Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.