RESUMEN
BACKGROUND: In this study, the early and mid-term outcomes of sartorius flap reconstruction after the development of a prior groin infection were investigated. METHODS: From January 2017 until June 2023, 44 patients from 2 centers in Italy underwent sartorius flap reconstruction after the development of a prior groin infection. Thirty-day outcome measures including major morbidity, amputation-free survival, and mortality were assessed. At 2-year follow-up, estimated outcomes of freedom from hemorrhagic complications, freedom from recurrent infection, freedom from reintervention, and amputation-free survival were analyzed using Kaplan-Meier curves. RESULTS: In 35 cases (79.5%) a previous vascular procedure was performed, whilst in the remaining 9 cases (20.5%) the patient was an intravenous drug abuser. Thirty-day mortality and major amputation rates were 4.5%, and 2.3%, respectively. Overall 30-day wound healing rate was 56.8% (25 cases). The overall median duration of follow-up was 12 months (IQR 4-24). Complete wound healing was obtained in 36 cases (81.8%) after a median period of 1 month (IQR 1-3). The 2-year Kaplan-Meier estimates of freedom from hemorrhagic complications, freedom from recurrent infection, freedom from reintervention, and amputation-free survival were 82.1%, 70%, 71.9%, and 97.7%, respectively. Multivariate analysis confirmed the association of female sex with recurrent infection (HR 3.4, P=.05). CONCLUSIONS: Sartorius flap reconstruction after the development of a prior groin infection following vascular procedures or intravenous drug injections yielded acceptable mid-term outcomes in terms of freedom from hemorrhagic complications, and freedom from recurrent infection. Female sex seemed to affect the rate of recurrent infection.
Asunto(s)
Ingle , Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Procedimientos Quirúrgicos Vasculares , Humanos , Femenino , Masculino , Ingle/irrigación sanguínea , Persona de Mediana Edad , Anciano , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Colgajos Quirúrgicos/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Estudios Retrospectivos , Italia , Amputación Quirúrgica , Cicatrización de Heridas , Inyecciones Intravenosas , Resultado del Tratamiento , Factores de Tiempo , Abuso de Sustancias por Vía Intravenosa/complicaciones , Factores de Riesgo , Recuperación del Miembro , Infección de la Herida QuirúrgicaRESUMEN
Groin wound dehiscence and infection are a common complication of femoral artery exposure. In patients with prosthetic conduits placed in the groin, these complications can lead to graft infection or anastomotic dehiscence with hemorrhage. Sartorius flaps can be useful in preventing graft infections or anastomotic breakdown in the setting of wound infections. Prophylactic sartorius flaps have been suggested to be a useful adjunct in patients who are at high risk for groin complications. Standard sartorius flaps can be difficult to perform and increase the operative time. We present our experience with a modified sartorius flap, a Transversely Hemisected Sartorius (THT), which avoids dissection to the anterior superior iliac spine. Patients who received femoral artery exposure and a modified prophylactic sartorius flap were included in this case series. The Penn Groin Assessment Scale (PGAS) was calculated for each patient and our primary outcome was the rate of deep space wound infections. Fifteen patients received a THT muscle flap. The average age of the cohort was 67.5 (35-86) years. Eight (50%) were male. The mean PGAS was 2.5 (0-6). Eight (50%) groins had a prosthetic conduit underlying the flap. Four (25%) patients had infrainguinal bypass, 3 (18.8%) for femoral-femoral bypass, and 1 (6.3%) patient received aortic-bifemoral bypass. Eight (50%) patients received sartorius flap after femoral artery exposure for thromboembolectomy, endarterectomy, or access complications. Six (37.5%) patients developed superficial surgical site infections however no deep space infections or prosthetic graft excisions resulted. This procedure was effective in preventing graft infections in all patients with high-risk features for groin infection in our retrospective case series. The segmental blood supply is maintained while providing good coverage of the femoral vessels with this rotational flap.
Asunto(s)
Implantación de Prótesis Vascular , Arteria Femoral , Ingle , Colgajos Quirúrgicos , Humanos , Masculino , Anciano , Ingle/irrigación sanguínea , Ingle/cirugía , Femenino , Persona de Mediana Edad , Resultado del Tratamiento , Arteria Femoral/cirugía , Anciano de 80 o más Años , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Colgajos Quirúrgicos/efectos adversos , Factores de Riesgo , Adulto , Estudios Retrospectivos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/cirugía , Prótesis Vascular/efectos adversos , Dehiscencia de la Herida Operatoria/prevención & control , Dehiscencia de la Herida Operatoria/etiología , Dehiscencia de la Herida Operatoria/cirugía , Factores de Tiempo , Infecciones Relacionadas con Prótesis/prevención & control , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/etiología , Músculo Esquelético/irrigación sanguíneaRESUMEN
BACKGROUND: Closed-incision negative pressure therapy may lower the risk of surgical site infections in patients after peripheral arterial surgery. AIM: To explore patient experience of negative pressure therapy applied to groin incisions after discharge following peripheral arterial surgery, and to study their perception and attitudes toward the self-care information sheet they received at the vascular department. METHODS: A qualitative study underpinned by Gadamer's philosophical hermeneutics was conducted semi-structured interviews by telephone around day seven after therapy ended with ten participants. All had received self-care information sheet at the discharge and been home with closed-incision negative pressure therapy for 3-6 days. The participants had open peripheral arterial surgery in the groin in form of femoral thromboendarterectomy. Kvale and Brinkmann's research guided the data collection, analysis, and interpretation. FINDINGS: Patients found themselves coping with an unfamiliar situation after peripheral arterial surgery and the need arose to conceal the pump and tubing that were part of their incision treatment to protect their self-image. Their treatment became a constant companion, with some patients viewing the equipment as an extension of their bodies and others feeling its impact on activities of daily living. Patients perceived the treatment as providing reassurance, albeit with constraints, leading to feelings of manageability and an increasing sense of control. They viewed the written information as informative but with room for improvement. CONCLUSIONS: Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery showed that they perceived it as safe and manageable. Patients need support, however, in learning how to hide the treatment and to expand their own involvement and improve self-care. The study found that patient involvement and individually tailored information is essential to facilitating a healthy transition from hospital to self-care at home and that written information must be improved further.
Asunto(s)
Terapia de Presión Negativa para Heridas , Procedimientos Quirúrgicos Vasculares , Humanos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Ingle/irrigación sanguínea , Ingle/cirugía , Alta del Paciente , Actividades Cotidianas , Terapia de Presión Negativa para Heridas/efectos adversos , Terapia de Presión Negativa para Heridas/métodos , Infección de la Herida Quirúrgica/etiología , Evaluación del Resultado de la Atención al PacienteRESUMEN
OBJECTIVE: Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention ,techniques including prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy, and adhesive drapes. METHODS: This review was conducted and reported in accordance with the PRISMA statement. A systematic review was conducted using the Google Scholar, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS: The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are as follows. We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin (Grade 2C). We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention (Grade 2C). Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use, we suggest closed-incision negative pressure wound therapy be used in groin surgical incisions at high risk for SSI (Grade 2B). Given the paucity of data regarding adhesive drapes, such as Ioban, no recommendation can be made regarding its use. CONCLUSIONS: This review highlights the effects of various preventative techniques and their potential benefit in the prevention of SSI in the groin. However, there is a glaring deficit in the available data, emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. The use of endovascular techniques continues to increase, thus limiting the number of open arterial procedures and the potential for further studies to be conducted. To provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.
Asunto(s)
Procedimientos Endovasculares , Terapia de Presión Negativa para Heridas , Herida Quirúrgica , Humanos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiología , Ingle/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Endovasculares/efectos adversos , Herida Quirúrgica/etiología , Antibacterianos/uso terapéutico , Terapia de Presión Negativa para Heridas/efectos adversos , Terapia de Presión Negativa para Heridas/métodosRESUMEN
SUMMARY: Clear awareness of the vascular variations is critical in surgeries, which may cause massive hemorrhage during surgical procedures. During educational dissection of a male cadaver, we encountered a combined variation of the left obturator artery and ipsilateral aberrant inferior epigastric artery. The left obturator artery originated from the external iliac artery, then coursed inward, adherent to the superior pubic ramus. The left inferior epigastric artery originated from the femoral artery, and coursed behind the femoral vein. These anatomical variations shown in one person were extremely rare. This is particularly true with regard to these variations while performing pelvic and inguinal region surgeries.
El conocimiento claro de las variaciones vasculares es fundamental en las cirugías, ya que pueden causar una hemorragia masiva durante los procedimientos quirúrgicos. Durante la disección educativa de un cadáver de sexo masculino, encontramos una variación combinada de la arteria obturatriz izquierda y la arteria epigástrica inferior ipsilateral aberrante. La arteria obturatriz izquierda se originaba en la arteria ilíaca externa, luego discurrió hacia medial, adhiriéndose a la rama púbica superior. La arteria epigástrica inferior izquierda se originaba en la arteria femoral y discurría por detrás de la vena femoral. Estas variaciones anatómicas mostradas en una sola persona son extremadamente raras. Esto es importante de conocer estas variaciones cuando se realizan cirugías de las regiones pélvica e inguinal.
Asunto(s)
Humanos , Masculino , Arterias/anomalías , Ingle/irrigación sanguínea , Cadáver , Arterias Epigástricas/anomalías , Vena Femoral/anomalíasRESUMEN
BACKGROUND: Surgical groin wounds are at risk of delayed healing and infection, leading to costly and prolonged postoperative recoveries. This study assesses the use of closed suction drains (CSDs) as a wound care adjunct in groin incisions to prevent surgical site infections (SSI). METHODS: A single-center retrospective review was performed on 210 consecutive patients after vascular surgery with common femoral artery exposure from 2016 to 2021. The cohort was divided into 2 groups, groins with and without CSD, looking for surgical site complications. A subgroup analysis comparing postoperative outcomes between complicated and uncomplicated groin incisions within both groups was also performed. RESULTS: Of 293 surgical groins, 20% (n = 59) had drains. Overall, the CSD group had higher SSI rates (14% vs. 5.6%), but also had higher proportion of smokers (92% vs. 83%; P = 0.019), diabetes (56% vs. 36%; P = 0.005), coronary artery disease (69% vs. 46%; P = 0.001), hyperlipidemia (69% vs. 51%; P = 0.01), and previous groin surgery (54% vs. 17%; P < 0.001). The higher risk of SSI was not significant after adjustment of these confounders. A separate analysis within each group showed SSI groins with CSD had lower reintervention rates (37.5%) than those without CSD (69%), as well as shorter length of hospital stay (7 [5-11] vs. 22 [7-25] days). CONCLUSIONS: Our study suggests that CSDs can be a beneficial adjunct for groin wounds after common femoral artery exposure in patients with comorbidities cited above. CSDs decrease the risk of reintervention and length of hospital stay.
Asunto(s)
Arteria Femoral , Herida Quirúrgica , Humanos , Arteria Femoral/cirugía , Ingle/irrigación sanguínea , Succión , Resultado del Tratamiento , Extremidad Inferior/irrigación sanguínea , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Procedimientos Quirúrgicos Vasculares/efectos adversos , Estudios RetrospectivosRESUMEN
BACKGROUND: Postoperative groin complication is a common cause of morbidity in vascular surgery. Prophylactic wound adjuncts addressing this issue have been shown to reduce complications in high-risk patients, but their widespread implementation is limited by their high cost. This study introduces a risk prediction model for patients at a high risk for groin complication which can be accessed through the iPhone application, Vasculink. METHODS: A literature search identified risk prediction models for groin complication in vascular surgery. Odds ratios of risk factors that were present in at least 2 published models were calculated with a pooled effect size. The weighted risk for each factor was used to create our model and a cutoff point defining high risk patients was chosen. The initial model was assessed and validated using a split-sample methodology on a cohort identified via a retrospective chart review of all patients undergoing open vascular surgery at our institution between 2017 and 2020. Model performance was assessed using the C-statistic. RESULTS: Risk factors included in our model were female gender, body mass index ≥28 kg/m2, ever-smoker, reoperation, use of prosthetic, emergency, and end-stage renal disease. Of 216 patients, 131 were at a high risk. The overall groin complication rate was 43%, and specific complication rates were 27% infection, 14.8% seroma, and 6.9% hematoma. Our model's sensitivity and specificity were 92.47% and 60.98%, respectively. The C-statistic is 0.768. CONCLUSIONS: By using risk factors identified in the literature we have been able to establish a highly sensitive risk prediction model for groin complication following open vascular surgery. By incorporating our model into an iPhone application, Vasculink, we hope to facilitate preoperative decision making regarding the use of prophylactic wound adjuncts.
Asunto(s)
Ingle , Infección de la Herida Quirúrgica , Femenino , Ingle/irrigación sanguínea , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: A previous meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of closed incision negative pressure wound therapy (ciNPWT) on vascular surgery groin wounds reported a reduction in surgical site infections (SSIs). Our aim was to perform a comprehensive, updated meta-analysis after the largest multicenter RCT on the subject to date reported no benefits from ciNPWT. METHODS: A systematic review identified RCTs that had compared the primary outcome of the incidence of postoperative SSIs of groin incisions treated with ciNPWT or standard dressings. The secondary outcomes included wound dehiscence, a composite incidence of seroma, lymph leakage, and hematoma, the need for reoperation, in-hospital mortality, the need for readmission, and the hospital length of stay. The odds ratios (ORs) were compared across the studies using a random effects meta-analysis. The risk of bias was assessed using the Cochrane risk of bias tool, Harbord test, and trim-and-fill analysis. RESULTS: Eight RCTs with 1125 incisions (ciNPWT, n = 555 [49.3%]; control, n = 570 [50.7%]) were included. The RCTs included three studies inside and five outside the United States. ciNPWT was associated with a significant reduction in the rate of SSIs (OR, 0.39; 95% confidence interval [CI], 0.24-0.63; P < .001). No significant differences were found in the rate of wound dehiscence (OR, 1.11; 95% CI, 0.67-1.83; P = .68), composite incidence of seroma, lymph leak, or hematoma (OR, 0.49; 95% CI, 0.13-1.76; P = .27), need for reoperation (OR, 0.68; 95% CI, 0.40-1.16; P = .16), or need for readmission (OR, 0.60; 95% CI, 0.30-1.21; P = .15). It was not possible to quantitatively evaluate in-hospital mortality or the hospital length of stay. The risk of bias assessment identified a high risk of bias for participant blinding in all eight studies, a low risk for randomization and outcome reporting, and variability between studies for the other methods. We found no evidence of publication bias. CONCLUSIONS: Our meta-analysis of pooled data has suggested that prophylactic use of ciNPWT for vascular groin incisions will be associated with reduced rates of SSIs. The greatest benefits were seen in the trials with higher baseline rates of SSIs in the control group.
Asunto(s)
Terapia de Presión Negativa para Heridas , Herida Quirúrgica , Ingle/irrigación sanguínea , Hematoma/epidemiología , Humanos , Estudios Multicéntricos como Asunto , Seroma/epidemiología , Seroma/etiología , Seroma/prevención & control , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Procedimientos Quirúrgicos Vasculares/efectos adversosAsunto(s)
Arterias Epigástricas/anomalías , Ingle/lesiones , Arteria Ilíaca/patología , Malformaciones Vasculares/diagnóstico , Angiografía por Tomografía Computarizada , Arterias Epigástricas/diagnóstico por imagen , Ingle/irrigación sanguínea , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/lesiones , Masculino , Persona de Mediana Edad , Malformaciones Vasculares/etiologíaAsunto(s)
Procedimientos Endovasculares/efectos adversos , Ingle/irrigación sanguínea , Imagenología Tridimensional , Terapia por Láser/efectos adversos , Neovascularización Patológica , Ultrasonografía Intervencional , Várices/cirugía , Humanos , Valor Predictivo de las Pruebas , Recurrencia , Resultado del Tratamiento , Várices/diagnóstico por imagen , Várices/patologíaRESUMEN
OBJECTIVE: Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. METHODS: Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. RESULTS: Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. CONCLUSION: Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.
Asunto(s)
Anastomosis Quirúrgica , Aorta Torácica , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Anciano , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Aorta Torácica/patología , Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Endofuga/etiología , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Ingle/irrigación sanguínea , Humanos , Japón/epidemiología , Masculino , Mortalidad , Evaluación de Procesos y Resultados en Atención de Salud , Arteria Subclavia/patología , Arteria Subclavia/cirugíaRESUMEN
BACKGROUND: Wound complications after open infrainguinal revascularization are a frequent cause of patient morbidity, resulting in increased healthcare costs. The purpose of the present study was to assess the effects of closed incision negative pressure therapy (ciNPT) on groin wound complications after infrainguinal bypass and femoral endarterectomy. METHODS: A total of 242 patients who had undergone infrainguinal bypass (n = 124) or femoral endarterectomy (n = 118) at five academic medical centers in New England from April 2015 to August 2019 were randomized to ciNPT (PREVENA; 3M KCI, St Paul, Minn; n = 118) or standard gauze (n = 124). The primary outcome measure was a composite endpoint of groin wound complications, including surgical site infections (SSIs), major noninfectious wound complications, or graft infections within 30 days after surgery. The secondary outcome measures included 30-day SSIs, 30-day noninfectious wound complications, readmission for wound complications, significant adverse events, and health-related quality of life using the EuroQoL 5D-3L survey. RESULTS: The ciNPT and control groups had similar demographics (age, 67 vs 67 years, P = .98; male gender, 71% vs 70%, P = .86; white race, 93% vs 93%, P = .97), comorbidities (previous or current smoking, 93% vs 94%, P = .46; diabetes, 41% vs 48%, P = .20; renal insufficiency, 4% vs 7%, P = .31), and operative characteristics, including procedure type, autogenous conduit, and operative time. No differences were found in the primary composite outcome at 30 days between the two groups (ciNPT vs control: 31% vs 28%; P = .55). The incidence of SSI at 30 days was similar between the two groups (ciNPT vs control: 11% vs 12%; P = .58). Infectious (13.9% vs 12.6%; P = .77) and noninfectious (20.9% vs 17.6%; P = .53) wound complications at 30 days were also similar for the ciNPT and control groups. Wound complications requiring readmission also similar between the two groups (ciNPT vs control: 9% vs 7%; P = .54). The significant adverse event rates were not different between the two groups (ciNPT vs control: 13% vs 16%; P = .53). The mean length of the initial hospitalization was the same for the ciNPT and control groups (5.2 vs 5.7 days; P = .63). The overall health-related quality of life was similar at baseline and at 14 and 30 days postoperatively for the two groups. Although not powered for stratification, we found no differences among the subgroups in gender, obesity, diabetes, smoking, claudication, chronic limb threatening ischemia, bypass, or endarterectomy. On multivariable analysis, no differences were found in wound complications at 30 days for the ciNPT vs gauze groups (odds ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .234). CONCLUSIONS: In contrast to other randomized studies, our multicenter trial of infrainguinal revascularization found no differences in the 30-day groin wound complications for patients treated with ciNPT vs standard gauze dressings. However, the SSI rate was lower in the control group than reported in other studies, suggesting other practice patterns and processes of care might have reduced the rate of groin infections. Further study might identify the subsets of high-risk patients that could benefit from ciNPT.
Asunto(s)
Implantación de Prótesis Vascular , Endarterectomía , Arteria Femoral/cirugía , Ingle/irrigación sanguínea , Terapia de Presión Negativa para Heridas , Cicatrización de Heridas , Anciano , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Endarterectomía/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Terapia de Presión Negativa para Heridas/efectos adversos , New England , Readmisión del Paciente , Estudios Prospectivos , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/terapia , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/terapia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Groin incision surgical site infections (SSIs) following arterial surgery are common and are a source of considerable morbidity. This review evaluates interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSIs in patients undergoing arterial interventions involving a groin incision. DATA SOURCES: MEDLINE, EMBASE, and CENTRAL databases were searched. REVIEW METHODS: This review was undertaken according to established international reporting guidelines and was registered prospectively with the International prospective register of systematic reviews (CRD42020185170). The MEDLINE, EMBASE, and CENTRAL databases were searched using pre-defined search terms without date restriction. Randomised controlled trials (RCTs) and observational studies recruiting patients with non-infected groin incisions for arterial exposure were included; SSI rates and other outcomes were captured. Interventions reported in two or more studies were subjected to meta-analysis. RESULTS: The search identified 1 532 articles. Seventeen RCTs and seven observational studies, reporting on 3 747 patients undergoing 4 130 groin incisions were included. A total of seven interventions and nine outcomes were reported upon. Prophylactic closed incision negative pressure wound therapy (ciNPWT) reduced groin SSIs compared with standard dressings (odds ratio [OR] 0.34, 95% CI 0.23 - 0.51; p < .001, GRADE strength of evidence: moderate). Local antibiotics did not reduce groin SSIs (OR 0.60 95% CI 0.30 - 1.21 p = .15, GRADE strength: low). Subcuticular sutures (vs. transdermal sutures or clips) reduced groin SSI rates (OR 0.33, 95% CI 0.17 - 0.65, p = .001, GRADE strength: low). Wound drains, platelet rich plasma, fibrin glue, and silver alginate dressings did not show any significant effect on SSI rates. CONCLUSION: There is evidence that ciNPWT and subcuticular sutures reduce groin SSI in patients undergoing arterial vascular interventions involving a groin incision. Local antibiotics did not reduce groin wound SSI, although the strength of this evidence is lower. No other interventions demonstrated a significant effect.
Asunto(s)
Antibacterianos/administración & dosificación , Arterias/cirugía , Ingle/irrigación sanguínea , Terapia de Presión Negativa para Heridas , Infección de la Herida Quirúrgica/prevención & control , Técnicas de Sutura , Procedimientos Quirúrgicos Vasculares/efectos adversos , Antibacterianos/efectos adversos , Humanos , Terapia de Presión Negativa para Heridas/efectos adversos , Estudios Observacionales como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/microbiología , Técnicas de Sutura/efectos adversos , Resultado del TratamientoRESUMEN
Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.
Asunto(s)
Ingle/irrigación sanguínea , Infección de la Herida Quirúrgica/prevención & control , Procedimientos Quirúrgicos Vasculares/efectos adversos , Humanos , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/microbiología , Resultado del TratamientoRESUMEN
OBJECTIVE: Vascular surgical groin wound infection (VS-GWI) has multiple causes and frequently is manifested as a limb- or life-threatening problem, resulting in significant morbidity and mortality. For patients undergoing operative extirpation, in situ repair, extra-anatomic bypass, or ligation can be used; however, limited data exist describing comparative results of the different operative choices or conduit subtypes. Therefore, we sought to describe our experience with management of VS-GWI and to detail outcomes of the different strategies. METHODS: Patients (2003-2017) undergoing surgical treatment of VS-GWI (Szilagyi grade III) secondary to primary infectious arteritis or infected pseudoaneurysm after percutaneous intervention as well as previous prosthetic graft placement were reviewed. The primary end point was major adverse limb events (MALEs; major amputation, graft occlusion, or unplanned reintervention). Secondary end points included 30-day mortality, wound healing, amputation-free survival (AFS), and all-cause mortality. Cox proportional hazards modeling was used to determine relative risk of end points; Kaplan-Meier methodology was employed to estimate freedom from outcomes. RESULTS: There were 149 patients (age, 65 ± 11 years; body mass index, 27 ± 6 kg/m2; 70% male; 32% diabetes) identified, of whom 120 (81%) had unilateral and 29 (19%) had bilateral VS-GWI. Indications included infected prosthetic bypass (88% [n = 131]; infrainguinal, 107; suprainguinal, 24) and primary infectious femoral artery complications (12% [n = 18]). A majority underwent single-stage operations (87% [n = 129]). In situ reconstruction occurred in 87% (n = 129); 9% (n = 13) underwent ligation, and 6% (n = 7) received extra-anatomic revascularization. Autogenous conduit was used most commonly (68% [n = 101/149]; 88% single stage), of which 81% (n = 80) were femoral vein. The remaining patients received cadaveric (15% [n = 23]; 87% single stage) or prosthetic (8% [n=12]; 67% single stage) grafts. Adjunctive myocutaneous flap was used in 37% (n = 54). Length of stay was 19 ± 15 days and 30-day mortality was 7% (n = 10), with no difference between conduit repair types. All femoral wounds healed (mean follow-up, 17 ± 11 months); however, 33% (n = 49) underwent reoperation (unplanned graft reintervention, 33%; graft occlusion, 16%; wound débridement, 15%; major amputation, 11%). Reinfection occurred in 17% (n = 27), with no difference between groups. MALE rate was 22% (n = 33; most were arterial reinterventions, 19%), with no difference in single-stage vs multistage, in situ vs extra-anatomic, or autogenous vs nonautogenous conduit strategies Predictors of MALE included younger age (hazard ratio [HR], 1.6 per decade; 95% confidence interval [CI], 1.1-2.5; P = .02) and lower body mass index (<25 kg/m2; HR, 1.6 per BMI category; 95% CI, 1.1-2.5; P = .02). Overall, 1- and 3-year freedom from MALE, AFS, and survival were as follows: MALE, 74% ± 5% and 63% ± 6%; AFS, 68% ± 4% and 58% ± 5%; survival, 78% ± 3% and 70% ± 4%. Autogenous conduit use was associated with better survival (HR, 0.5; 95% CI, 0.3-0.8; 1-year: 83% ± 4% vs nonautogenous, 78% ± 4%; 3-year: 68% ± 8% vs 53% ± 9%; log-rank, P = .006). CONCLUSIONS: An individualized approach to operative strategy and conduit choice leads to comparable outcomes in this challenging group of patients. VS-GWI can be safely managed with in situ, autogenous reconstruction in a majority of patients with acceptable mortality, excellent wound healing rates, and improved overall survival. However, a significant proportion of patients experience reinfection and MALEs, the preponderance of which are arterial reintervention, mandating need for close follow-up and graft surveillance.
Asunto(s)
Aneurisma Falso/cirugía , Aneurisma Infectado/cirugía , Arteritis/cirugía , Implantación de Prótesis Vascular/efectos adversos , Prótesis Vascular/efectos adversos , Remoción de Dispositivos , Procedimientos Endovasculares/efectos adversos , Ingle/irrigación sanguínea , Infecciones Relacionadas con Prótesis/cirugía , Infección de la Herida Quirúrgica/cirugía , Anciano , Amputación Quirúrgica , Aneurisma Falso/diagnóstico , Aneurisma Falso/microbiología , Aneurisma Falso/mortalidad , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/microbiología , Aneurisma Infectado/mortalidad , Arteritis/diagnóstico , Arteritis/microbiología , Arteritis/mortalidad , Implantación de Prótesis Vascular/instrumentación , Bases de Datos Factuales , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/mortalidad , Procedimientos Endovasculares/instrumentación , Femenino , Oclusión de Injerto Vascular/etiología , Humanos , Ligadura , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Supervivencia sin Progresión , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Reinfección , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/microbiología , Infección de la Herida Quirúrgica/mortalidad , Factores de Tiempo , Cicatrización de HeridasRESUMEN
BACKGROUND: While the percutaneous approach is increasingly preferred, suture-mediated closure devices have been put into clinical practice to close the femoral artery during procedures requiring a large-sized introducer. However, scar in the groin is considered a contraindication or an exclusion criterion for percutaneous procedures. The aim of our study was to investigate the outcomes and safety of Pro-Glide device as suture-mediated closure device in patients who underwent thoracic endovascular aortic repair with percutaneous femoral access ≥22 F who had previous groin intervention. METHODS: A total of 73 patients who underwent endovascular repair with percutaneous femoral access were retrospectively included in the study. Previous groin intervention was defined as history of open surgical access or large sheath insertion (>18 F) to femoral artery because of endovascular or valvular intervention. Patients were divided into two groups as who had previous groin intervention PGI (+) and had not PGI (-). RESULTS: A total of 73 patients [60 male (82.2%)] were included in the study. Seventeen patients had PGI, and 56 did not. When groups were compared in terms of sheath sizes, a significantly higher sheath sizes were used in PGI (+) patients (24.5 ± 1.1 F vs. 23.8 ± 0.9 F, p = 0.005). The overall success rate in the femoral approach with pre-close technique was statistically insignificant between two groups (94.1% vs. 96.4%, p = 0.55). One patient in PGI (+) group and two patients in PGI (-) had technical failure for percutaneous femoral approach. One patient (5.9%) in PGI (+) group and one patient (1.8%) in PGI (-) group had femoral complications after the procedures; however, there was no significant difference between the groups in terms of complications (5.9% vs. 1.8%, p = 0.13). CONCLUSION: Pro-Glide device may be a safe and less invasive method for femoral access in patients with PGI and might not be considered as a contraindication for patients with history of PGI.
Asunto(s)
Aorta Torácica/cirugía , Cateterismo Periférico , Procedimientos Endovasculares , Arteria Femoral , Ingle/irrigación sanguínea , Hemorragia/prevención & control , Técnicas Hemostáticas/instrumentación , Técnicas de Sutura/instrumentación , Dispositivos de Cierre Vascular , Anciano , Cateterismo Periférico/efectos adversos , Procedimientos Endovasculares/efectos adversos , Diseño de Equipo , Femenino , Hemorragia/etiología , Técnicas Hemostáticas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Punciones , Estudios Retrospectivos , Técnicas de Sutura/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Tissue surrounding the superficial inferior epigastric vein (SIEV) can be harvested for vascularised lymph node transfer (vLNT) for the treatment of lymphoedema. The aim of this study is to define the anatomical relationship of lymph nodes surrounding the SIEV. METHODS: Twenty-five fresh-frozen cadaveric groin specimens were harvested en bloc to the level of the deep fascia along the following anatomical boundaries, yielding quadrilateral tissue blocks: pubic tubercle (medial), anterior superior iliac spine (lateral), 5â¯cm superior and inferior to the inguinal ligament. The SIEV was marked at its entry point with the femoral vein. Specimens were oriented, secured and fixed in formaldehyde and analysed using longitudinal slices at 3â¯mm intervals. RESULTS: A total of 86 lymph nodes were identified. The average position of lymph nodes examined was 0.4â¯cm medial and 3.2â¯cm inferior to the mid-inguinal point. CLINICAL RELEVANCE: An improved understanding of the anatomical locations of lymph nodes surrounding the SIEV will allow a more purposeful harvest during vLNT, allowing a greater number of lymph nodes to be captured whilst limiting donor site morbidity.
Asunto(s)
Ganglios Linfáticos/anatomía & histología , Vasos Linfáticos/anatomía & histología , Venas/anatomía & histología , Abdomen/anatomía & histología , Abdomen/irrigación sanguínea , Ingle/anatomía & histología , Ingle/irrigación sanguínea , Humanos , Escisión del Ganglio LinfáticoRESUMEN
OBJECTIVE: Surgical site infection after groin incision is a common complication and a financial burden to patients and healthcare systems. Closed incision negative pressure therapy (ciNPT) has been associated with decreased surgical site infection rates in published literature. This meta-analysis examines the effect of ciNPT (PREVENA™ Incision Management System; KCI, San Antonio, TX) versus traditional postsurgical dressing use in reducing surgical site infection rates over closed groin incisions following vascular surgery. METHODS: A systematic literature search using PubMed, OVID, EMBASE, and QUOSA was performed on 3 January 2019, by two independent researchers and focused on publications between 1 January 2005 and 31 December 2018. The review conformed to the statement and reporting check list of the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Inclusion criteria included abstract or manuscript written in English, published studies, conference abstracts, randomized controlled trials (RCTs), ciNPT usage over closed groin incisions in vascular surgery, comparison of ciNPT use and traditional dressings, study endpoint/outcome of surgical site infection, and study population of >10. Characteristics of study participants, surgical procedure, type of dressing used, duration of treatment, incidence of surgical site infection, and length of follow-up were extracted. Weighted odds ratios and 95% confidence intervals were calculated to pool study and control groups in each publication for analysis. Treatment effects were combined using Mantel-Haenszel risk ratios, and the Chi-Square test was used to assess heterogeneity. Overall, high-risk patients, normal-risk patients, and Szilagyi I, II, III outcomes were assessed between ciNPT and control groups. The Cochrane Collaboration tool was utilized to assess the risk of bias for all studies included in the analysis. RESULTS: A total of 615 articles were identified from the literature search. After removal of excluded studies and duplicates, six RCT studies were available for analysis. In these studies, a total of 362 patients received ciNPT, and 371 patients received traditional dressings (control). Surgical site infection events occurred in 41 ciNPT patients and 107 control patients. The heterogeneity test was nonsignificant (p > 0.05). The overall RCT meta-analysis showed a highly significant effect in favor of ciNPT (OR = 3.06, 95% CI [2.05, 4.58], p < 0.05). High-risk, normal-risk, Szilagyi I, and Szilagyi II meta-analyses were also statistically significant in favor of ciNPT use (p < 0.05). The varying RCT inclusion/exclusion criteria, such as differences in procedure types, and patient populations form the major limitations of this study. CONCLUSIONS: A statistically significant reduction in the incidence of surgical site infection was seen following ciNPT usage in patients undergoing vascular surgery with groin incisions.
Asunto(s)
Vendajes , Ingle/irrigación sanguínea , Terapia de Presión Negativa para Heridas , Infección de la Herida Quirúrgica/prevención & control , Procedimientos Quirúrgicos Vasculares/efectos adversos , Vendajes/efectos adversos , Humanos , Incidencia , Terapia de Presión Negativa para Heridas/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/microbiología , Resultado del TratamientoRESUMEN
Massive hemorrhage from the inguinal space is an indication for the use of the Femostop device in the emergency department. This case report describes a middle-aged male with metastatic and recurrent penile cancer status post inguinal lymph node dissection and chemoradiation with a nonhealing left groin wound with extension to the femoral vessels. The patient experienced massive bleeding from erosion of an open wound in left groin into femoral vein requiring massive transfusion. Direct pressure and pressure dressings were unable to control the bleeding present in the patient's left groin. The Femostop device was applied and hemostasis was immediately achieved.