Invited commentary

Abstract

Infections after placement of a prosthetic graft, for either aortic or peripheral arterial reconstruction, are feared and potentially devastating complications. These infections can have significant morbidity and can also lead to subsequent infections. In this issue of the Journal of Vascular Surgery, Fariñas et al report their experience with postoperative infectious complications after placement of prosthetic grafts for both lower extremity and aortic reconstruction. Their all-cause infection rate was 27.2%. The majority of infections were surgical site infections, and only two graft infections were noted. The authors identified preoperative active lower extremity soft tissue infection as an independent risk factor for infectious complications after both aortic and lower extremity operations. Although active lower extremity infection may not be able to be resolved for patients with advanced critical limb ischemia or those who undergo emergent aortic surgery, efforts should be undertaken to treat soft tissue infection before elective aortic aneurysm repair. Prolonged mechanical ventilation was noted to be a predictor for infectious complications after aortic surgery, once again emphasizing the importance of expeditious extubation in the immediate postoperative period, although it is unclear whether this is a marker of overall illness. There are several lessons to be learned from this analysis. Studies of postoperative infectious complications should not combine very different procedures together as “vascular surgery procedures.” To correctly identify high-risk patients and to set in place systems for improvement, each specific type of intervention and indication needs to be closely examined. Leg bypass and aortic surgery are very different from one another with regard to a number of issues. For example, postoperative nasogastric tubes are often used after aortic procedures and seldom after leg bypass. Prolonged intubation with postoperative tracheostomy placement is less of an issue for lower extremity bypass as it is for major open abdominal surgery. Finally, for aortic surgery, an operation performed for aneurysmal disease is very different from one executed to treat occlusive disease, and a ruptured aneurysm is much different from an elective aneurysm repair. To decrease these rates of postoperative infections, risks identification and interventions should be tailored for specific scenarios. Studies need to be optimally designed to answer the questions that they set up to ask. Future prospective work is needed as granular details are needed, including surgical and preparation technique. Risks factors identified in this study, such as poor glucose control, anemia, and prolonged ventilation, can also be analyzed and teased out to see if they are really factors that predict a poor outcome or merely markers for ill and sick patients with more advanced disease. As such, risk reduction methods should focus specifically on each procedure and indication. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Risk factors and outcomes for nosocomial infection after prosthetic vascular graftsJournal of Vascular SurgeryVol. 66Issue 5PreviewThe objective of this study was to determine risk factors for nosocomial infections (NIs) and predictors of mortality in patients with prosthetic vascular grafts (PVGs). Full-Text PDF Open Archive