grouped according to intervention type: complete excision and partial excision of arteriovenous prosthetic grafts. Partial excisions were further substratified based on whether flow had been restored through the arteriovenous access. The primary outcome was freedom from subsequent intervention for infection, defined as the number of days from excision to subsequent reoperation for reinfection. Freedom from infection was analyzed using the Kaplan-Meier method.ResultsA total of 117 patients had undergone surgical intervention for 122 infected arteriovenous grafts from 2003 to 2016. Of these 117 patients, 79 (64.8%) had undergone partial excision of infected arteriovenous grafts, and 43 (35.2%) had undergone complete excision with vascular repair. Within the partial excision cohort, 71 infected arteriovenous grafts (58.2%) were not flow restored and 8 (6.6%) were flow restored using either prosthetic or autogenous interpositions. The median follow-up time was 2.4 years (interquartile range, 0.6-4.5 years). The most common causative organisms included methicillin-resistant Staphylococcus aureus (n = 34; 27.9%), methicillin-sensitive S. aureus (n = 17; 13.9%), and S. epidermidis (n = 15; 12.3%). The recurrent infection rate in the partial excision group was 16.5% (n = 13) compared with 2.3% (n = 1) in the complete excision group. In the flow-restored subcohorts, those with restoration using prosthetic interposition grafts had the greatest reinfection rate at 57.1% (n = 4), and those with restoration using autogenous conduits did not experience reinfection (P = .033).ConclusionsIncomplete excision of infected arteriovenous prosthetic grafts was associated with a higher rate of reinfection compared with complete graft excision. Complete excision presents technical challenges but could provide superior source control in managing infected dialysis access. Complete excision with vascular reconstruction should be performed when possible to avoid leaving remnant prosthetic material.     

Aortic and peripheral prosthetic graft infection: differential management and causes of mortality

This report of 25 patients with prosthetic graft infection has compared the diagnosis, management, and outcome in 14 patients with infected aortic grafts with 11 patients with infected peripheral grafts (two axillofemorofemoral, five femorofemoral, five femoropopliteal, and one femoral interposition). Peripheral graft infection had a significantly shorter interval to diagnosis compared with aortic graft infection. Total graft removal combined with either autogenous revascularization or extraanatomic bypass using prosthetic graft was performed in all 14 patients with infected aortic grafts. Management of peripheral graft infection consisted of total graft removal in eight patients (four with autogenous revascularization and two with amputation) and partial graft removal in three patients (two with amputation). Mortality and amputation rates for infected aortic grafts were 43 percent and 25 percent, respectively compared with 36 percent and 27 percent for infected peripheral grafts. Recommendations for management of the infected aortic prosthetic graft include total graft removal, but methods and timing of revascularization are dependent on the specific features of the individual case. However, preferred management for the infected peripheral prosthetic graft includes total graft removal and, if indicated, revascularization using autogenous tissue.     

Infected lower extremity extra-anatomic bypass grafts: Management of a serious complication in high-risk patients

To determine optimal management and outcome of infected extra-anatomic bypass grafts (EABG), we reviewed 28 patients (19 men and 9 women; mean age 70 years) treated over a 13-year period. Mean follow-up was 42 months. There were 16 axillofemoral (AF), 10 femorofemoral (FF), and two axillopopliteal (AP) grafts. Risk factors included previous prosthetic graft infection in 13 patients, enterocutaneous fistula in two, and mycotic aortic aneurysm in one. Initial management involved complete graft excision in 12 patients, partial graft excision in 10, and nonresectional therapy in six. Failure of nonresectional therapy and partial excision in three patients each required further operative intervention with graft excision. Reconstruction in patients eventually requiring graft excision (n=25) entailed placement of a new prosthetic AF or AP graft in eight, an autogenous FF graft in five, combined prosthetic AF and autogenous FF bypass in two, autogenous iliofemoral bypass in one, obturator bypass in one, or no reconstruction in eight. Four autogenous FF reconstructions thrombosed immediately postoperatively, and three prosthetic reconstructions became infected. The mortality rate was 18% (FF=20%, AF=19%, AP=0%). The amputation rate was 25% (AP=100%, AF=25%, FF=10%) and was higher without arterial reconstruction (56% vs. 12%,p=0.02). Two patients required hemipelvectomies and one had bilateral hip disarticulation. We conclude that EABG infections can be successfully treated but carry significant morbidity and mortality. Optimal management includes EABG resection and prompt revascularization, bearing in mind the risk of early thrombosis in autogenous grafts and reinfection in prosthetic grafts.Presented at the Thirteenth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif., September 16–18, 1994.     

A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery

In the last 10 years we have treated 28 patients with 33 groin infections involving a common femoral artery anastomosis of prosthetic arterial grafts (2 aortic Dacron grafts, 31 peripheral polytetrafluoroethylene grafts). Management included complete graft preservation for patent infected grafts (11 cases), subtotal excision of occluded infected grafts leaving an oversewn 2 to 3 mm graft remnant attached to a patent artery critical for limb survival (16 cases), and total graft excision with arterial oversewing or ligation for anastomotic bleeding (6 cases). Essential treatment adjuncts included (1) radical operative wound debridement, and (2) secondary revascularization by means of bypasses tunneled via lateral uninfected routes, and unusual approaches to uninvolved patent outflow arteries (i.e., the distal superficial or deep femoral or popliteal arteries) after isolation of the infected wound. Follow-up averaged 3 years (1 to 10 years). This plan of treatment resulted in an 11% (3/28) hospital mortality and an amputation rate of 13% (4/30 threatened limbs). Of the 25 survivors with 30 infected groin grafts, 87% (26) of the wounds healed uneventfully by secondary intention within 1 to 8 weeks (mean, 4 weeks) and have remained healed. One infected groin wound did not heal and required delayed total graft excision. Three patients had late anastomotic disruption with hemorrhage at 8 months, 2 years, and 4 years after initial treatment. This selected use of complete or partial graft preservation and other essential treatment adjuncts are proposed as a safer, easier method for managing infected prosthetic arterial grafts in the groin.     

Infected arterial grafts: clinical manifestations and surgical management

The clinical manifestations and results of management in twenty-five patients treated for infected vascular grafts are reviewed. The overall incidence of infection in this series of prosthetic grafts is 1.4%. Staphylococcus aureus was found to be the single most common infecting organism and multiple organisms were found in nine patients. Therapy was divided into three methods of management: local therapy alone resulted in a mortality of 45% and an amputation rate of 36.3%; partial graft excision resulted in a mortality of 20% and an amputation rate of 60%; total graft excision resulted in a mortality of 22% and an amputation rate of 22% as well. All amputations were above-knee amputations and the most common cause of death was continuing sepsis. The overall mortality of 32% and a loss of limb rate of 44% are testimony to the serious nature of this problem.