Rectus femoris muscle flap based on proximal insertion mobilization to cover a groin infected vascular graft Luís Silvestre, MD, Luís Mendes Pedro, PhD, Ruy Fernandes e Fernandes, MD, Emanuel Silva, MD, and José Fernandes e Fernandes, PhD, Lisbon, Portugal The rectus femoris (RF) muscle flap, which is widely used to cover groin infected vascular grafts, is usually harvested through distal tendon division and an extensive muscle elevation and transposition into the groin wound defect. A case of a vascular prosthetic graft infection in the groin was successfully controlled after coverage with an RF flap that was harvested based on proximal portion mobilization instead of the conventional distal one. This case suggests that the RF muscle flap based on proximal insertion mobilization is a feasible, effective, technically simpler, and less invasive alternative to cover infected vascular grafts in the groin. (J Vasc Surg 2014;-:1-4.)
The vascularized rectus femoris (RF) muscle flap has been proved to be effective to cover infected vascular grafts in the groin,1,2 with a reported graft salvage rate of nearly 80%.2 The technique of harvesting of this flap is well established and involves distal tendon division, through a separate midanterior incision extending over the distal two thirds of the thigh, and muscle mobilization toward the proximal insertion to ensure that the descending branch of the lateral circumflex femoral artery, the flap’s dominant blood supply, is preserved.2 Such a procedure requires almost complete muscle mobilization and is inherently an extensive reconstruction, with a large donor area, that can reduce knee extensor strength up to 20%.3,4 We present a case of a vascular graft infection in the groin that was successfully controlled after coverage with an RF flap harvested after proximal portion mobilization instead of the conventional distal one. CASE REPORT A 74-year-old man, with a history of arterial hypertension and tobacco smoking, was admitted with necrosis of the fourth and fifth right toes and rest pain of the left foot because of bilateral diffuse aortoiliac and femoropopliteal arterial occlusive disease. On the following day, he underwent an aortobifemoral bypass with a bifurcated Dacron graft. The proximal anastomosis was performed on the supraceliac aorta because heavy calcification of the infrarenal aorta precluded safe cross-clamping at that level,
From the Academic Department of Vascular Surgery, Hospital de Santa Maria, Faculty of Medicine, University of Lisbon. Author conflict of interest: none. Reprint requests: Luís Silvestre, MD, Serviço de Cirurgia Vascular, Hospital de Santa Maria, Avenida Prof. Egas Moniz, 1649-035 Lisboa, Portugal (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.02.056
whereas distal anastomoses were both located on the proximal segment of the profunda femoris artery. Simultaneously, a bypass from the right distal prosthetic limb to the below-knee popliteal artery was performed with a reversed ipsilateral great saphenous vein graft, which was tunneled subsartorially. Amputation of the fourth and fifth right toes was also accomplished, and the resulting wound was left open for secondary intention healing. Perioperatively, the patient was empirically medicated with piperacillin/tazobactam, which was maintained for 14 days. He remained hospitalized, without fever or other signs of infection, and both surgical incisions and the right foot wound were healing uneventfully. One month after surgery, a growing lymphocele developed in the right groin and was initially drained with a syringe and needle in a sterile fashion; it subsequently became infected, coursing with cellulitis and purulent drainage. Bacterial culture confirmed infection by Staphylococcus aureus sensitive to methicillin. The purulent collection was immediately drained, irrigation with povidone-iodine solution was performed on a daily basis, and broad-spectrum antibiotic therapy was started with intravenous meropenem, daptomycin, and rifampicin. Computed tomography scanning excluded any collection surrounding the intra-abdominal portion of the graft. One week later, the right groin was still draining purulent fluid (Fig 1, A) and was surgically revised. A longitudinal incision revealed a prosthetic graft that was unincorporated in the groin, although both the proximal part of the graft, as it entered below the inguinal ligament, and the distal part, which included the distal anastomosis on the profunda femoris artery and the proximal anastomosis of the femoropopliteal venous graft on the distal prosthetic limb, were incorporated (Fig 1, B). The sartorius muscle was not identified because it had been damaged during the previous procedure and by the infectious process. After wound débridement (including removal of a pseudosheath around the prosthesis) and irrigation with diluted rifampicin, the proximal segment of the RF muscle was exposed, through the same incision, and its insertion on the anterior inferior iliac spine was divided. The upper part of the muscle was then dissected, rotated medially over the vascular graft, and secured with separate stitches to the underlying inguinal ligament and adductor muscles, covering the entire
1
2 Silvestre et al
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Fig 1. A, Graft infection in the right groin with purulent drainage. The upper scar corresponds to the femoral artery bifurcation exposure incision; the lower one results from ipsilateral great saphenous vein harvesting. B, After skin incision, the prosthetic graft was found to be unincorporated, without anastomosis exposure.
Fig 2. A, After rectus femoris (RF) proximal insertion division (white arrow), the upper portion of the muscle was medially rotated and secured over the vascular prosthetic graft (black arrows). B, Healed groin wound 2 months after the operation. segment of exposed graft (Fig 2, A). The main vascular pedicle of the muscle was observed, preserved, and left without tension. Two closed suction drains were placed near the vascular graft and in the former bed of the RF muscle, and a multilayer primary wound closure was performed.
Postoperatively, the groin wound healed uneventfully (Fig 2, B), and the aforementioned broad-spectrum antibiotic therapy was continued for 6 weeks. Then, it was replaced by oral flucloxacillin and the patient was discharged, maintaining the antibiotic until the sixth postoperative month. He returned to his active normal
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Silvestre et al 3
Fig 3. A, Anatomy of the rectus femoris (RF) muscle: Proximal and distal insertions and relation with the descending branch of the lateral femoral circumflex artery, from which the main vascular pedicle of the muscle derives. B, Standard RF flap. C, RF flap based on proximal insertion mobilization.
lifestyle, without significant functional deficit in the right lower limb, walking without assistance and having no difficulties with sitting or standing. After 7 months of follow-up, he remains well, without clinical or laboratory signs of graft infection.
DISCUSSION Muscle flaps play a decisive role in conservative management of infected vascular grafts in the groin, in conjunction with wound débridement and targeted antimicrobial therapy.1,2,5 The sartorius muscle flap has been considered the flap of choice for groin wound reconstruction because anatomic proximity to the femoral vessels allows easy access and exposure through the same groin incision and a straightforward technical execution.1,5 However, its segmental blood supply mainly from the superficial femoral artery may be compromised in patients with peripheral arterial occlusive disease, whereas the reduced mass of muscle provided by this flap limits its use to smaller and lower risk wounds.1,5 Conversely, in case of larger complicated groin wounds, the RF flap is more effective than the sartorius flap1,2 because the RF is a long bulky muscle, with a wide arc of rotation and a robust blood supply from the deep femoral artery (Fig 3, A) that provides an effective coverage to a larger wound area. The standard technique to harvest this flap is well established and involves distal insertion division through a separate thigh incision and proximal mobilization through a tunnel into the débrided groin wound (Fig 3, B). The proximal portion of the muscle is not elevated to preserve its main vascular supply,1,2
which derives from the descending branch of the lateral femoral circumflex artery, either as a single dominant pedicle (in about 60% of the cases) or with a codominant pedicle from the oblique branch of the lateral femoral circumflex artery (in the remaining 40%).6 These pedicles reach the deep surface of the muscle approximately 8 cm below the inguinal ligament. Such muscle mobilization requires an inherently extensive dissection that leaves a large donor area and can reduce knee extensor strength up to 20%.3,4 Alternative flaps, including those based on rectus abdominis, gracilis, or tensor fascia lata muscles, require more complex harvesting techniques, through separate incisions, with the corresponding donor site morbidity. For this case, instead of by the standard technique, the RF muscle flap was harvested based on a proximal insertion division and mobilization (Fig 3, C). This technique allowed mobilization of a muscle segment long enough to cover the unincorporated prosthetic graft, through the same groin incision, and simultaneous preservation of the main vascular pedicle. Thus, the extensive harvest that would be necessary to perform a standard RF flap was avoided and replaced by a less invasive and technically simpler procedure, which is similar to harvesting of the sartorius flap but provides a larger amount of wellvascularized muscle. To our knowledge, this technique of RF flap harvest has not been previously described, and even if it has, it is surely not widespread in the medical literature on the management of infected arterial grafts. This case suggests, however, that the RF muscle flap based on proximal insertion mobilization is a feasible, effective, technically simpler,
4 Silvestre et al
and less invasive procedure than the standard RF flap. It is an attractive alternative to cover vascular grafts in the groin, particularly useful in those cases in which the wound defect is not large but the sartorius muscle is unavailable or insufficient for such wound coverage to be performed. REFERENCES 1. Fischer JP, Mirzabeigi MN, Sieber BA, Nelson JA, Wu LC, Kovach SJ, et al. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg 2013;66: 1396-404. 2. Alkon JD, Smith A, Losee JE, Illig KA, Green RM, Serletti JM. Management of complex groin wounds: preferred use of the rectus femoris flap. J Plast Reconstr Surg 2005;115:776-83.
JOURNAL OF VASCULAR SURGERY --- 2014
3. Sbitany H, Koltz PF, Girotto JA, Vega SJ, Langstein HN. Assessment of donor-site morbidity following rectus femoris harvest for infrainguinal reconstruction. Plast Reconstr Surg 2010;126:933-40. 4. Daigeler A, Dodic T, Awiszus F, Schneider W, Fansa H. Donor-site morbidity of the pedicled rectus femoris muscle flap. Plast Reconstr Surg 2005;115:786-92. 5. Landry GJ, Carlson JR, Liem TK, Mitchell EL, Edwards JM, Moneta GL. The sartorius muscle flap: an important adjunct for complicated femoral wounds involving vascular grafts. Am J Surg 2009;197:655-9. 6. Wong CH, Ong YS, Wei FC. Revisiting vascular supply of the rectus femoris and its relevance in the harvest of the anterolateral thigh flap. Ann Plast Surg 2013;71:586-90.
Submitted Jan 14, 2014; accepted Feb 25, 2014.
The vascularized rectus femoris (RF) muscle flap has been proved to be effective to cover infected vascular grafts in the groin,1,2 with a reported graft salvage rate of nearly 80%.2 The technique of harvesting of this flap is well established and involves distal tendon division, through a separate midanterior incision extending over the distal two thirds of the thigh, and muscle mobilization toward the proximal insertion to ensure that the descending branch of the lateral circumflex femoral artery, the flap’s dominant blood supply, is preserved.2 Such a procedure requires almost complete muscle mobilization and is inherently an extensive reconstruction, with a large donor area, that can reduce knee extensor strength up to 20%.3,4 We present a case of a vascular graft infection in the groin that was successfully controlled after coverage with an RF flap harvested after proximal portion mobilization instead of the conventional distal one. CASE REPORT A 74-year-old man, with a history of arterial hypertension and tobacco smoking, was admitted with necrosis of the fourth and fifth right toes and rest pain of the left foot because of bilateral diffuse aortoiliac and femoropopliteal arterial occlusive disease. On the following day, he underwent an aortobifemoral bypass with a bifurcated Dacron graft. The proximal anastomosis was performed on the supraceliac aorta because heavy calcification of the infrarenal aorta precluded safe cross-clamping at that level,
From the Academic Department of Vascular Surgery, Hospital de Santa Maria, Faculty of Medicine, University of Lisbon. Author conflict of interest: none. Reprint requests: Luís Silvestre, MD, Serviço de Cirurgia Vascular, Hospital de Santa Maria, Avenida Prof. Egas Moniz, 1649-035 Lisboa, Portugal (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.02.056
whereas distal anastomoses were both located on the proximal segment of the profunda femoris artery. Simultaneously, a bypass from the right distal prosthetic limb to the below-knee popliteal artery was performed with a reversed ipsilateral great saphenous vein graft, which was tunneled subsartorially. Amputation of the fourth and fifth right toes was also accomplished, and the resulting wound was left open for secondary intention healing. Perioperatively, the patient was empirically medicated with piperacillin/tazobactam, which was maintained for 14 days. He remained hospitalized, without fever or other signs of infection, and both surgical incisions and the right foot wound were healing uneventfully. One month after surgery, a growing lymphocele developed in the right groin and was initially drained with a syringe and needle in a sterile fashion; it subsequently became infected, coursing with cellulitis and purulent drainage. Bacterial culture confirmed infection by Staphylococcus aureus sensitive to methicillin. The purulent collection was immediately drained, irrigation with povidone-iodine solution was performed on a daily basis, and broad-spectrum antibiotic therapy was started with intravenous meropenem, daptomycin, and rifampicin. Computed tomography scanning excluded any collection surrounding the intra-abdominal portion of the graft. One week later, the right groin was still draining purulent fluid (Fig 1, A) and was surgically revised. A longitudinal incision revealed a prosthetic graft that was unincorporated in the groin, although both the proximal part of the graft, as it entered below the inguinal ligament, and the distal part, which included the distal anastomosis on the profunda femoris artery and the proximal anastomosis of the femoropopliteal venous graft on the distal prosthetic limb, were incorporated (Fig 1, B). The sartorius muscle was not identified because it had been damaged during the previous procedure and by the infectious process. After wound débridement (including removal of a pseudosheath around the prosthesis) and irrigation with diluted rifampicin, the proximal segment of the RF muscle was exposed, through the same incision, and its insertion on the anterior inferior iliac spine was divided. The upper part of the muscle was then dissected, rotated medially over the vascular graft, and secured with separate stitches to the underlying inguinal ligament and adductor muscles, covering the entire
1
2 Silvestre et al
JOURNAL OF VASCULAR SURGERY --- 2014
Fig 1. A, Graft infection in the right groin with purulent drainage. The upper scar corresponds to the femoral artery bifurcation exposure incision; the lower one results from ipsilateral great saphenous vein harvesting. B, After skin incision, the prosthetic graft was found to be unincorporated, without anastomosis exposure.
Fig 2. A, After rectus femoris (RF) proximal insertion division (white arrow), the upper portion of the muscle was medially rotated and secured over the vascular prosthetic graft (black arrows). B, Healed groin wound 2 months after the operation. segment of exposed graft (Fig 2, A). The main vascular pedicle of the muscle was observed, preserved, and left without tension. Two closed suction drains were placed near the vascular graft and in the former bed of the RF muscle, and a multilayer primary wound closure was performed.
Postoperatively, the groin wound healed uneventfully (Fig 2, B), and the aforementioned broad-spectrum antibiotic therapy was continued for 6 weeks. Then, it was replaced by oral flucloxacillin and the patient was discharged, maintaining the antibiotic until the sixth postoperative month. He returned to his active normal
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Silvestre et al 3
Fig 3. A, Anatomy of the rectus femoris (RF) muscle: Proximal and distal insertions and relation with the descending branch of the lateral femoral circumflex artery, from which the main vascular pedicle of the muscle derives. B, Standard RF flap. C, RF flap based on proximal insertion mobilization.
lifestyle, without significant functional deficit in the right lower limb, walking without assistance and having no difficulties with sitting or standing. After 7 months of follow-up, he remains well, without clinical or laboratory signs of graft infection.
DISCUSSION Muscle flaps play a decisive role in conservative management of infected vascular grafts in the groin, in conjunction with wound débridement and targeted antimicrobial therapy.1,2,5 The sartorius muscle flap has been considered the flap of choice for groin wound reconstruction because anatomic proximity to the femoral vessels allows easy access and exposure through the same groin incision and a straightforward technical execution.1,5 However, its segmental blood supply mainly from the superficial femoral artery may be compromised in patients with peripheral arterial occlusive disease, whereas the reduced mass of muscle provided by this flap limits its use to smaller and lower risk wounds.1,5 Conversely, in case of larger complicated groin wounds, the RF flap is more effective than the sartorius flap1,2 because the RF is a long bulky muscle, with a wide arc of rotation and a robust blood supply from the deep femoral artery (Fig 3, A) that provides an effective coverage to a larger wound area. The standard technique to harvest this flap is well established and involves distal insertion division through a separate thigh incision and proximal mobilization through a tunnel into the débrided groin wound (Fig 3, B). The proximal portion of the muscle is not elevated to preserve its main vascular supply,1,2
which derives from the descending branch of the lateral femoral circumflex artery, either as a single dominant pedicle (in about 60% of the cases) or with a codominant pedicle from the oblique branch of the lateral femoral circumflex artery (in the remaining 40%).6 These pedicles reach the deep surface of the muscle approximately 8 cm below the inguinal ligament. Such muscle mobilization requires an inherently extensive dissection that leaves a large donor area and can reduce knee extensor strength up to 20%.3,4 Alternative flaps, including those based on rectus abdominis, gracilis, or tensor fascia lata muscles, require more complex harvesting techniques, through separate incisions, with the corresponding donor site morbidity. For this case, instead of by the standard technique, the RF muscle flap was harvested based on a proximal insertion division and mobilization (Fig 3, C). This technique allowed mobilization of a muscle segment long enough to cover the unincorporated prosthetic graft, through the same groin incision, and simultaneous preservation of the main vascular pedicle. Thus, the extensive harvest that would be necessary to perform a standard RF flap was avoided and replaced by a less invasive and technically simpler procedure, which is similar to harvesting of the sartorius flap but provides a larger amount of wellvascularized muscle. To our knowledge, this technique of RF flap harvest has not been previously described, and even if it has, it is surely not widespread in the medical literature on the management of infected arterial grafts. This case suggests, however, that the RF muscle flap based on proximal insertion mobilization is a feasible, effective, technically simpler,
4 Silvestre et al
and less invasive procedure than the standard RF flap. It is an attractive alternative to cover vascular grafts in the groin, particularly useful in those cases in which the wound defect is not large but the sartorius muscle is unavailable or insufficient for such wound coverage to be performed. REFERENCES 1. Fischer JP, Mirzabeigi MN, Sieber BA, Nelson JA, Wu LC, Kovach SJ, et al. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg 2013;66: 1396-404. 2. Alkon JD, Smith A, Losee JE, Illig KA, Green RM, Serletti JM. Management of complex groin wounds: preferred use of the rectus femoris flap. J Plast Reconstr Surg 2005;115:776-83.
JOURNAL OF VASCULAR SURGERY --- 2014
3. Sbitany H, Koltz PF, Girotto JA, Vega SJ, Langstein HN. Assessment of donor-site morbidity following rectus femoris harvest for infrainguinal reconstruction. Plast Reconstr Surg 2010;126:933-40. 4. Daigeler A, Dodic T, Awiszus F, Schneider W, Fansa H. Donor-site morbidity of the pedicled rectus femoris muscle flap. Plast Reconstr Surg 2005;115:786-92. 5. Landry GJ, Carlson JR, Liem TK, Mitchell EL, Edwards JM, Moneta GL. The sartorius muscle flap: an important adjunct for complicated femoral wounds involving vascular grafts. Am J Surg 2009;197:655-9. 6. Wong CH, Ong YS, Wei FC. Revisiting vascular supply of the rectus femoris and its relevance in the harvest of the anterolateral thigh flap. Ann Plast Surg 2013;71:586-90.
Submitted Jan 14, 2014; accepted Feb 25, 2014.
