Selective application of sartorius muscle flaps and aggressive staged surgical debridement can influence long-term outcomes of complex prosthetic graft infections

Abstract

The complexity of variables associated with vascular surgical site infections (VSSI) often contribute adversely to reinfection, limb salvage, and mortality rates. This report details our experience with the selective use of a sartorius muscle flaps (SMF) as part of an overall treatment strategy focused on staged surgical debridement (SSD) to control prosthetic graft bed infection prior to a graft preservation or revision plan. From our vascular registry, we identified 422 VSSI of which 89 (21%) had SMF for 24 aorto-bifemoral (ABF), 19 extra-anatomic bypasses (EAB), 34 infrainguinal bypasses, and 12 combined inflow/outflow reconstructions. All 86 patients had Szilagyi grade III prosthetic (Dacron-36, polytetrafluoroethylene [PTFE]-50) graft infections. The treatment algorithm included: SSD, culture-directed parenteral antibiotics, graft preservation (n = 3), or reconstruction (graft excision/EAB, n = 4; rifampin-bonded PTFE, n = 22; autologous conduit, n = 57) based on microbiology and consideration for SMF for extensive soft tissue defects (n = 43) or non-sterilized graft beds (n = 40). Analysis of microbiology, recurrent infection, vascular reconstruction, limb salvage, and mortality was completed over a mean follow-up of 52 months (range: 12 to 132 months). Thirty-day mortality was 2% with two aortic graft infections dying from sepsis. Survival by life table analysis at 1, 3, and 5 years was 94%, 92%, and 90%, respectively. Wound isolates were most commonly gram positive organisms (n = 58, 65%), with gram negative isolates and mixed infections accounting for 19% and 10%, respectively. A single recurrent groin infection was documented at 30 days. Freedom from recurrent infection (n = 6) at 1 and 5 years was 98% and 92% by life tables. Methicillin-resistant Staphylococcus aureus (MRSA) was involved for 50% of reinfections. No amputations were attributable to uncontrolled VSSI and graft patency was 100% in surveillance monitored patients. These results suggest that selective utilization of SMF as part of SSD treatment plan in an attempt to achieve graft bed sterilization can effectively control the complex infectious process allowing for potentially improved outcomes for in situ or preservation graft salvage techniques. Lifelong graft surveillance is recommended.