Mortality and limb loss with infected infrainguinal bypass grafts

Abstract

A recent experience with infrainguinal graft infections was reviewed in an effort to identify factors related to limb loss and mortality. The records of 32 patients who had operative treatment of 33 episodes of infrainguinal graft infection between 1978 and 1985 were reviewed to evaluate the effects of 20 factors possibly affecting outcome. The amputation rate was 79%. Of the 20 factors studied, only the presence of overt limb sepsis was associated with the need for amputation, with 100% of patients having limb sepsis requiring amputation vs. 72% of patients without limb sepsis (p = 0.03). The in-hospital mortality rate was 22%. Eighty-six percent of the deaths were due to ongoing sepsis. Again, a single factor was associated with death. Five of the 12 patients (42%) in whom preservation of axial flow was attempted died in contrast to only 2 of 20 patients (10%) who did not have attempted arterial reconstruction (p = 0.04). Limb salvage did not occur in any of the patients in whom preservation of axial flow was attempted and nine required above-knee amputation. Thirteen of the remaining 20 patients had occluded femoral vessels either because of operative ligation (nine) or previous thrombosis (four). Above-knee amputations healed in all but one of these 13 patients. Determined attempts at increasing limb preservation were associated with no improvement in amputation rate or level and were accompanied by an unacceptably high mortality rate. Aggressive control of sepsis through the early amputation of septic limbs after graft removal may improve survival without further detriment to limb preservation.

Neutrophil Adhesion to Vascular Prosthetic Surfaces Triggers Nonapoptotic Cell Death

“…When these events unfold, they are associated with death rates of 30% to 50% and limb loss in approximately one third to one half of survivors. [1][2][3][4] The epidemiology of vascular prosthetic infections supports the hypothesis that implant infections occur because of contamination of the prosthesis with small numbers of bacteria that find the prosthetic surface favorable for survival. 5,6 The recognition of matrix proteins that coat implant surfaces by bacterial adhesion receptors 7 structure of these surfaces, which may provide bacteria with niches in which to hide; and the fact that material-adherent bacteria become encapsulated in a secreted glycocalyx 8,9 all contribute to enhanced bacterial survival in the prosthetic graft milieu.…”

“…For transmission electron microscopy, neutrophils were fixed in Trump McDowell fixative containing 3.7% formaldehyde and 10% glutaraldehyde in a phosphate buffer (pH 7.3) and postfixed in 1% OsO 4 . After dehydration, the samples were preinfiltrated with acetone, infiltrated with Spurr's epoxy, and embedded.…”

Cyanoacrylate for Wound Closure in Prosthetic Vascular Graft Surgery to Prevent Infections Through Contamination

“…The mortality rate associated with a PVGI after aortoiliac reconstruction has been reported to range from 25% to 88%, and the amputation rate may be as high as 80% after an infrainguinal vascular reconstruction. 4,5 The factors predisposing to PVGI may include the type of surgery and approach, the presence of ulcers or gangrene, and the graft material used. 1 The incidence of PVGI is estimated to be 0.5%-6%.…”

Infection-Related Exposure of the Lower Anastomosis of Femorodistal Bypass: Salvage through Use of Pedicle Muscle Flaps

“…4,5 In cases involving systemic infection, bypass removal is mandatory, often in association with amputation or bypass using a different pathway and anastomotic sites. 4,6 In cases involving localized infection of the distal anastomosis, the same solutions may be adopted but other options are available, including rerouting the bypass to another patent artery and conservative treatment.…”