VASCULAR GRAFT INFECTIONS MANAGEMENT

Abstract

Introduction: Despite routine antibiotic prophylaxis and refinements in implantation technique, microbial infection of the vascular prostehesis can occur. Infection involving a vascular graft is difficult to eradicate. If not recognized or treated promptly, implant failure will occur by producing sepsis, hemorrhage or thrombosis. Management involves graft excision alone, graft preservation within the implant wound, in/situ graft replacement, or graft excision in conjunction with extra-anatomic bypass grafting. Matherial and method: We retrospectively analysed the operative registers of our clinic as well as the regular archives, from 2000 until 2008, searching for reported graft infections which needed excisions and extraanatomical bypasses or for conservative therapy. There were 50 patients in this interval admitted and treated in Surgical Clinic No.1, out of a total of 950 vascular interventions. 10 of them were early graft infections( 4 months). Using Szilagyi’s classification, 10 were grade I, 17 were grade II and 23 grade III.We followed antibiotic prophylaxis protocols in all of the cases, prior to first vascular intervention. Staphylococcus aureus was the most prevalent pathogen ( 95% ) found affecting our grafts. Results: We performed 20 graft excisions for infrainguinal graft infections, with the removal of the entire graft, radical debridement of infected perigraft tissues, closure of the arteriotomies with monofilament suture and the administration of systemic and topical antibiotics. We attempted graft preservation in 5 cases of infrainguinal prosthetic bypass graft infection( with serial surgical wound debridement, coupled with antibiotic therapy, early muscle flap coverage and repeated wound cultures to identify any development of bacterial resistance or change in the microbial flora). We used the staged approach in 20 cases, beginning with drainage of the perigraft abscess, followed in 2 or 3 days by graft excision and autogenous vein grafting. We performed none in-situ replacements with Rifampin-bonded prosthesis, partly because they were not available until a few years. For the patients with infection localized to only a portion of an aortofemoral graft, we preferred, for the decreased morbidity, the excision of the infected portion of the graft(partial graft excision) and after solving the inguinal infection, a staged extra-anatomical bypass- in cases.As for the gold standard regarding the aortic graft- total graft excision and ex-situ bypass, we only performed 5 of them. 3 patients died and 2 required major amputation. Conclusions: Dissatisfaction with the morbidity and the mortality of treating vascular graft infections, regardless of location, by total graft excision and remote bypass has been the impulse for the expanded application of lately performed in-situ bypasses or even for the prophylactic use of antibiotic-bonded grafts, in carefully selected cases.