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Extra-anatomic Bypass and Excision is Superior to Graft Salvage Attempts with Antibiotic Beads to Treat Vascular Graft Infections in the Groin

Published:September 01, 2022DOI:https://doi.org/10.1016/j.avsg.2022.08.008

      Abstract

      Objectives

      To determine if conventional extra-anatomic bypass and graft removal vs aggressive attempts at graft preservation has better survival and limb salvage in patients with localized groin wound infections of vascular grafts.

      Methods

      We conducted a retrospective review of 53 consecutive patients with vascular graft infections presenting in the groin. Treatment groups consisted of group 1) extra-anatomic bypass and graft excision (N=22) and group 2) initial graft preservation attempts with utilization of antibiotic beads (N=31). In group 2, patients underwent serial debridement and placement of antibiotic beads until culture negative wounds were achieved. Significantly more patients underwent muscle flap coverage in group 2 (27 of 31) compared to group 1 (7 of 22) (p<0.001). Data collected included demographics, comorbidities, intraoperative details, and outcomes including patency, limb salvage, mortality, and number of procedures. Continuous variables were examined with Student’s t-test and dichotomous variables were examined with Chi-Squared. Linear and logistic regression were used to analyze factors associated with outcomes, and Kaplan-Meier with log rank.

      Results

      Both groups were similar with respect to demographics. The overall Kaplan-Meier 1- and 3-year survival rates were 66.2% and 34.1% with no statistically significant difference between groups. The Kaplan-Meier 1- and 3-year limb salvage rates were 68.8% and 36.6% for group 1 vs 58.5% and 38.7% for group 2 (p=NS). The 1- and 3-year primary patency rates were 71% and 71% in traditional group 1 vs 72% and 56% in group 2 (p=NS). 1- and 3-year secondary patency rates in traditional group 1 were 83% and 71% vs 85% and 61% in group 2 (p=NS). Patients in group 1 underwent fewer total procedures when compared to group 2 (2.3+.2 vs 5.1 +.7, p=0.03). The late reinfection rate was significantly less in group 1- 4.5% vs group 2- 26% (p=0.04). Freedom from reinfection at 1- and 3-years was 94% and 94% in traditional group 1 vs 74% and 62% in group 2 (p=0.03). Multivariable analysis showed a higher incidence of amputation in patients who suffered reinfection (N=13, p=0.049). There was a higher mortality in patients with septic shock (N=10, p=0.007) and reinfection (N=13, p=0.036). Reinfection was associated with the highest mortality (p=0.03).

      Conclusions

      Conventional graft excision with extra-anatomic bypass resulted in similar mortality when compared to aggressive attempts at graft preservation, and trended towards improved limb salvage and patency. However, attempts at graft preservation with antibiotic beads resulted in a significantly higher reinfection rate and greater number of procedures, and therefore this approach should be used very selectively.

      Keywords

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