Anticoagulation and temporary graft occlusion to determine the need for revascularization following vascular graft infection

The patient with a patent, infected vascular graft presents a dilemma to the surgeon, who must decide whether revascularization is necessary in addition to removal of the infected graft. When a graft infection points superficially or requires drainage, the graft may be well enough exposed to provide easy access. A technique to determine preoperatively the need for revascularization in two patients with patent, exposed grafts is discussed. Following therapeutic anticoagulation, the exposed grafts were occluded with a screw clamp. Within 1 hour, one patient developed ischemic rest pain, associated with a fall in ankle blood pressure to < 60 mm Hg. Consequently, the patient underwent excision of the infected graft and revascularization with another extraanatomic bypass graft. The second patient, who had moderate intermittent claudication, tolerated clamping of the graft without ischemic symptoms at rest. Revascularization was performed through noninfected tissue, with the knowledge that the graft could be removed if necessary, without causing ischemic rest pain. This technique helps to determine preoperatively whether patients with exposed, infected grafts require revascularization as well as graft excision.