Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts

Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4 sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n=8) or DSI (n=12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft. Average hospital and intensive care stay as well as hospital costs were not significantly different for the two groups. The majority of infected, patent lower extremity grafts with intact anastomoses can be successfully preserved with either MFs or DSI wound healing. We found no significant difference in outcome or cost for the two methods of treatment.Supported by the John F. Connelly Foundation, the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, and New York Institute for Vascular Studies.Presented at the Eighteenth Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993.