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Are gram-negative bacteria a contraindication to selective preservation of infected prosthetic arterial grafts?
K D Calligaro1, F J Veith, M L Schwartz
1Division of Vascular Surgery, Montefiore Medical Center/Albert Einstein School of Medicine, New York.
Abstract:
Management of infected prosthetic arterial grafts has traditionally included total graft excision especially when gram-negative bacteria were cultured. Between 1973 and 1991 we treated 42 patients with infected prosthetic grafts (33 polytetrafluoroethylene (PTFE), 9 Dacron) by complete graft preservation when the graft was patent, the anastomoses were intact, and the patient did not have sepsis. The infection involved the anastomosis (36 cases) or the body (6 cases) of 33 peripheral grafts and the distal segment of five aortofemoral and four iliac-distal grafts. Cultures of the 42 infected grafts grew gram-positive bacteria in 33 cases and gram-negative bacteria in 22 cases. Treatment adjuncts included repeated, radical operative wound debridement and rarely (7 of 42) rotational muscle flaps. This management resulted in a 10% (4 of 42) hospital mortality rate and an amputation rate in survivors of 3% (1 of 38 threatened limbs). All four deaths were due to sepsis: gram-positive bacteria were cultured in all cases and gram-negative bacteria in two cases. Of the 38 survivors, 29 (76%) wounds healed and remained healed after average follow-up of 3 years (range, 1 to 18 years). Nine other patients required total graft excision for nonhealing wounds (7 cases) or delayed anastomotic hemorrhage (2 cases). Gram-negative bacteria were cultured in four, and gram-positive bacteria were cultured in six of these nine wounds. Four of nine (44%) graft infections that cultured Pseudomonas organisms healed without complications versus 23 of 33 (70%) wounds that cultured gram-positive bacteria, and 12 of 13 (92%) wounds that cultured gram-negative bacteria other than Pseudomonas organisms.(ABSTRACT TRUNCATED AT 250 WORDS)
Insights
Graft preservation for infected arterial grafts, even with gram-negative bacteria, can be successful. This approach, combined with debridement, offers a viable alternative to total graft excision, reducing mortality and amputation rates.
Area of Science:
- Vascular Surgery
- Infectious Diseases
- Prosthetic Graft Management
Background:
- Infected prosthetic arterial grafts traditionally require complete excision, particularly with gram-negative bacterial infections.
- This study investigates an alternative management strategy focusing on graft preservation.
Purpose of the Study:
- To evaluate the efficacy of complete graft preservation for infected prosthetic arterial grafts.
- To compare outcomes of graft preservation versus traditional excision in a cohort of patients.
Main Methods:
- A retrospective review of 42 patients with infected prosthetic grafts (polytetrafluoroethylene and Dacron) treated between 1973 and 1991.
- Graft preservation was employed in patent grafts without sepsis, supplemented by radical wound debridement and occasional muscle flaps.
Main Results:
- A 10% hospital mortality rate and a 3% amputation rate in survivors were observed.
- Of 38 survivors, 76% experienced wound healing, while 9 patients ultimately required graft excision.
- Healing rates varied by bacterial type: Pseudomonas (44%), gram-positive (70%), and other gram-negative bacteria (92%).
Conclusions:
- Complete graft preservation is a feasible management option for selected infected prosthetic arterial grafts.
- This approach, combined with aggressive debridement, can lead to successful outcomes, including wound healing and limb salvage.
- Bacterial species influence healing outcomes, with Pseudomonas infections presenting a greater challenge.