Szilagyi Grade Research Articles

Randomized trial of rifampicin-bonded Dacron grafts for extra-anatomic vascular reconstruction: 2-year results

Abstract Background Serious infection complicates a small proportion of prosthetic vascular grafts and usually follows implantation of bacteria at the time of graft insertion. The aim of this study was to determine whether the use of a rifampicin-bonded, gelatin-coated Dacron graft (Gelsoft/Gelseal; Sulzer Vascutek) could reduce the rate of infective complications after extra-anatomic bypass. Methods In a multicentre study involving 14 vascular units, 257 patients underwent extra-anatomic bypass. There were 178 men and 79 women, of median age 69 (range 43–92) years. Some 132 (51 per cent) had no risk factors for wound or graft sepsis, 82 (32 per cent) had one and 43 (17 per cent) had two or more risk factors. Patients were randomized to rifampicin bonding (rifampicin 1 mg ml−1 soak for 15 min before insertion) (n = 123) or control (n = 134). The authors have previously reported small, but not statistically significant, reductions in total perioperative wound complications, antibiotic requirements and delayed hospital discharge in favour of patients with bonded grafts. Results Of 257 patients originally randomized, follow-up to 2 years or death is available for 197 patients; 60 have died. A total of ten patients have had serious wound or graft infections (Szilagyi grade III), four with unbonded and six with bonded grafts (P not significant). All occurred within 6 months of operation. The graft fabric was involved in eight patients. Treatment and outcome are listed in the Table below. Conclusion It has not been possible to show any advantage for the routine use of antibiotic bonding for extra-anatomic reconstruction.

An aggressive local approach to vascular graft infection

Purpose: To present the use of sartorius myoplasty (SM) and superficial femoral vein (SFV) in a graft-sparing approach to vascular graft infection. Methods: Twenty-five patients were treated for Szilagyi grade III groin infections during the last 10 years. Fifteen presented early (E), mean 2 months; 10 late (L), mean 6.5 years. Bacteria E/L: Staphylococcus epidermidis 1/7, S aureus 6/0, other Gram positive 1/0, Gram negative 4/1, mixed 6/0 (one pseudomonas). There were 13 aortofemoral (AF), 5 crossover, and 7 femoral distal reconstructions. SM was used to cover exposed grafts after radical debridement. When the graft was free-floating or bleeding, this segment was removed and replaced with SFV. The remaining infection was controlled with antibiotics. Results: One of 10 patients treated by SM alone required SFV replacement for bleeding. Four of 9 AFs treated by partial SFV replacement ± SM had persistent infection treated by complete graft removal in 3. Six grafts were removed electively in lower risk situations. There was no perioperative mortality, and no early or late limb loss. Conclusions: This experience supports an attempt at aggressive local treatment in frail patients.

Outcomes in the Management of Vascular Prosthetic Graft Infections Confined to the Groin: A Reappraisal

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n = 6), an aortobifemoral graft limb (n = 5), an ileofemoral bypass (n = 3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n = 1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafted treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.

Wound infection after arterial surgical procedures

During the period October 1983 to March 1987, 603 patients who underwent arterial surgical procedures were studied to determine the incidence and treatment of wound infections. Bypass procedures were performed in 395 patients (65.5%), in which autogenous vein was used for 158 grafts (26%), synthetic Dacron for 216 grafts (36%), and umbilical vein for 21 grafts (3.5%). Thrombo-endarterectomies, embolectomies and patch-grafts were performed in 208 patients (34.5%). An Infection Control Nurse examined and registered the wounds. The definition of wound infection used in our study is equivalent to Szilagyi grade II infection. Vascular surgery is classified as clean surgery, the clean wound infection rate being a useful measurement to evaluate preventative measures and surgical technique. Thirty-one patients (5.1%) developed a wound infection as a postoperative complication. The overall incidence of wound complications including haematoma and seroma following arterial reconstruction was 13%. The site of wound infection was predominantly the groin. The most common pathogen was Staphylococcus aureus which was found in 17 patients (2.8%). All infections resolved without further surgical intervention. The influence of possible aetiological factors is considered and the importance of prophylactic antibiotics and good surgical technique is stressed.