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Comparison of Muscle Flaps and Delayed Secondary Intention Wound Healing for Infected Lower Extremity Arterial Grafts
Comparison of Muscle Flaps and Delayed Secondary Intention Wound Healing for Infected Lower Extremity Arterial Grafts Keith D. Calligaro, MD, Frank J. Veith, MD, Clifford M. Sales, MD, Matthew J. Dougherty, MD, Ronald P. Savarese, MD, and D.A. DeLaurentis, MD, New York, New York, and Philadelphia, Pennsylvania
Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n = 8) or DSI (n = 12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft. Average hospital and intensive care stay as well as hospital costs were not significantly different for the two groups. The majority of infected, patent lower extremity grafts with intact anastomoses can be successfully preserved with either MFs or DSI wound healing. We found no significant difference in outcome or cost for the two methods of treatment. (Ann Vasc Surg 1994;8:31-37.)
From the Division of Vascular Surgery, Montefiore Medical Center~Albert Einstein College of Medicine (F.J.V. and C.M.S.), New York, N.Y., and the Section of Vascular Surgery, Pennsylvania Hospital~University of Pennsylvania School of Medicine (K.D.C., M.J.D., R.P.S., and D.A.D.), Philadelphia, Pa. Supported by the John F. Connelly Foundation, the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, and New York Institute for Vascular Studies. Presented at the Eighteenth Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993. Reprint requests: Keith D. Calligaro, MD, 700 Spruce St., Ste. 101, Philadelphia, PA 19106.
Traditional treatment of arterial graft infections has included graft excision to prevent anastomotic hemorrhage, nonhealing wounds, and systemic sepsis. Amputation rates of 27% to 79% have been reported after routine excision of infected lower extremity arterial grafts. ~-5 We agree that graft excision is mandatory when a patient presents with an infected graft that is occluded or associated with a disrupted anastomosis or systemic sepsis. However, complete preservation of selected infected extracavitary arterial grafts can result in equivalent mortality rates and improved 31
32
Annals of Vascular Surgery
Calligaro et al.
a m p u t a t i o n rates c o m p a r e d w i t h r o u t i n e graft e x c i s i o n . 6-s Selective g r a f t p r e s e r v a t i o n c a n b e s u c c e s s f u l l y a c c o m p l i s h e d u s i n g a g g r e s s i v e operative w o u n d d e b r i d e m e n t , f r e q u e n t dressing c h a n g e s , a n d d e l a y e d s e c o n d a r y i n t e n t i o n (DSI) w o u n d h e a l i n g . 69
Table I. Type of i n f e c t e d b y p a s s Bypass
No.
Femorodistal Femoral interposition/patch Iliac-distal Popliteal-distal Femorofelnoral crossover
17 6 2 2 1 28
P l a c e m e n t of a r o t a t i o n a l m u s c l e flap ( M F ) h a s b e e n p r o p o s e d as a n a l t e r n a t i v e m e t h o d to achieve successful w o u n d healing a n d graft preservation) ~ T h e p r o p o s e d a d v a n t a g e s of M F s i n c l u d e f a s t e r w o u n d closure, s h o r t e r l e n g t h of h o s p i t a l i z a t i o n , a n d h i g h e r r a t e s of g r a f t p r e s e r vation. Disadvantages in c lu d e the potential comp l i c a t i o n s a n d a d d e d cost of a n o t h e r m a j o r o p e r a t i o n . T h e p u r p o s e of t h i s r e p o r t w a s to c o m p a r e t h e o u t c o m e a n d c o s t of t r e a t i n g i n f e c t e d l o w e r extremity arterial grafts in our patients u s i n g selective g r a f t p r e s e r v a t i o n w i t h e i t h e r m u s c l e flaps ( M F s ) or DSI h e a l i n g .
PATIENTS AND METHODS Twenty-eight consecutive patients with infected l o w e r e x t r e m i t y a r t e r i a l grafts w h o fulfilled crite-
T a b l e I I A . A t t e m p t e d h e a l i n g b y DSI: S u c c e s s f u l c o m p l e t e p r e s e r v a t i o n of i n f e c t e d g r a f t s Age
Interval (mo) Location
ICU
stay (days)
stay (days)
Operation
77/M
120 <1
R. CFA
Salmonella
30
9
-
3
$33,383
<1
L. CFA
Bacteroides fragilis
29
7
--
12
$32,326
62/F
Aobi-DFA Dacron R. CFA PTFE interposition L. CFA-R. DFA PTFE L. CFA-POP PTFE
<1
L. CFA
51
8
--
44
$50,980
73/M
L. SFA-POP PTFE
<1
L. SFA
15
8
-
27
$19,660
72/F
R. CFA-TIB vein R. CFA-TIB PTFE R. CFA PTFE patch
37 < 1 <1
R. TIB
Staphylococcus aureus, S. faecalis Pseudornonas aeruginosa S. faecalis
23
10
--
18
$27,720
21
12
--
20
$27,080
L. CFA-POP PTFE Thrombectomy R. CFA-L. CFA PTFE Thrombectomy Ao-L. CFA PTFE L. CFA-POP PTFE R. CFA-TIB PTFE Thrombectomy L. CFA-POP PTFE L, EIA-POP PTFE
<1 <1 <1
L. CFA
S. faecalis, Escherichia coli, Proteus mirabitis, Bacteroides fragilk S. aureus, Acinetobacter S. aureus, Escherichia coli
124
4
Debride • 2
12
$116,710
31
3
--
3
$30,830
--
15
$38,160
<1 <1 132
12
$60,940
R. POP-TIB vein
<1
67/F
51/F 75/M
63/F
76/F 69/M
60/M Average
<1 <1
R. CFA
R. CFA
Addit'l O.R.
Follow-up (mo) Total cost*
(yr)/sex
68/F
Bacteria
Hosp.
L. CFA
S. faecalis, Motganella morgagni
35
lO
R. CFA
S. aureus
56
30
L. POP
S. aureus, Pseudomonas aeruginosa S. epidermidis
28
8
Debride • 2
7
$35,390
11
3
--
60
$13,430
37.8
9.3
R. TIB
STSG
$40,550
Ao ~ aorta; CFA = common femoral artery; DFA = deep femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any infrapopliteal artery; EIA ~ external iliac artery. *Total costs included anesthesiologist's, surgeon's, and operating room fees in addition to the daily cost of a semiprivate and ICU bed.
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Selected preservation of infected lower extremity grafts
ria for selective complete graft preservation were treated b e t w e e n J a n u a r y 1985 and December 1991 at Montefiore Medical Center in New York and at Pennsylvania Hospital in Philadelphia. Their ages ranged from 51 and 85 years (average 70 years). The 28 patients fulfilled our criteria for att e m p t e d selective graft preservation: (1) the graft was patent, (2) the a n a s t o m o s e s were intact, a n d (3) the patient s h o w e d no systemic sepsis. 6-~ Patients w h o p r e s e n t e d w i t h an infected graft that was occluded or h a d signs of systemic sepsis or a disrupted anastomosis u n d e r w e n t graft excision. 6-8 The types of infected grafts were 19 polytetrafluoroethylene (PTFE), eight autologous vein, and one Dacron graft. The indication for the bypass was limb salvage in 24 patients, disabling calf claudication in two patients, and repair of an a n a s t o m o t i c p s e u d o a n e u r y s m in two patients. The types of bypasses are listed in Table I. M1 patients had p u r u l e n t drainage from the infected w o u n d w i t h pus in contact w i t h an intact anastomosis. M a n a g e m e n t of these 28 infected grafts included a t t e m p t e d w o u n d healing by DSI in 18 patients (Table II) and a d v a n c e m e n t of a rotational MF in 10 patients (Table III). Choice of w o u n d m a n a g e m e n t was m a d e in a n o n r a n d o m -
33
ized fashion by the attending surgeon. All patients were initially treated by aggressive operative w o u n d d e b r i d e m e n t and observation in the intensive care unit until the graft were covered by p l a c e m e n t of MFs or by granulation tissue (DSI). Initial d e b r i d e m e n t s were performed in the operating r o o m w h e r e all infected soft tissue and a n y e x u d a t e on the graft could be excised carefully. Patients received appropriate intravenous antibiotics for at least 6 weeks based on w o u n d and blood cultures. Of the 18 w o u n d s allowed to heal by DSI, repeated operative d e b r i d e m e n t s were p e r f o r m e d until h e a l t h y granulation was present (Table II). This was s u p p l e m e n t e d by frequent bedside debridements. Moist dressings were applied three times a day using w e t - t o - d r y antibiotic dressings. Ten patients were treated by a d v a n c e m e n t of a rotational MF o n t o the exposed graft (Table III). MFs were placed at the time of the first operative w o u n d d e b r i d e m e n t in 8 of i0 patients. In the other two patients the flaps were advanced on the second and third day after the initial debridement. There were four sartorius, three gracilis, one s e m i m e m b r a n o u s , one gastrocnemius, and one rectus abdominis MF. E s t i m a t e d costs of treating the graft infections using MFs or DSI included surgeons' and anesthesiologists' fees, operating r o o m expenses, and
T a b l e IIB. A t t e m p t e d healing by DSI: Unsuccessful preservation of infected grafts Age (yr)/sex
Hosp. stay (days)
Operation
Interval (too)
Location
Bacteria
55/M
L. S F A - P O P PTFE
24
L. S F A
Staphylococcus aureus
14
72/F
R. C F A - P O P PTFE R. SFA-TIB v e i n Thrombectomy L. C F A - P O P v e i n L. C F A - P O P PTFE
39 < 1 < 1 < 1 < 1
R. SFA
Escherichia coli
L. C F A
S. aureus
51/F
51/M
L. CFA-POP Dacron
62/F
L. CFA-POP PTFE & L. POP-TIB vein L. DFA-POP vein
78/F
ICU stay (days)
Follow-up Addit'l O.R.
(too)
Results
6
-
35
21
4
--
4
25
3
--
11
Recurrent abscess (31 m o ) ( g r a f t e x c i s i o n , occluded) Healed wound, thrombosed graft Nonhealing w o u n d (5 m o )
3
L. CFA
S. aureus
66
12
Debride • 1
24
<1
L. TIB
S. epidermidis
NA
16
Excise graft
6
<1
L. DFA S. viridans,
NA
5
--
<1
(graft excision, EIA-TIB PTFE) Nonhealing wound (2 wk) (graft excision) Hemorrhage (3 wk); death (respir) Death (MI)
Klebsiella CFA = c o m m o n femoral artery; DFA infrapopliteal artery.
deep femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any
34
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Calligaro et al.
Table IliA. Attempted healing by MF placement: Successful complete preservation of infected grafts Age (yr)/sex 67/F
Operation L. CFA PTFE Embolectomy X
85/M
50/M 71/M
67/M
73/F 73/F
73/M
Interval (too) Location 22, 1
L. CFA Staphylococcus
R. EIA-L CFA PTFE
Addit'l O.R.
FoUow-up (mo)
Type of muscle flap
Total cost*
16
8
Debride x 1
60
Rectus
$26,435
11
2
-
12
Semimembranous
$15,464
L. CFA S. epidermidis,
28
13
-
8
Gracilis
$40,365
S. aureus R. CFA Bacteroides cloaca
15
5
--
6
Gracilis
$21,288
R. POP S. aureus
23
6
Debride x 1
7
Gastrocnemius
$31,128
R. CFA S. aureus, S,
32
8
--
24
Sartorius
$39,662
39
12
Debride x 1
3
Sartorius
$52,490 t
106
10
Debride x 1
5
Sartorius
$109,520 t
33.7
8
2
L. CFA PTFE interposition R. CFA-POP vein Thrombectorny R. CFA-POP PTFE L. CFA PTFE interposition R. CFA-TIB vein L. CFA-POP PTFE R. CFA-POP PTFE R. CFA-POP vein R. CFA-POP vein R. SFA-TIB vein Vein p a t c h SFA
Bacteria
Hosp. ICU stay stay (days) (days)
aureus 1 8
R. POP S. epidermidis,
Pseudomonas aeruginosa
2 2 4 < 1 < 1 48 < 1 < 1 < 1 < 1
< 1
faecalis R. SFA S. epidermidis, S. faecalis, Pseudomonas aeruginosa, Escherichia coli R. EIA S. faecalis, Bacteroides fra#ilis
Average
$42,044
NOTE: Of the 8 patients treated with MFs who had successfully preserved arterial grafts, 6 had the flap placed at the same time as the
first operative debridement. Two patients had the flap placed several days after the first debridement. Two patients had additional debridements when the flaps necrosed. CFA = common femoral artery; POP = popliteal artery; TIB = any inffapopliteal artery. *Total costs included anesthesiologist's, surgeon's, and operating room fees in addition to the daily cost of a semiprivate and ICU bed. tFlap necrosis (rectus flap + STSG-healed).
Table IIIB. Attempted healing by MF placement: Unsuccessful preservation of infected grafts Age (yr)/sex 81/M 53/F
Operation* R. SFA-TIB vein L. CFA-POP PTFE L. CFA PTFE interposition
Interval (too) Location
Bacteria
Hosp. ICU stay stay Addit'l Follow-up (days) (days) O.R. (too)
< 1
R. SFA
S. aureus
NA
3
--
< 1
< 1
L. CFA
S. epidermidis, Morganella morgagnL Proteus mirabills, d i p h t h e -
NA
16
--
2
roides
Type of muscle flap Gracilis Sartorius
Results D e a t h (MI o n postop, day 3) Death (sepsis) (total graft excision, above -knee amputation, hip disartic, death)
NOTE: The two patients with MFs who died had the flap placed at the same time as the first operative debridement. EIA = external iliac artery; CFA = common femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any infrapopliteal artery.
Vol. 8, No. 1 1994
the daily cost of intensive care unit beds and semiprivate rooms. Patients who died or suffered complications were not included in this cost analysis. Patients who died early after presentation of their infection would have unfairly lowered the average length of hospital stay and overall costs of a particular form of treatment. Additionally, certain complications such as a myocardial infarction or pneumonia would have directly affected the length of hospitalization and overall costs of a particular treatment regardless of the method chosen to achieve w o u n d healing. Expenses were averaged for the two medical centers when calculating the cost to each patient. Surgeons' fees were based on 1991 Medicare Mlowed Fee Schedules. RESULTS Mortality. Selective complete graft preservation in these 28 patients resulted in a hospital mortality of 14% (4/28). Two patients died from postoperative myocardial infarctions: one on the third postoperative day after MF placement and one who was being treated by DSI wound healing and died on the fifth day after the initial operative wound debridement. Another patient treated by DSI hemorrhaged from the distal anastomosis of a popliteal-anterior tibial vein graft 3 weeks after presentation and died of respiratory complications 5 months later while still hospitalized. The fourth patient died after being treated with a sartorius MF for a groin infection involving a PTFE interposition graft of the common femoral artery. Seven days later the PTFE graft and MF were excised because of a nonhealing wound and systemic sepsis. The patient died 2 months later of septic complications. W o u n d healing a n d g r a f t preservation. In the 24 surviving patients, complete graft preservation was successfully accomplished in 20 (83%) cases with follow-up averaging 24 months (range 8 to 64 months). The other four patients required graft excision for nonhealing wounds in two cases (after 2 weeks and 5 months of aggressive wound care), for graft thrombosis 2 weeks after initial treatment of the infection in one patient, and for a recurrent abscess 3 years later in the remaining case. Initial treatment of the original graft infection was by DSI w o u n d healing in all four patients. The wounds in the first three patients were never considered acceptable for placement of a muscle flap because of persistent infected tissue and a lack of healthy granulation tissue. Two other patients initially treated with sartorius MFs developed flap necrosis and were treated
Selected preservation of infected lower extremity grafts
35
by excision of the necrotic flap and placement of new flaps. Both patients ultimately did well with long-term preservation of the grafts. L i m b loss. Although four infected grafts in the 24 surviving patients required excision, no patient required a major amputation. One of the four patients required a secondary bypass; the other three patients maintained a viable limb without requiring additional revascularization. Because the grafts in the remaining 20 patients were patent and successfully preserved, none of the threatened extremities required additional revascularization procedures or amputation. Costs a n d length o f hospitalization. Hospital costs and length of hospital stay were analyzed in the 20 patients whose grafts were successfully preserved after long-term follow-up (Tables IIA and IIIA). The average hospital stay, ICU stay, and cost for the eight patients treated by MFs averaged 33.7 days, 8.0 days, and $42,044 compared with 37.8 days, 9.3 days, and $40,550 for the 12 patients treated by DSI (p > 0.05). Bacteriology. Both gram-positive and gramnegative bacteria were cultured from 10 wounds, only gram-positive bacteria from 13 wounds, and only gram-negative bacteria from five wounds (Table IV). Similar rates of graft preservation and wound healing were accomplished regardless of
Table IV. Bacteriology of 28 infected grafts treated by selective graft preservation*
Gram-positive bacteria Staphylococcus (19) aureus epidermidis
13 6
Streptococcus (8) faecalis viridans Diph theroides
7 1 1
Gram-negative bacteria Pseudomonas aeruginosa Escherichia coli Bacteroides (4) fragilis cloaca Proteus mirabilis Morganella morgagni Salmonella Acinetobacter Klebsiella
4 4 3 1 2 2 1 1 1
*Of the 28 infections, 13 wounds cultured only gram-positive bacteria, 5 only gram-negative bacteria, and 5 both types of bacteria. Since many wounds cultured more than one type of gram-positive or gram-negative bacteria, the numbers total more than 28.
Annals of Vascular Surgery
36 Calligaro et al.
the type of bacteria cultured from the wound (Tables II and in).
DISCUSSION These findings confirm that both MFs and DSI wound healing can be successful in the majority of patients with infected peripheral arterial grafts treated by graft preservation. No significant cost difference for the two techniques was noted. The primary advantage of selective graft preservation is markedly improved limb salvage rates. When an infected lower extremity graft is routinely excised, amputation rates of 27% to 79% have been reported. 1-~ None of the surviving patients in our series required a major amputation, and complete preservation of patent grafts was accomplished in 83% (20/24) of the cases. Other authors have reported 100% limb salvage rates in patients treated by selective graft preservation and rotational MFs) T M Our results suggested a higher rate of successful arterial graft preservation in survivors w h e n MFs were used (8/8) compared with DSI wound healing (12/16). However, three of the four patients treated by DSI that required graft excision were not candidates for MFs because of a persistent infection in the surrounding soft tissue. Reports that noted very high success rates using MFs probably represented a selected group of patients with minimal cellulitis and good granulation tissue. For example, Mixter et al. '~ reported a 96% (20/21) success rate when they selectively treated infected grafts with rotational MFs. Meyer et al. ~1 reported successful preservation of all eight infected vein grafts using MFs. Petrasek et al. ~3 noted that 10 of 11 infected grafts did not develop any complications after MF placement. Our current recommendation is that if wound necrosis and cellulitis persist, MFs should not be placed but repeated, aggressive, wide operative wound debridement is required until healthy granulation tissue is present. If purulent drainage or necrotic tissue persists despite repeated operative debridements, graft excision should be performed. All eight grafts in our surviving patients with MFs were successfully preserved, but two of four sartorius flaps to treat groin infections necrosed and placement of new MFs was required to achieve wound healing and successful graft preservation. Other reports have documented the tenuous blood supply to the sartorius muscle and have noted a high failure rate when this muscle was used as a rotational flap. mA2A4Consequently,
we currently recommend that sartorius MFs not be used preferentially for groin infections, although they may yield good results for infections involving the midthigh. Alternatives include the gracilis, semimembranous, rectus abdominis, rectus femoris, tensor fascia lata, gastrocnemius, or soleus muscles, m'14'15 It is commonly believed that selective graft preservation has a higher likelihood of success if infection involves a vein graft than if a prosthetic graft is involved. 11"12 Although autologous tissue may initially resist infection better t h a n prosthetic material, we and others have shown that an infected, patent prosthetic graft with intact anastomoses has an equal or better chance of being successfully preserved than does a vein graft. 6s'13"~ The present updated series demonstrates that selective graft preservation can be highly successful in the treatment of either infected prosthetic or vein grafts and that MF placement did not offer any proven advantage.
CONCLUSION Our results suggest that selective graft preservation may be a safer and improved method of treating infected lower extremity arterial grafts as compared with routine graft excision. We found that MFs did not result in significantly shorter hospital stays, lower overall costs, or significantly higher rates of successful graft preservation compared with DSI w o u n d healing. Despite these findings, we believe that MFs will help achieve successful complete graft preservation in selected good-risk patients with granulating or minimally contaminated wounds who can tolerate another operation. DSI w o u n d healing can yield a successful outcome in the majority of patients and is especially useful in poor-risk patients. REFERENCES 1. SzilagyiDE, Smith RF, Elliott JP, et al. Infectionin arterial reconstructionwith syntheticgrafts.Ann Surg 1972; 176:321333. 2. Bunt TJ. Syntheticvascular graft infections. I. Graft infections. Surgery 1983;6:733-746. 3. KiktaMJ, GoodsonSF, Bishara RA, et al. Mortalityand limb loss with infected infrainguinalbypass grafts. J Vasc Surg 1987;5:566-571. 4. LiekwegWGJr, GreenfieldLI. Vascularprosthetic infections: Collectedexperienceand results of treatment. Surgery1977; 81:335-342. 5. LorentzenJE, Nielsen OM, Arendrup H, et al. Vascular graft infection: An analysis of sixty-twograft infections in 2411 consecutively implanted synthetic vascular grafts. Surgery 1985;98:81-86.
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6. Veith FJ. Surgery of the infected aortic graft. In Bergan J J, Yao JST, eds. Surgery of the Aorta and and Its Body Branches. New York: Grune & Stratton, 1979, pp 521-533. 7. Calligaro KD, Veith FJ, Gupta SK, et al. A modified m e t h o d for m a n a g e m e n t of prosthetic graft infections involving a n a n a s t o m o s i s to the c o m m o n femoral artery. J Vasc Surg i990; 11:485-492. 8. S a m s o n RH, Veith F J, Janko GS, et al. A modified classification and approach to the m a n a g e m e n t of infections involving peripheral arterial prosthetic grafts. J Vasc Surg 1988;8:147153. 9. K w a a n JHM, Connolly JE. Successful m a n a g e m e n t of prosthetic graft infection with continuous povidone-iodine irrigation. Arch Surg 1981;116:16-20. 10. Mixter RC, Turnipseed WD, Smith DJ Jr, et al. Rotational muscle flaps: A n e w technique for covering infected vascular grafts. J Vasc Surg 1989;9:472-478. l l. Meyer JP, D u r h a m JR, Schwarcz TH, et al. The use of sartorius muscle rotation-transfer in the m a n a g e m e n t of w o u n d complications after infrainguinal vein bypass: A report of eight cases a n d description of the technique. J Vasc Snrg 1989;9:731-735.
Selected preservation of infected lower extremity grafts 37
12. K a u f m a n JL, Shah DM, Corson JD, et al. Sartorius muscle coverage for the treatment of complicated vascular surgical wounds. J Cardiovasc Surg 1989;30:475-483. 13. Petrasek PF, K a l m a n PG, Martin RD. Sartorius myoplasty for deep groin w o u n d s following vascular reconstruction. A m J Surg 1990;160:175-178. 14, Perler BA, Vander Kolk CA, Dufresene CR, et al. Can infected prosthetic grafts be salvaged with rotational muscle flaps? Surgery 1991;110:30-34. 15. A m m a r AD, Turrentine MW. Exposed synthetic vascular grafts of the groin: Graft preservation by m e a n s of a tensor fasciae latae flap. J Vasc Surg 1989;I0:202-204. 16. Chang N, M a t h e s SJ. Comparison of the effect of bacterial inoculation in m u s c u l o c u t a n e o u s and random-pattern flaps. Plast Reconstr Surg 1982;70:1-9. 17. Dacey L J, Miett TOC, H u n t s m a n WT, et al. Efficacy of muscle flaps in the treatment of prosthetic vascular graft infections. J Surg Res 1988;4:566-572. 18. Calligaro KD, Veith FJ, Schwartz ML, et al. M a n a g e m e n t of infected lower extremity autologous vein grafts by selective graft preservation. A m J Surg 1992;164:291-294.
Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n = 8) or DSI (n = 12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft. Average hospital and intensive care stay as well as hospital costs were not significantly different for the two groups. The majority of infected, patent lower extremity grafts with intact anastomoses can be successfully preserved with either MFs or DSI wound healing. We found no significant difference in outcome or cost for the two methods of treatment. (Ann Vasc Surg 1994;8:31-37.)
From the Division of Vascular Surgery, Montefiore Medical Center~Albert Einstein College of Medicine (F.J.V. and C.M.S.), New York, N.Y., and the Section of Vascular Surgery, Pennsylvania Hospital~University of Pennsylvania School of Medicine (K.D.C., M.J.D., R.P.S., and D.A.D.), Philadelphia, Pa. Supported by the John F. Connelly Foundation, the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, and New York Institute for Vascular Studies. Presented at the Eighteenth Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993. Reprint requests: Keith D. Calligaro, MD, 700 Spruce St., Ste. 101, Philadelphia, PA 19106.
Traditional treatment of arterial graft infections has included graft excision to prevent anastomotic hemorrhage, nonhealing wounds, and systemic sepsis. Amputation rates of 27% to 79% have been reported after routine excision of infected lower extremity arterial grafts. ~-5 We agree that graft excision is mandatory when a patient presents with an infected graft that is occluded or associated with a disrupted anastomosis or systemic sepsis. However, complete preservation of selected infected extracavitary arterial grafts can result in equivalent mortality rates and improved 31
32
Annals of Vascular Surgery
Calligaro et al.
a m p u t a t i o n rates c o m p a r e d w i t h r o u t i n e graft e x c i s i o n . 6-s Selective g r a f t p r e s e r v a t i o n c a n b e s u c c e s s f u l l y a c c o m p l i s h e d u s i n g a g g r e s s i v e operative w o u n d d e b r i d e m e n t , f r e q u e n t dressing c h a n g e s , a n d d e l a y e d s e c o n d a r y i n t e n t i o n (DSI) w o u n d h e a l i n g . 69
Table I. Type of i n f e c t e d b y p a s s Bypass
No.
Femorodistal Femoral interposition/patch Iliac-distal Popliteal-distal Femorofelnoral crossover
17 6 2 2 1 28
P l a c e m e n t of a r o t a t i o n a l m u s c l e flap ( M F ) h a s b e e n p r o p o s e d as a n a l t e r n a t i v e m e t h o d to achieve successful w o u n d healing a n d graft preservation) ~ T h e p r o p o s e d a d v a n t a g e s of M F s i n c l u d e f a s t e r w o u n d closure, s h o r t e r l e n g t h of h o s p i t a l i z a t i o n , a n d h i g h e r r a t e s of g r a f t p r e s e r vation. Disadvantages in c lu d e the potential comp l i c a t i o n s a n d a d d e d cost of a n o t h e r m a j o r o p e r a t i o n . T h e p u r p o s e of t h i s r e p o r t w a s to c o m p a r e t h e o u t c o m e a n d c o s t of t r e a t i n g i n f e c t e d l o w e r extremity arterial grafts in our patients u s i n g selective g r a f t p r e s e r v a t i o n w i t h e i t h e r m u s c l e flaps ( M F s ) or DSI h e a l i n g .
PATIENTS AND METHODS Twenty-eight consecutive patients with infected l o w e r e x t r e m i t y a r t e r i a l grafts w h o fulfilled crite-
T a b l e I I A . A t t e m p t e d h e a l i n g b y DSI: S u c c e s s f u l c o m p l e t e p r e s e r v a t i o n of i n f e c t e d g r a f t s Age
Interval (mo) Location
ICU
stay (days)
stay (days)
Operation
77/M
120 <1
R. CFA
Salmonella
30
9
-
3
$33,383
<1
L. CFA
Bacteroides fragilis
29
7
--
12
$32,326
62/F
Aobi-DFA Dacron R. CFA PTFE interposition L. CFA-R. DFA PTFE L. CFA-POP PTFE
<1
L. CFA
51
8
--
44
$50,980
73/M
L. SFA-POP PTFE
<1
L. SFA
15
8
-
27
$19,660
72/F
R. CFA-TIB vein R. CFA-TIB PTFE R. CFA PTFE patch
37 < 1 <1
R. TIB
Staphylococcus aureus, S. faecalis Pseudornonas aeruginosa S. faecalis
23
10
--
18
$27,720
21
12
--
20
$27,080
L. CFA-POP PTFE Thrombectomy R. CFA-L. CFA PTFE Thrombectomy Ao-L. CFA PTFE L. CFA-POP PTFE R. CFA-TIB PTFE Thrombectomy L. CFA-POP PTFE L, EIA-POP PTFE
<1 <1 <1
L. CFA
S. faecalis, Escherichia coli, Proteus mirabitis, Bacteroides fragilk S. aureus, Acinetobacter S. aureus, Escherichia coli
124
4
Debride • 2
12
$116,710
31
3
--
3
$30,830
--
15
$38,160
<1 <1 132
12
$60,940
R. POP-TIB vein
<1
67/F
51/F 75/M
63/F
76/F 69/M
60/M Average
<1 <1
R. CFA
R. CFA
Addit'l O.R.
Follow-up (mo) Total cost*
(yr)/sex
68/F
Bacteria
Hosp.
L. CFA
S. faecalis, Motganella morgagni
35
lO
R. CFA
S. aureus
56
30
L. POP
S. aureus, Pseudomonas aeruginosa S. epidermidis
28
8
Debride • 2
7
$35,390
11
3
--
60
$13,430
37.8
9.3
R. TIB
STSG
$40,550
Ao ~ aorta; CFA = common femoral artery; DFA = deep femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any infrapopliteal artery; EIA ~ external iliac artery. *Total costs included anesthesiologist's, surgeon's, and operating room fees in addition to the daily cost of a semiprivate and ICU bed.
Vol. 8, No. 1 1994
Selected preservation of infected lower extremity grafts
ria for selective complete graft preservation were treated b e t w e e n J a n u a r y 1985 and December 1991 at Montefiore Medical Center in New York and at Pennsylvania Hospital in Philadelphia. Their ages ranged from 51 and 85 years (average 70 years). The 28 patients fulfilled our criteria for att e m p t e d selective graft preservation: (1) the graft was patent, (2) the a n a s t o m o s e s were intact, a n d (3) the patient s h o w e d no systemic sepsis. 6-~ Patients w h o p r e s e n t e d w i t h an infected graft that was occluded or h a d signs of systemic sepsis or a disrupted anastomosis u n d e r w e n t graft excision. 6-8 The types of infected grafts were 19 polytetrafluoroethylene (PTFE), eight autologous vein, and one Dacron graft. The indication for the bypass was limb salvage in 24 patients, disabling calf claudication in two patients, and repair of an a n a s t o m o t i c p s e u d o a n e u r y s m in two patients. The types of bypasses are listed in Table I. M1 patients had p u r u l e n t drainage from the infected w o u n d w i t h pus in contact w i t h an intact anastomosis. M a n a g e m e n t of these 28 infected grafts included a t t e m p t e d w o u n d healing by DSI in 18 patients (Table II) and a d v a n c e m e n t of a rotational MF in 10 patients (Table III). Choice of w o u n d m a n a g e m e n t was m a d e in a n o n r a n d o m -
33
ized fashion by the attending surgeon. All patients were initially treated by aggressive operative w o u n d d e b r i d e m e n t and observation in the intensive care unit until the graft were covered by p l a c e m e n t of MFs or by granulation tissue (DSI). Initial d e b r i d e m e n t s were performed in the operating r o o m w h e r e all infected soft tissue and a n y e x u d a t e on the graft could be excised carefully. Patients received appropriate intravenous antibiotics for at least 6 weeks based on w o u n d and blood cultures. Of the 18 w o u n d s allowed to heal by DSI, repeated operative d e b r i d e m e n t s were p e r f o r m e d until h e a l t h y granulation was present (Table II). This was s u p p l e m e n t e d by frequent bedside debridements. Moist dressings were applied three times a day using w e t - t o - d r y antibiotic dressings. Ten patients were treated by a d v a n c e m e n t of a rotational MF o n t o the exposed graft (Table III). MFs were placed at the time of the first operative w o u n d d e b r i d e m e n t in 8 of i0 patients. In the other two patients the flaps were advanced on the second and third day after the initial debridement. There were four sartorius, three gracilis, one s e m i m e m b r a n o u s , one gastrocnemius, and one rectus abdominis MF. E s t i m a t e d costs of treating the graft infections using MFs or DSI included surgeons' and anesthesiologists' fees, operating r o o m expenses, and
T a b l e IIB. A t t e m p t e d healing by DSI: Unsuccessful preservation of infected grafts Age (yr)/sex
Hosp. stay (days)
Operation
Interval (too)
Location
Bacteria
55/M
L. S F A - P O P PTFE
24
L. S F A
Staphylococcus aureus
14
72/F
R. C F A - P O P PTFE R. SFA-TIB v e i n Thrombectomy L. C F A - P O P v e i n L. C F A - P O P PTFE
39 < 1 < 1 < 1 < 1
R. SFA
Escherichia coli
L. C F A
S. aureus
51/F
51/M
L. CFA-POP Dacron
62/F
L. CFA-POP PTFE & L. POP-TIB vein L. DFA-POP vein
78/F
ICU stay (days)
Follow-up Addit'l O.R.
(too)
Results
6
-
35
21
4
--
4
25
3
--
11
Recurrent abscess (31 m o ) ( g r a f t e x c i s i o n , occluded) Healed wound, thrombosed graft Nonhealing w o u n d (5 m o )
3
L. CFA
S. aureus
66
12
Debride • 1
24
<1
L. TIB
S. epidermidis
NA
16
Excise graft
6
<1
L. DFA S. viridans,
NA
5
--
<1
(graft excision, EIA-TIB PTFE) Nonhealing wound (2 wk) (graft excision) Hemorrhage (3 wk); death (respir) Death (MI)
Klebsiella CFA = c o m m o n femoral artery; DFA infrapopliteal artery.
deep femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any
34
Annals of Vascular Surgery
Calligaro et al.
Table IliA. Attempted healing by MF placement: Successful complete preservation of infected grafts Age (yr)/sex 67/F
Operation L. CFA PTFE Embolectomy X
85/M
50/M 71/M
67/M
73/F 73/F
73/M
Interval (too) Location 22, 1
L. CFA Staphylococcus
R. EIA-L CFA PTFE
Addit'l O.R.
FoUow-up (mo)
Type of muscle flap
Total cost*
16
8
Debride x 1
60
Rectus
$26,435
11
2
-
12
Semimembranous
$15,464
L. CFA S. epidermidis,
28
13
-
8
Gracilis
$40,365
S. aureus R. CFA Bacteroides cloaca
15
5
--
6
Gracilis
$21,288
R. POP S. aureus
23
6
Debride x 1
7
Gastrocnemius
$31,128
R. CFA S. aureus, S,
32
8
--
24
Sartorius
$39,662
39
12
Debride x 1
3
Sartorius
$52,490 t
106
10
Debride x 1
5
Sartorius
$109,520 t
33.7
8
2
L. CFA PTFE interposition R. CFA-POP vein Thrombectorny R. CFA-POP PTFE L. CFA PTFE interposition R. CFA-TIB vein L. CFA-POP PTFE R. CFA-POP PTFE R. CFA-POP vein R. CFA-POP vein R. SFA-TIB vein Vein p a t c h SFA
Bacteria
Hosp. ICU stay stay (days) (days)
aureus 1 8
R. POP S. epidermidis,
Pseudomonas aeruginosa
2 2 4 < 1 < 1 48 < 1 < 1 < 1 < 1
< 1
faecalis R. SFA S. epidermidis, S. faecalis, Pseudomonas aeruginosa, Escherichia coli R. EIA S. faecalis, Bacteroides fra#ilis
Average
$42,044
NOTE: Of the 8 patients treated with MFs who had successfully preserved arterial grafts, 6 had the flap placed at the same time as the
first operative debridement. Two patients had the flap placed several days after the first debridement. Two patients had additional debridements when the flaps necrosed. CFA = common femoral artery; POP = popliteal artery; TIB = any inffapopliteal artery. *Total costs included anesthesiologist's, surgeon's, and operating room fees in addition to the daily cost of a semiprivate and ICU bed. tFlap necrosis (rectus flap + STSG-healed).
Table IIIB. Attempted healing by MF placement: Unsuccessful preservation of infected grafts Age (yr)/sex 81/M 53/F
Operation* R. SFA-TIB vein L. CFA-POP PTFE L. CFA PTFE interposition
Interval (too) Location
Bacteria
Hosp. ICU stay stay Addit'l Follow-up (days) (days) O.R. (too)
< 1
R. SFA
S. aureus
NA
3
--
< 1
< 1
L. CFA
S. epidermidis, Morganella morgagnL Proteus mirabills, d i p h t h e -
NA
16
--
2
roides
Type of muscle flap Gracilis Sartorius
Results D e a t h (MI o n postop, day 3) Death (sepsis) (total graft excision, above -knee amputation, hip disartic, death)
NOTE: The two patients with MFs who died had the flap placed at the same time as the first operative debridement. EIA = external iliac artery; CFA = common femoral artery; SFA = superficial femoral artery; POP = popliteal artery; TIB = any infrapopliteal artery.
Vol. 8, No. 1 1994
the daily cost of intensive care unit beds and semiprivate rooms. Patients who died or suffered complications were not included in this cost analysis. Patients who died early after presentation of their infection would have unfairly lowered the average length of hospital stay and overall costs of a particular form of treatment. Additionally, certain complications such as a myocardial infarction or pneumonia would have directly affected the length of hospitalization and overall costs of a particular treatment regardless of the method chosen to achieve w o u n d healing. Expenses were averaged for the two medical centers when calculating the cost to each patient. Surgeons' fees were based on 1991 Medicare Mlowed Fee Schedules. RESULTS Mortality. Selective complete graft preservation in these 28 patients resulted in a hospital mortality of 14% (4/28). Two patients died from postoperative myocardial infarctions: one on the third postoperative day after MF placement and one who was being treated by DSI wound healing and died on the fifth day after the initial operative wound debridement. Another patient treated by DSI hemorrhaged from the distal anastomosis of a popliteal-anterior tibial vein graft 3 weeks after presentation and died of respiratory complications 5 months later while still hospitalized. The fourth patient died after being treated with a sartorius MF for a groin infection involving a PTFE interposition graft of the common femoral artery. Seven days later the PTFE graft and MF were excised because of a nonhealing wound and systemic sepsis. The patient died 2 months later of septic complications. W o u n d healing a n d g r a f t preservation. In the 24 surviving patients, complete graft preservation was successfully accomplished in 20 (83%) cases with follow-up averaging 24 months (range 8 to 64 months). The other four patients required graft excision for nonhealing wounds in two cases (after 2 weeks and 5 months of aggressive wound care), for graft thrombosis 2 weeks after initial treatment of the infection in one patient, and for a recurrent abscess 3 years later in the remaining case. Initial treatment of the original graft infection was by DSI w o u n d healing in all four patients. The wounds in the first three patients were never considered acceptable for placement of a muscle flap because of persistent infected tissue and a lack of healthy granulation tissue. Two other patients initially treated with sartorius MFs developed flap necrosis and were treated
Selected preservation of infected lower extremity grafts
35
by excision of the necrotic flap and placement of new flaps. Both patients ultimately did well with long-term preservation of the grafts. L i m b loss. Although four infected grafts in the 24 surviving patients required excision, no patient required a major amputation. One of the four patients required a secondary bypass; the other three patients maintained a viable limb without requiring additional revascularization. Because the grafts in the remaining 20 patients were patent and successfully preserved, none of the threatened extremities required additional revascularization procedures or amputation. Costs a n d length o f hospitalization. Hospital costs and length of hospital stay were analyzed in the 20 patients whose grafts were successfully preserved after long-term follow-up (Tables IIA and IIIA). The average hospital stay, ICU stay, and cost for the eight patients treated by MFs averaged 33.7 days, 8.0 days, and $42,044 compared with 37.8 days, 9.3 days, and $40,550 for the 12 patients treated by DSI (p > 0.05). Bacteriology. Both gram-positive and gramnegative bacteria were cultured from 10 wounds, only gram-positive bacteria from 13 wounds, and only gram-negative bacteria from five wounds (Table IV). Similar rates of graft preservation and wound healing were accomplished regardless of
Table IV. Bacteriology of 28 infected grafts treated by selective graft preservation*
Gram-positive bacteria Staphylococcus (19) aureus epidermidis
13 6
Streptococcus (8) faecalis viridans Diph theroides
7 1 1
Gram-negative bacteria Pseudomonas aeruginosa Escherichia coli Bacteroides (4) fragilis cloaca Proteus mirabilis Morganella morgagni Salmonella Acinetobacter Klebsiella
4 4 3 1 2 2 1 1 1
*Of the 28 infections, 13 wounds cultured only gram-positive bacteria, 5 only gram-negative bacteria, and 5 both types of bacteria. Since many wounds cultured more than one type of gram-positive or gram-negative bacteria, the numbers total more than 28.
Annals of Vascular Surgery
36 Calligaro et al.
the type of bacteria cultured from the wound (Tables II and in).
DISCUSSION These findings confirm that both MFs and DSI wound healing can be successful in the majority of patients with infected peripheral arterial grafts treated by graft preservation. No significant cost difference for the two techniques was noted. The primary advantage of selective graft preservation is markedly improved limb salvage rates. When an infected lower extremity graft is routinely excised, amputation rates of 27% to 79% have been reported. 1-~ None of the surviving patients in our series required a major amputation, and complete preservation of patent grafts was accomplished in 83% (20/24) of the cases. Other authors have reported 100% limb salvage rates in patients treated by selective graft preservation and rotational MFs) T M Our results suggested a higher rate of successful arterial graft preservation in survivors w h e n MFs were used (8/8) compared with DSI wound healing (12/16). However, three of the four patients treated by DSI that required graft excision were not candidates for MFs because of a persistent infection in the surrounding soft tissue. Reports that noted very high success rates using MFs probably represented a selected group of patients with minimal cellulitis and good granulation tissue. For example, Mixter et al. '~ reported a 96% (20/21) success rate when they selectively treated infected grafts with rotational MFs. Meyer et al. ~1 reported successful preservation of all eight infected vein grafts using MFs. Petrasek et al. ~3 noted that 10 of 11 infected grafts did not develop any complications after MF placement. Our current recommendation is that if wound necrosis and cellulitis persist, MFs should not be placed but repeated, aggressive, wide operative wound debridement is required until healthy granulation tissue is present. If purulent drainage or necrotic tissue persists despite repeated operative debridements, graft excision should be performed. All eight grafts in our surviving patients with MFs were successfully preserved, but two of four sartorius flaps to treat groin infections necrosed and placement of new MFs was required to achieve wound healing and successful graft preservation. Other reports have documented the tenuous blood supply to the sartorius muscle and have noted a high failure rate when this muscle was used as a rotational flap. mA2A4Consequently,
we currently recommend that sartorius MFs not be used preferentially for groin infections, although they may yield good results for infections involving the midthigh. Alternatives include the gracilis, semimembranous, rectus abdominis, rectus femoris, tensor fascia lata, gastrocnemius, or soleus muscles, m'14'15 It is commonly believed that selective graft preservation has a higher likelihood of success if infection involves a vein graft than if a prosthetic graft is involved. 11"12 Although autologous tissue may initially resist infection better t h a n prosthetic material, we and others have shown that an infected, patent prosthetic graft with intact anastomoses has an equal or better chance of being successfully preserved than does a vein graft. 6s'13"~ The present updated series demonstrates that selective graft preservation can be highly successful in the treatment of either infected prosthetic or vein grafts and that MF placement did not offer any proven advantage.
CONCLUSION Our results suggest that selective graft preservation may be a safer and improved method of treating infected lower extremity arterial grafts as compared with routine graft excision. We found that MFs did not result in significantly shorter hospital stays, lower overall costs, or significantly higher rates of successful graft preservation compared with DSI w o u n d healing. Despite these findings, we believe that MFs will help achieve successful complete graft preservation in selected good-risk patients with granulating or minimally contaminated wounds who can tolerate another operation. DSI w o u n d healing can yield a successful outcome in the majority of patients and is especially useful in poor-risk patients. REFERENCES 1. SzilagyiDE, Smith RF, Elliott JP, et al. Infectionin arterial reconstructionwith syntheticgrafts.Ann Surg 1972; 176:321333. 2. Bunt TJ. Syntheticvascular graft infections. I. Graft infections. Surgery 1983;6:733-746. 3. KiktaMJ, GoodsonSF, Bishara RA, et al. Mortalityand limb loss with infected infrainguinalbypass grafts. J Vasc Surg 1987;5:566-571. 4. LiekwegWGJr, GreenfieldLI. Vascularprosthetic infections: Collectedexperienceand results of treatment. Surgery1977; 81:335-342. 5. LorentzenJE, Nielsen OM, Arendrup H, et al. Vascular graft infection: An analysis of sixty-twograft infections in 2411 consecutively implanted synthetic vascular grafts. Surgery 1985;98:81-86.
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1994
6. Veith FJ. Surgery of the infected aortic graft. In Bergan J J, Yao JST, eds. Surgery of the Aorta and and Its Body Branches. New York: Grune & Stratton, 1979, pp 521-533. 7. Calligaro KD, Veith FJ, Gupta SK, et al. A modified m e t h o d for m a n a g e m e n t of prosthetic graft infections involving a n a n a s t o m o s i s to the c o m m o n femoral artery. J Vasc Surg i990; 11:485-492. 8. S a m s o n RH, Veith F J, Janko GS, et al. A modified classification and approach to the m a n a g e m e n t of infections involving peripheral arterial prosthetic grafts. J Vasc Surg 1988;8:147153. 9. K w a a n JHM, Connolly JE. Successful m a n a g e m e n t of prosthetic graft infection with continuous povidone-iodine irrigation. Arch Surg 1981;116:16-20. 10. Mixter RC, Turnipseed WD, Smith DJ Jr, et al. Rotational muscle flaps: A n e w technique for covering infected vascular grafts. J Vasc Surg 1989;9:472-478. l l. Meyer JP, D u r h a m JR, Schwarcz TH, et al. The use of sartorius muscle rotation-transfer in the m a n a g e m e n t of w o u n d complications after infrainguinal vein bypass: A report of eight cases a n d description of the technique. J Vasc Snrg 1989;9:731-735.
Selected preservation of infected lower extremity grafts 37
12. K a u f m a n JL, Shah DM, Corson JD, et al. Sartorius muscle coverage for the treatment of complicated vascular surgical wounds. J Cardiovasc Surg 1989;30:475-483. 13. Petrasek PF, K a l m a n PG, Martin RD. Sartorius myoplasty for deep groin w o u n d s following vascular reconstruction. A m J Surg 1990;160:175-178. 14, Perler BA, Vander Kolk CA, Dufresene CR, et al. Can infected prosthetic grafts be salvaged with rotational muscle flaps? Surgery 1991;110:30-34. 15. A m m a r AD, Turrentine MW. Exposed synthetic vascular grafts of the groin: Graft preservation by m e a n s of a tensor fasciae latae flap. J Vasc Surg 1989;I0:202-204. 16. Chang N, M a t h e s SJ. Comparison of the effect of bacterial inoculation in m u s c u l o c u t a n e o u s and random-pattern flaps. Plast Reconstr Surg 1982;70:1-9. 17. Dacey L J, Miett TOC, H u n t s m a n WT, et al. Efficacy of muscle flaps in the treatment of prosthetic vascular graft infections. J Surg Res 1988;4:566-572. 18. Calligaro KD, Veith FJ, Schwartz ML, et al. M a n a g e m e n t of infected lower extremity autologous vein grafts by selective graft preservation. A m J Surg 1992;164:291-294.