Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study
Article Outline
Background
To look at wound complications with either a transverse or vertical groin incision in vascular surgery.
Methods
All patients undergoing vascular procedure requiring access to femoral vessels were randomized to either a vertical or transverse incision. Patients were followed up for 28 days after the procedure and examined for wound infection, wound breakdown, development of lymphatic leak and lymphatic collection.
Results
88 patients (116 groins) were randomised to either incision. Of these, 55 groins had transverse incisions and the remaining had vertical incisions. There was no significant difference in the patient's age, sex, smoking, diabetes, operative times and use of prosthetic material. 29/61 (47.5%) of vertical incisions and 7/55 (12.7%) of transverse incisions had wound complications (p<0.001). There were 13(11%) wound infections in the 116 groins by day 28. There were 3 wound infections in the transverse group and 10 infections in the vertical group (p=0.062). There were 17 (27.9%) lymphatic leaks in the vertical incisions compared to 7(12.7%) in the transverse incisions (p=0.044). The majority of infections were diagnosed after patient discharge from hospital.
Conclusion
Wound complications are higher with vertical incision. Many infections are diagnosed after patient discharge. We recommend transverse incisions for access to the femoral vessels in the groin.
Introduction
Open access to the femoral vessels is traditionally through a vertical incision. Although this approach gives good surgical access, wound healing can be complicated by sepsis, lymphatic leaks, and wound breakdown. This can ultimately lead to the feared complication in vascular surgery of graft sepsis.1
Some predisposing factors for wound infection in vascular surgery are well known, including emergency surgery, diabetes, and the presence of a groin incision.1 The effect of the type of groin incision (vertical or transverse/oblique) on wound complications has been debated. There are a limited number of studies that have looked at the effect of the type of wound incision on wound infection and lymphatic problems.2, 3 These studies have been limited by either a short follow-up2 or by being a retrospective case analysis.3 These studies also did not look at the adequacy of the surgical access between the different incisions. We therefore conducted a prospective randomized study addressing these problems.
Method
Patients undergoing vascular surgery requiring exposure of the femoral artery at two institutions (Westmead and Liverpool Hospitals) were randomized to either a vertical or a transverse incision. Patients were excluded from the study if they had undergone previous vascular surgery in the index groin or died before the completion of the study period. Patients were randomized to their incision based on the last digit of the hospital number either even or odd. For bilateral groin incisions, based on the randomization, both groins underwent the same incision. This study had ethical approval at both hospitals and informed consent was obtained from all the patients.
The operation was performed by consultant vascular surgeons or vascular trainees, but a consultant vascular surgeon was present at all operative procedures. All patients were given prophylactic intravenous antibiotics at induction by the anesthetist; the type of antibiotic used was determined by the operating team depending on individual indications. The use of preoperative and postoperative antibiotics was also determined on an individual basis according to indications. The surgical technique used for the study was standardized by protocol. The transverse incision was as follows: an incision above the groin skin crease when the main vessel to be accessed was the common femoral artery, while it was placed below the groin skin crease when the main vessels to be accessed were the profunda femoris or superficial femoral arteries. The deep dissection was the same as that used for vertical incisions (i.e., along the line of the femoral vessel). Closure of the incision was also standardized by protocol, which included the following points: (1) suction drain to all groin wounds, with the type of drain and duration of drainage determined at the surgeon's discretion; (2) layered closure of all wounds using at least two deep layers (interrupted or continuous at the surgeon's discretion) and always using synthetic absorbable monofilament (e.g., PDS); and (3) skin closure with subcuticular monofilament, absorbable or nonabsorbable, in all cases.
The use of adhesive dressings was common but not required by protocol. The operation was classified as suprainguinal if the vessel was accessed for an abdominal procedure (e.g., aortobifemoral graft), inguinal if the vessel was accessed primarily (e.g., transfemoral embolectomy), and infrainguinal if the procedure was an infrainguinal bypass (e.g., femoropopliteal bypass).
The groin wounds were examined at 4, 10, and 28 days. Patients who had been discharged from hospital before the completion of the study were contacted, and if there was any reported wound problems, the vascular team then examined the patients. For this study, a surgical access problem was considered present when the operating surgeon reported increased or undue difficulty in performing the vascular procedure because of the nature of the allocated incision. Wound infection was classified according to the criteria of the Centers for Disease Control and Prevention's 1999 “Guidelines for the Prevention of Surgical Site Infection.”4 The assessment of wound lymphatic problems and their significance was complicated. A lymph leak is a “hard” endpoint and simple to assess; a lymph collection is a variable feast in size, duration, and method of assessment (e.g., ultrasound versus clinical). Furthermore, a lymphatic leak is more likely to represent a risk for wound infection than a lymph collection. For the purpose of this study, therefore, we assessed for both lymph leak and lymph collection, but only included the hard endpoint of lymph leak in the definition of uncomplicated wound healing.
Graft infection was not a primary endpoint of our study as graft infections may manifest well after 28 days; furthermore, proving the presence or absence of a graft infection is not always easy. As it was, two definite cases of synthetic graft infection were recorded during the study, both infrainguinal procedures using a vertical incision. Statistical analysis was done using SPSS (SPSS Inc., Chicago, IL) with the chi-squares and Fisher's exact test used to compare the two groups.
Results
Ninety consecutive patients (119 groins) were eligible for the study. One patient (two groins) was excluded before randomization due to the surgeon's request, and one patient (one groin) was excluded from the final analysis due to death at day 4. Therefore, 88 patients (116 groins) were randomized and included in the final analysis. Of these, 55 groins underwent transverse incisions and 61 had vertical incisions.
The operations in this study were performed by two vascular trainees and by six consultant vascular surgeons; each operator would perform both vertical and transverse incisions depending on patient randomization.
The patient details are summarized in Table I, and operative variables are summarized in Table II. These were not significantly different between the two groups. All patients in both groups received an intraoperative dose of intravenous antibiotics; postoperative antibiotic use varied depending on the underlying vascular problem. Perioperative anticoagulation of the patients was not collected as a variable in this study.
Table I. Characteristics of patients undergoing surgery in both transverse and vertical incision groups
| Patient Characteristic | Vertical Incision (n = 61) | Transverse Incision (n = 55) | p |
|---|---|---|---|
| Age (yr) | |||
 <60 | 12 (19.7) | 11 (20) | |
| 61-70 | 29 (47.5) | 25 (45.5) | 0.514 |
| 71-80 | 16 (26.2) | 11 (20) | |
| >80 | 4 (6.6) | 8 (14.5) | |
| Gender | |||
| Male | 42 (68.9) | 41 (74.5) | 0.497 |
| Females | 19 (31.1) | 14 (25.5) | |
| Smokers | 19 (31.1) | 20 (36.4) | 0.55 |
| Diabetes | 17 (27.9) | 17 (30.9) | 0.72 |
| BMI >25 kg/m2 | 35 (57.4) | 27 (49.1) | 0.37 |
| ASA∗ | |||
| Two | 6 (9.8) | 5 (8.1) | 0.56 |
| Three | 43 (70.5) | 42 (76.4) | |
| Four | 12 (19.7) | 8 (15.5) | |
| Indication | |||
| Elective surgery | 30 (53.6) | 26 (46.4) | 0.837 |
| Urgent/emergency | 31 (49.2) | 29 (50.9) | |
| Infrainguinal operation | 49 (52.1) | 45 (47.9) | |
| Infrainguinal prosthetic graft | 15 (55.6) | 12 (44.4) | 0.62 |
| Suprainguinal operation | 12 (54.5) | 10 (45.5) | |
| Wound class∗∗ | |||
| Clean | 57 (93.4) | 50 (90.9) | 0.734 |
| Clean contaminated | 4 (6.6) | 5 (8.1) | |
∗American Society of Anesthesiologists (ASA) 1963: a fove category physical status classification system for assessing a patient before surgery. |
∗∗The principal determinant of “clean contaminated” categorization would be tissue breakdown in the ipsilateral limb.Percentages are given in parentheses. |
Table II. Operative variables
| Operative Variable | Vertical Incision (n = 61) | Transverse Incision (n = 55) | p |
|---|---|---|---|
| Operation type | 0.896 | ||
| Suprainguinal | 12 (19.7%) | 10 (18.2%) | |
| Inguinal | 34 (55.7%) | 33 (60%) | |
| Infrainguinal | 15 (24.6%) | 12 (21.8%) | |
| Operative time | 0.946 | ||
| <3 hr | 27 (44.3%) | 24 (43.6%) | |
| >3 hr | 34 (55.7%) | 31 (56.4%) | |
| Prosthetic graft | 35 (57.4%) | 33 (60%) | 0.775 |
| Antibiotic intraoperatively | 61 (100%) | 55 (100%) | |
Wound Complications
The overall incidence of wound complications (composite of wound infection, wound breakdown, and lymphatic leak) was greater in vertical than in transverse incisions (29 of 61 (47.5%) for vertical versus 7 of 55 (12.7%) transverse incisions, p < 0.0001). This combined endpoint shows an absolute risk reduction of 0.35 with a 95% confidence interval of 0.20 to 0.50 when using a transverse incision.
Overall, 13 (11%) wound infections were diagnosed by day 28. There were 3 wound infections in the transverse group and 10 infections in the vertical group (p = 0.062). There was no significant difference in the wound infections between the two hospitals (7 of 76 [9.2%] for Westmead versus 6 of 40 [15%] for Liverpool, p = 0.348). One wound infection was diagnosed by day 4, five infections by day 10, and the remaining seven by day 28.
The incidence of wound breakdown was higher in vertical incisions (13 of 61 [21.3%] vertical versus 5 of 55 [9.1%] transverse, p = 0.069).
As stated, analysis of wound lymphatic problems and their significance was complicated. Table III shows that the incidence of lymphatic problems with the two incision types. The overall incidence of lymphatic problems between the two incisions is similar, but lymphatic leaks are significantly more likely with vertical incisions than with transverse incisions (p = 0.011). In summary, both incision types are prone to lymphatic problems, but the vertical incision is associated more with lymph leaks.
Table III. Relationship of incision to lymph problems
| Incision | ||||
|---|---|---|---|---|
| Problem | Total (n = 112) | Vertical (n = 61) | Transverse (n = 55) | p |
| No lymphatic problem | 78 (67%) | 40 (65.6%) | 38 (69.1%) | 0.687 |
| Lymphatic problem | 38 (33%) | 21 (34.4%) | 17 (30.9%) | |
| Leak | 14 (12%) | 17 (27.9%) | 7 (12.7%) | |
| Collection | 24 (21%) | 4 (6.6%) | 10 (18.2%) | 0.011∗ |
∗Chi-squared test. |
No access problem was encountered in the vertical incision group. In 7 of 55 (12.7%) of transverse incisions, the operating surgeon thought that there was difficulty in access. Six of these cases were caused by trying to harvest the long saphenous vein at the saphenofemoral junction, and in one case access to the common femoral artery was difficult. The procedure in all cases was successfully completed, but in two cases, the transverse incision was continued vertically as a “hockey stick” incision. These two cases were counted as transverse incisions on the basis of both intention-to-treat and the fact that the great majority of the incision remained transverse.
Discussion
Groin incisions are prone to complications, including infection, wound dehiscence, lymphatic leaks, and hematoma. This has been shown in prospective studies to range from 10% to 33%.5, 6 Groin incisions over many years have consistently shown to be a risk factor for wound infection as well as graft infections.7, 8, 9, 10 Traditional groin incisions have been vertical. This follows the path of the femoral vessels and allows for good surgical access as well as the ability to extend the wound proximally or distally along the axis of the vessels if needed. A study by Roberts et al. in 1992 showed that the vertical groin incisions had lower rates of lymphatic collections (1%) than transverse incisions (4%).3 However, in the same year, Chester et al.2 conducted a randomized study on the two incisions and showed that transverse incisions had a 0% infection rate while the vertical incision had 5.9% infection rate.
Our study strongly supports the findings of Chester et al. and demonstrates the superiority of the transverse incision for surgical access to the femoral vessels in reducing wound complications.2 We also highlight the high incidence of wound problems in vascular surgery. The incidence of wound infection may seem high in our series but this is not much different from the study by Chester et al. They had an infection rate of 3% (compared with 5.2% in our series) where patients were only followed up for 10 days. However, our infection rate increased to 11% by day 28, and this highlights an important problem—namely, late infections. This is similar to a study by Mitchell et al.11 from our institution of 1360 patients that included 59 vascular patients. They had an overall 10.1% wound infection rate with 69% of infections diagnosed after the patient's discharge. In their series, the infection rate in vascular surgery was 1.7% predischarge and 5.1% postdischarge. There have also been some recent publications highlighting the low incidence of wound complications with transverse incisions, but these studies have been in patients undergoing endovascular aneurysm repair who generally have lower rates of wound complications than patients undergoing distal bypass surgery.12, 13, 14
In our series, the incidence of lymphatic problems overall was 32.6%. This is in contrast to previous series where lymphatic problems were only seen in 1% to 4% of patients.3, 5, 15, 16 The higher incidence of lymphatic problem in our series is again likely to be due to our longer follow-up of these patients. In our series, there was no difference in the incidence of lymphatic problems using the two incisions, although vertical incision tended to lead to lymphatic leaks, whereas the transverse incision was more likely to be lymphoceles.
We believe the reason for the transverse incision having better healing is that it runs along Langer's lines. This allows the wound to close when the hip is extended, and when the hip is flexed, the wound closes farther (Fig. 1, Fig. 2). In contrast, with the vertical incision, the wound falls open when the hip is extended and opens up farther when the hip is flexed (Fig. 3, Fig. 4). This mechanical distractive force on the vertical wound plays a significant part in its impaired healing. The inguinal skin crease is often moist and heavily colonized, especially in the obese and the diabetic; the vertical incision perforce goes through this area, whereas the transverse incision lies above it. Hence, the transverse incision may be less prone to sepsis.
Fig. 1
The transverse wound with hip extended; note how the wound closes.
Fig. 2
The transverse wound with the hip flexed; note how the wound closes further.
Fig. 3
The vertical wound with hip extended; note how the wound gapes.
Fig. 4
The vertical wound with hip flexed; note how the wound gapes further.
Not surprisingly, access was not as good through the transverse incision but this was mainly related to harvesting the long saphenous vein rather than access to the femoral vessels themselves. Also, an incorrectly placed vertical incision can be extended to obtain better exposure, whereas a misplaced transverse incision is less forgiving.
Conclusion
Although this study is underpowered, it would appear to support the hypothesis that transverse incisions for femoral vessel access sustain fewer complications than vertical incisions, and this would support the conclusions of Chester et al. We therefore recommend that a transverse incision be the incision of choice in vascular surgery to access the femoral vessels. This may be of particular importance if prosthetic graft is to be used. The transverse incision is probably somewhat harder to use than a vertical incision; hence, it could be argued that the “occasional groin surgeon” (with little skill in vascular surgery) should continue using the vertical incision. As a result of this study, the authors now use the transverse incision in the majority of femoral access cases. Some of the authors still use the vertical incision when access to an extended length of femoral artery is anticipated (e.g., distal iliac and common femoral endarterectomy with profundoplasty).
The authors acknowledge the contributing surgeons who took part in the study: Prof. Richard Allen, Dr. E. Farmer, Dr. Stuart Hazleton, and Dr. Arthur Richardson. The authors also thank Kerry Hitos for help in the statistical analysis.
References
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PII: S0890-5096(09)00174-5
doi:10.1016/j.avsg.2009.07.020
© 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
