Management and outcome of infrapopliteal arterial graft infections with distal graft involvement

Abstract

The purpose of this study was to determine the outcome of patients with infrapopliteal artery graft infections (InfraPopGIs) who presented with graft infection distal to the popliteal artery. Between July 1, 1979 and June 30, 1994, 27 patients presented with infrapopliteal artery graft infections (18 polytetrafluoroethylene [PTFE], 9 autologous vein). The infection involved the anastomosis in 22 cases (8 anterior tibial, 8 posterior tibial, 4 peroneal, 2 dorsalis pedis arteries) and was localized to the body of the graft in 5 cases (4 calf, 1 ankle). All bypasses were originally performed for limb salvage. Twelve patients with patent grafts and intact anastomoses were managed by complete graft preservation. Fifteen patients presented with occluded grafts (10), anastomotic hemorrhage (4), or systemic sepsis (1) and were treated by total or subtotal graft excision. The hospital mortality rate was 19% (5 of 27) and the amputation rate in survivors was 27% (6 of 22). These results were compared with a mortality rate of 13% (15 of 114; P > 0.05) and a limb loss rate of 10% (10 of 99)(P = 0.05) in 114 patients during this period who presented with infection proximal to the tibial arteries. Of 6 survivors with graft infections who required amputations, 5 lacked a suitable outflow artery for a secondary bypass and 1 developed progressive gangrene despite a patent secondary bypass. Among the other 16 survivors, 7 (44%) limbs remained viable without requiring a secondary bypass, 6 (37%) limbs were salvaged with successful preservation of patent grafts, and 3 (19%) required secondary bypasses to prevent limb loss. Patients presenting with infrapopliteal artery graft infections have higher amputation rates than patients with more proximal infected peripheral grafts. Selective graft preservation and selective revascularization when outflow arteries are available are essential adjuncts to minimize high rates of limb loss associated in patients with graft infections.