Management of failed prosthetic grafts at the time of major lower extremity amputation

During a 2-year period 75 patients underwent 77 major lower extremity amputations for arterial insufficiency deemed untreatable by reconstruction (36 primary and 41 after failed infrainguinal arterial bypass). Patients with nonfunctional prosthetic grafts were randomized prospectively to either partial graft removal or complete graft removal, performed simultaneously with amputation, to determine which technique more effectively reduces delayed wound healing, stump infection, operative revision, and process-related death. Patients with known graft and deep wound infection were excluded from this review, as were patients who had positive graft cultures at the time of amputation. Partial graft removal resulted in an increased rate of delayed wound healing (47.8% vs 7.7%; chi 2 5.9, p less than 0.025) and secondary stump infection (39.1% vs 7.7%; chi 2 4.4, p less than 0.05), when compared with complete graft removal. The operative revision and process-related mortality rates were also higher in limbs that had partial graft removal, although not statistically significant. The operative morbidity and mortality rate was no greater in the group with complete graft removal, although the mean operative time was nearly doubled (1.4 vs 2.6 hours). Therefore we recommend that all nonfunctional prosthetic graft material be removed concomitant with major lower extremity amputation to avoid the excessive number of wound healing and suppurative complications that are encountered when residual graft material is present in the amputation stump.