O R I G I N A l . ARTICLES From the Eastern Vascular Society
A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artcry Keith D. Calligaro, M D , * F r a n k J. Veith, M D , Sushil K. Gupta, M D , Enrico Ascer, M D , Alan M. Dietzek, M D , Charles D. Franco, M D , and K u r t R. W e n g e r t e r , M D , New York, N.Y. In the last 10 years we have treated 28 patients with 33 groin infections involfing 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 revascularizaton by mean s of bypasses nmneled 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 wth 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. (J VASe SURG 1990;11:485-92.)
Traditional management o f infections involving an anastomosis o f a prosthetic graft o f the periphcral arterial systcm usually includes total excision o f the infected graft but is associatcd with amputation rates ranging from 9% to 52% and mortality rates o f 9% to 36%. ~-6 The managemcnt o f infccted prosthctic grafts in the groin is particularly troublesome because
excision o f a graft with infection involving an anastomosis to the common femoral arte W usually results in a severely ischemic thigh and leg requiring highthigh amputation or complex difficult secondary revascularization procedures. The purpose o f the present communication is to report a management plan that allows simpler and possibly more effective treatment o f infected prosthetic arterial grafts in the groin.
From the Division of Vascular Surgery,,MontefiorcMedical Center/Albert Einstein College of Medicine. ~Dr. Calligaro presently at Pennsylvania Hospital/University of Pennsylvania School of Medicine, Philadelphia. Supported in part by the James Hilton Manning and EmmaAustin Manning Foundation,the Anna S. BrownTrust, and New York Institute for Vascular Studies. Presented at the Third Annual Meeting of the Eastern Vascular Society, Bermuda, May 4-7, 1989. Reprint requests: Keith D. Calligaro, MD, 700 Spruce St., Suite 101, Philadelphia, PA 19106. 24/6/18228
PATIENTS AND METHODS Between )'an. 1, 1977, and Dec. 31, 1987, we trcated 28 patients with 33 groin infections involving an anastomosis o f a prosthetic arterial graft to the common femoral artery. Some o f these infected anastomoses also extended above the inguinal ligament to the adjacent external iliac artery, and others extended distally on to the dcep or superficial femoral artcry. Infection involvcd the groin anastomosis o f 485
486
Journalof VASCULAR SURGERY
CaIligaro et aI.
Table I. Type of infected prosthetic groin graft
Graft Aortofemoral Dacron Peripheral PTFE Femorodistal (to poplitcal, crural or pedal arteries) Femorofcmoral (bilateral infection) Axillofemorodistal Axillofcmoral Total
2 16 7 5 2 1 33
two aortofemoral Dacron grafts and 31 peripheral polytetrafluoroethylene (PTFE) grafts (Table I). Infections developed in 24 patients after operations performed in our institution, whereas four patients were referred after operation elsewhere. Twenty-seven of the 33 infected grafts (both aortic Dacron grafts and 25 PTFE grafts) had purulent drainage from the groin without anastomotic breakdown and hemorrhage. In all 27 cases pus was present in direct contact with the graft anastomosis to the common femoral artery. Eleven of these grafts were patent (including both aortic Dacron grafts), and 16 were occluded. The other six infected grafts (all PTFE; four occluded, two patent) had hemorrhage or false aneurysm as the first manifestation of infection. Follow-up ranged between 1 and 10 years with a mean of 3 years. The patients ranged in age from 34 to 85 years with a mean of 62 years. There were 14 men and 14 women. Half of the patients had diabetes mellitus. Seventeen of the 28 patients (60%) had undergone more than one previous vascular operation on the infected groin with an average of 2.3 prior dissections per infected site. A first-generation cephalosporin (Cefazolin or Kefzol 1 gm intravenously) was administered prophylactically 1 hour before all noncomplicated arterial operations and continued for 24 hours after surgery. Aerobic and anaerobic cultures were obtained from all infected groin wounds. Arterial wall specimens were not routinely acquired since preservation of the uninvolved patent artery was attempted in most cases.
Operative management The manner of presentation of the infected prosthctic graft in the groin determined our management. If an infection involved an intact anastomosis of a patent graft (11 cases), complete graft preservation was the preferred method of treatment (Table II). When the infection involved an intact anastomosis
of an occluded graft (16 cases) to a patent scgmmtc of the common and deep femoral artery, subtotal excision of the graft was performed leaving an oversewn 2 to 3 mm graft remnant on the artery (Table III). If an infected graft presented with hemorrhage or pseudoancurysm of the anastomosis (six cases), total graft excision with arterial ovcrscwing or proximal and distal ligation was urgently performed (Table IV). One patient with bilateral groin infections and different presenting symptoms in each side of the groin is included in both Table III and Table IV. This simplified management plan for infected prosthetic grafts of the groin was only possible when the following essential adjuncts were pcrfbrmed along with it. First, wide radical operative wound excision was performed under general anesthesia. This allowed definition of the extent of the infection and facilitated removal of all infected or necrotic tissue, debris, and exudatc. The patients were obsc~'s:d in the intensive care unit after operative dcbridcn-ient of the groin for potential anastomotic bleeding until healthy granulation tissue covered the exposed anastomosis. Povidonc-iodine 50% or antibiotic-soaked dressing changes wcrc performed evc~, 4 to 6 hours. Appropriate intravenous antibiotics wcrc given, and repeated operative dcbridcmcnts wcrc carried out as necessary to keep the wound frcc of necrotic tissue and to expedite granulation and healing. Continued hospitalization was necessary until the entire graft was covered and the wound had healed bv delayed secondary intention or by split-thickaaess sidn grafting onto healthy granulation tissue. Second, when total excision of a bleeding infected graft or subtotal excision of an occluded graft resulted in an ischcmic threatened leg, secondary revascul( ization via a lateral route through sterile, uninfected tissue was performed. Inflow sources such as the axillary artery, the descending thoracic aorta, the abdominal aorta, or the iliac artery wcrc used. Usually these latter two sources were approached rctroperitoncally. After isolation of the infected groin with adhesive drapes or sterile towels, the new grafts were tunneled laterally just medial or lateral to the anterior superior iliac spine. When the aorta or iliac arteries were used as inflow sources, a tunnel was made dccp to the inguinal ligament and then continued distally in a subcutaneous lateral plane to patent, uninvolved outflow arteries. A subcutaneous lateral route was used entirely for axillofcmoral or axillopoplitcal bypasses. These lateral tunneling routes required the use of unusual approaches to uninfected patent distal outflow arteries (Fig. 1).These included an antcrolateral approach to the distal superficial or deep fern-
Volume 11 Number 4 April 1990
Infected prosthetic grafts in the groin
487
x able II. Total graft preservation for patent infected grafts Age ~ s e x
Operation ~
Interval (mo)
Anatomic location ~
68/F
L CFA-R DFA
A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artcry Keith D. Calligaro, M D , * F r a n k J. Veith, M D , Sushil K. Gupta, M D , Enrico Ascer, M D , Alan M. Dietzek, M D , Charles D. Franco, M D , and K u r t R. W e n g e r t e r , M D , New York, N.Y. In the last 10 years we have treated 28 patients with 33 groin infections involfing 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 revascularizaton by mean s of bypasses nmneled 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 wth 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. (J VASe SURG 1990;11:485-92.)
Traditional management o f infections involving an anastomosis o f a prosthetic graft o f the periphcral arterial systcm usually includes total excision o f the infected graft but is associatcd with amputation rates ranging from 9% to 52% and mortality rates o f 9% to 36%. ~-6 The managemcnt o f infccted prosthctic grafts in the groin is particularly troublesome because
excision o f a graft with infection involving an anastomosis to the common femoral arte W usually results in a severely ischemic thigh and leg requiring highthigh amputation or complex difficult secondary revascularization procedures. The purpose o f the present communication is to report a management plan that allows simpler and possibly more effective treatment o f infected prosthetic arterial grafts in the groin.
From the Division of Vascular Surgery,,MontefiorcMedical Center/Albert Einstein College of Medicine. ~Dr. Calligaro presently at Pennsylvania Hospital/University of Pennsylvania School of Medicine, Philadelphia. Supported in part by the James Hilton Manning and EmmaAustin Manning Foundation,the Anna S. BrownTrust, and New York Institute for Vascular Studies. Presented at the Third Annual Meeting of the Eastern Vascular Society, Bermuda, May 4-7, 1989. Reprint requests: Keith D. Calligaro, MD, 700 Spruce St., Suite 101, Philadelphia, PA 19106. 24/6/18228
PATIENTS AND METHODS Between )'an. 1, 1977, and Dec. 31, 1987, we trcated 28 patients with 33 groin infections involving an anastomosis o f a prosthetic arterial graft to the common femoral artery. Some o f these infected anastomoses also extended above the inguinal ligament to the adjacent external iliac artery, and others extended distally on to the dcep or superficial femoral artcry. Infection involvcd the groin anastomosis o f 485
486
Journalof VASCULAR SURGERY
CaIligaro et aI.
Table I. Type of infected prosthetic groin graft
Graft Aortofemoral Dacron Peripheral PTFE Femorodistal (to poplitcal, crural or pedal arteries) Femorofcmoral (bilateral infection) Axillofemorodistal Axillofcmoral Total
2 16 7 5 2 1 33
two aortofemoral Dacron grafts and 31 peripheral polytetrafluoroethylene (PTFE) grafts (Table I). Infections developed in 24 patients after operations performed in our institution, whereas four patients were referred after operation elsewhere. Twenty-seven of the 33 infected grafts (both aortic Dacron grafts and 25 PTFE grafts) had purulent drainage from the groin without anastomotic breakdown and hemorrhage. In all 27 cases pus was present in direct contact with the graft anastomosis to the common femoral artery. Eleven of these grafts were patent (including both aortic Dacron grafts), and 16 were occluded. The other six infected grafts (all PTFE; four occluded, two patent) had hemorrhage or false aneurysm as the first manifestation of infection. Follow-up ranged between 1 and 10 years with a mean of 3 years. The patients ranged in age from 34 to 85 years with a mean of 62 years. There were 14 men and 14 women. Half of the patients had diabetes mellitus. Seventeen of the 28 patients (60%) had undergone more than one previous vascular operation on the infected groin with an average of 2.3 prior dissections per infected site. A first-generation cephalosporin (Cefazolin or Kefzol 1 gm intravenously) was administered prophylactically 1 hour before all noncomplicated arterial operations and continued for 24 hours after surgery. Aerobic and anaerobic cultures were obtained from all infected groin wounds. Arterial wall specimens were not routinely acquired since preservation of the uninvolved patent artery was attempted in most cases.
Operative management The manner of presentation of the infected prosthctic graft in the groin determined our management. If an infection involved an intact anastomosis of a patent graft (11 cases), complete graft preservation was the preferred method of treatment (Table II). When the infection involved an intact anastomosis
of an occluded graft (16 cases) to a patent scgmmtc of the common and deep femoral artery, subtotal excision of the graft was performed leaving an oversewn 2 to 3 mm graft remnant on the artery (Table III). If an infected graft presented with hemorrhage or pseudoancurysm of the anastomosis (six cases), total graft excision with arterial ovcrscwing or proximal and distal ligation was urgently performed (Table IV). One patient with bilateral groin infections and different presenting symptoms in each side of the groin is included in both Table III and Table IV. This simplified management plan for infected prosthetic grafts of the groin was only possible when the following essential adjuncts were pcrfbrmed along with it. First, wide radical operative wound excision was performed under general anesthesia. This allowed definition of the extent of the infection and facilitated removal of all infected or necrotic tissue, debris, and exudatc. The patients were obsc~'s:d in the intensive care unit after operative dcbridcn-ient of the groin for potential anastomotic bleeding until healthy granulation tissue covered the exposed anastomosis. Povidonc-iodine 50% or antibiotic-soaked dressing changes wcrc performed evc~, 4 to 6 hours. Appropriate intravenous antibiotics wcrc given, and repeated operative dcbridcmcnts wcrc carried out as necessary to keep the wound frcc of necrotic tissue and to expedite granulation and healing. Continued hospitalization was necessary until the entire graft was covered and the wound had healed bv delayed secondary intention or by split-thickaaess sidn grafting onto healthy granulation tissue. Second, when total excision of a bleeding infected graft or subtotal excision of an occluded graft resulted in an ischcmic threatened leg, secondary revascul( ization via a lateral route through sterile, uninfected tissue was performed. Inflow sources such as the axillary artery, the descending thoracic aorta, the abdominal aorta, or the iliac artery wcrc used. Usually these latter two sources were approached rctroperitoncally. After isolation of the infected groin with adhesive drapes or sterile towels, the new grafts were tunneled laterally just medial or lateral to the anterior superior iliac spine. When the aorta or iliac arteries were used as inflow sources, a tunnel was made dccp to the inguinal ligament and then continued distally in a subcutaneous lateral plane to patent, uninvolved outflow arteries. A subcutaneous lateral route was used entirely for axillofcmoral or axillopoplitcal bypasses. These lateral tunneling routes required the use of unusual approaches to uninfected patent distal outflow arteries (Fig. 1).These included an antcrolateral approach to the distal superficial or deep fern-
Volume 11 Number 4 April 1990
Infected prosthetic grafts in the groin
487
x able II. Total graft preservation for patent infected grafts Age ~ s e x
Operation ~
Interval (mo)
Anatomic location ~
68/F
L CFA-R DFA
