Treatment of Deep Infection Following Thoracic Aorta Graft Replacement Without Graft Removal

The traditional approach for patent and exposed and infected infrainguinal bypass grafts in the groin has included wide operative debridement and secondary or delayed primary closure. However, this has been associated with significant risk of further contamination and length of stay. The authors reviewed their experience using the wide debridement, sartorius muscle flap transposition, and primary wound closure as an alternative. During the past 5 years, they have had 50 patients with major wound necrosis or infection in the groin or thigh with the graft or native artery being exposed after debridement. This group included 28 men; 74% of the patients had hypertension, 58% had diabetes, and 20% had renal failure. The grafts were split evenly between native vein and prosthetic material. After wide debridement, closure was performed by the vascular surgeon using the sartorius muscle flap. Postoperatively, there was an 8% major amputation rate and a 12% mortality rate in the first 30 days. One patient developed a pseudoaneurysm 5 weeks after placement of the flap. This patient underwent removal of the infected polytetrafluoroethylene graft with ligation of the common femoral artery. None of the procedures have resulted in further systemic or graft sepsis. None have resulted in arterial or graft blowout. Follow-up was for an average of 18 months. Closure of groin and thigh wounds with exposed bypass graft or native artery can be safely performed with the sartorius muscle flap with excellent results. The length of stay of these patients compared to historical controls is acceptable. Furthermore, the chance of infection of the native artery or bypass may be reduced. Familiarity with this simple technique can be a valuable tool for the vascular surgeon.

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“…4,5 This approach has, however, been predominantly discussed in relation to thoracic, abdominal, and distal leg grafts.…”

Section: Discussionmentioning

confidence: 99%

Early Transposition of the Sartorius Muscle for Exposed Patent Infrainguinal Bypass Grafts

Schutzer¹,

Hingorani²,

Ascher³

et al. 2005

Vasc Endovascular Surg

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“…The incidence of surgical site infections ranges from 2% to 13% for coronary artery bypass graft (CABG) surgery [3][4][5][6][7] and from 3% to 11% for valve replacement surgery 3,8,9 . Staphylococcus aureus and coagulase-negative staphylococci account for over 50% of the organisms associated with surgical site infections.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Postoperative Chest Wound Infections Due to Gram-negative Bacteria in Cardiac Surgery Patients

Garey¹,

Kumar²,

Dao³

et al. 2006

Journal of Chemotherapy

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Gram-negative bacteria account for up to 35% of postoperative sternal wound infections (SWI) in patients undergoing cardiac surgery. Despite this, risk factors for Gram-negative SWI have not been investigated. The objective of this study was to define risk factors associated with Gram-negative SWI in patients undergoing cardiac surgery. 2590 patients undergoing cardiac surgery between 2002-2005 were prospectively monitored for development of SWI. Patient, operative, and post-operative risk factors were compared among patients that developed Gram-negative SWI and Gram-positive SWI to uninfected controls using univariate and multivariate analysis. A p < 0.05 was considered significant. Surgical site infections developed in 152 (5.9%) patients. Isolates were recovered from the sternum for 128 (5.0%) patients, from the leg donor site for 19 (0.73%) patients, and from the sternum and donor site for 5 (0.19%) patients. Gram-positive pathogens were isolated from 83 (3.3%) patients, Gram-negative pathogens from 42 (1.6%) patients, and mixed pathogens from 27 (1.0%) patients. Hospital admission greater than 48 hours before surgery (OR: 2.25; 95% CI: 1.11 - 4.58), ventilator-dependency preoperatively (OR: 5.32 95% CI: 2.22 - 12.75), and thoracentesis procedure postoperatively (OR: 3.71; 95% CI: 1.45 - 9.49) and diabetes (OR: 2.04; 95% CI: 1.17 - 3.55) were identified as significant risk factors for SWI due to Gram-negative bacteria using multivariate logistic regression. Diabetes, increased age, and peripheral vascular disease were identified as significant risk factors for SWI due to Gram-positive bacteria (p < 0.05, each). The risk factors associated with Gram-negative SWI differed significantly from those associated with Gram-positive SWI. Risk factors associated with Gram-negative SWI were identified. Unique interventions may be necessary to prevent Gram-negative SWI in cardiac surgery patients.

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“…However, with older patient and with higher comorbidities, the above modality has been associated with 25–35% mortality 11 12. Further location of the graft such as ascending aorta, arch of the aorta and descending thoracic aorta has also been considered difficult for resection and these patients have been treated conservatively 13. In a previous series of five patients with aortic graft infection being treated conservatively with long-term antibiotics, all patients were reported to be alive and without complications with a median survival of 32 months and a maximum of 6 years 14.…”

Section: Discussionmentioning

confidence: 99%

Vascular graft infections and role of PET/CT in patients with persistent bacteraemia

Shahani

2015

BMJ Case Reports

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Prosthetic vascular graft infection although a rare complication of vascular reconstruction surgery; has been associated with significant morbidity and mortality. The author presents two patients with prosthetic aortic graft presenting as fever and methicillin sensitiveStaphylococcus aureusbacteraemia without any other localising sign of infection. Both patients had a history of postoperative wound infection after their graft placement. Patients remained persistently bacteraemic on appropriate antimicrobial therapy making the clinician suspicious of a vascular graft infection. A [18 F] fluoro-2-deoxy-dglucose positron emission tomography associated to CT scan was used to identify the prosthetic vascular graft infection and since both patients were high-risk surgical candidates, a conservative medical approach was used. They were treated with 6 weeks of nafcillin and rifampin, followed by long-term doxycycline for suppression. This highlights the importance of considering vascular graft infection in patients with recurrent and persistent bacteraemia despite adequate therapy.

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Treatment of Deep Infection Following Thoracic Aorta Graft Replacement Without Graft Removal

Cited by 23 publications

References 12 publications

Early Transposition of the Sartorius Muscle for Exposed Patent Infrainguinal Bypass Grafts

Early Transposition of the Sartorius Muscle for Exposed Patent Infrainguinal Bypass Grafts

Risk Factors for Postoperative Chest Wound Infections Due to Gram-negative Bacteria in Cardiac Surgery Patients

Vascular graft infections and role of PET/CT in patients with persistent bacteraemia

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