Use of rifampicin and graft removal are associated with better outcomes in prosthetic vascular graft infection.

OBJECTIVES: Prosthetic vascular graft infection (PVGI) is a very severe disease. We aimed to determine the factors associated with treatment failure. METHODS: Patients admitted to two University Hospitals with PVGI were included in this retrospective study. PVGI was classified as possible, probable or proven according to an original set of diagnostic criteria. We defined treatment failure if one of the following events occurred within the first year after PVGI diagnosis: death and infection recurrence due to the same or another pathogen. RESULTS: One hundred and twelve patients were diagnosed with possible (n = 26), probable (n = 22) and proven (n = 64) PVGI. Bacterial documentation was obtained for 81% of patients. The most frequently identified pathogen was Staphylococcus aureus (n = 39). Surgery was performed in 96 patients (86%). Antibiotics were administered for more than 6 weeks in 41% of patients. Treatment failure occurred in 30 patients (27.5%). The factors associated with a lower probability of treatment failure were total removal of the infected graft (OR = 0.2, 95% CI [0.1-0.6]), rifampicin administration (OR = 0.3 [0.1-0.9]) and possible PVGI according to the GRIP criteria (OR = 0.3 [0.1-0.9]). CONCLUSIONS: Treatment failure occurred in 27.5% of patients with PVGI. Total removal of the infected graft and rifampicin administration were associated with better outcomes.

Outcome of rectus femoris muscle flaps for groin coverage after vascular surgery.

OBJECTIVE: The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage. METHODS: All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay. RESULTS: A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%). CONCLUSIONS: This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.

A systematic review on the use of muscle flaps for deep groin infection following vascular surgery.

OBJECTIVE: The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage. METHODS: The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated. RESULTS: A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences. CONCLUSIONS: Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.

[Thigh muscle flaps for postoperative inguinal wound complications in vascular surgery : Sartorius muscle versus rectus femoris muscle]. / Oberschenkelmuskellappen bei inguinalen postoperativen Komplikationen in der Gefäßchirurgie : Musculus sartorius vs. Musculus rectus femoris.

BACKGROUND: Inguinal wound complications often cause postoperative morbidity and also mortality following vascular surgical interventions. The aim of this study was to report experiences and a comparison of the outcomes using rectus femoris muscle flaps (RFF) and sartorius muscle flaps (SMF). MATERIAL AND METHODS: A retrospective study was performed at two locations of a cross-border vascular center and all muscle flap interventions performed at the two centers within the vascular surgery department were reviewed. Primary outcomes were muscle flap survival, graft salvage and major amputations. RESULTS: A total of 44 RFFs were performed in 39 patients (mean age 67 years, 73% males) and 25 SMFs in 24 patients (mean age 64 years, 76% males). Wound infections were the most common indications for muscle flap reconstruction. At a mean follow-up of 24 months (±24) and 17 months (±20), respectively, comparable flap survival rates (91% vs. 84%), wound healing rates (72% vs. 83%), graft salvage (65% vs. 73%) and amputation rates (9% vs. 8%) were found. CONCLUSION: Muscle flap reconstruction is an effective way to cover groin defects resulting from deep wound infections after vascular surgery, achieving good results in a high-risk group of patients. No differences were found between SMF and RFF regarding amputation and graft loss. Both techniques can be safely performed, depending on the preference and experience of the surgical team. The RFF technique should be preferentially used to cover large tissue defects, whereas the SMF procedure can be preferred to cover smaller defects in the groin.

Medical treatment of prosthetic vascular graft infections: Review of the literature and proposals of a Working Group.

More than 400000 vascular grafts are inserted annually in the USA. Graft insertion is complicated by infection in 0.5-4% of cases. Vascular graft infections (VGIs) are becoming one of the most frequent prosthesis-related infections and are associated with considerable mortality, ranging from 10 to 25% within 30 days following the diagnosis. Treatment of VGI is based on urgent surgical removal of the infected graft followed by prolonged antibiotherapy. Data regarding the best antibiotherapy to use are lacking since no well designed trial to study antimicrobial treatment of VGI exists. Moreover, since VGIs demonstrate very specific pathophysiology, guidelines on other material-related infections or infective endocarditis treatment cannot be entirely applied to VGI. A French multidisciplinary group gathering infectious diseases specialists, anaesthesiologists, intensivists, microbiologists, radiologists and vascular surgeons was created to review the literature dealing with VGI and to make some proposals regarding empirical and documented antibiotic therapy for these infections. This article reveals these proposals.

Sustained release of vancomycin from novel biodegradable nanofiber-loaded vascular prosthetic grafts: in vitro and in vivo study.

This study describes novel biodegradable, drug-eluting nanofiber-loaded vascular prosthetic grafts that provide local and sustained delivery of vancomycin to surrounding tissues. Biodegradable nanofibers were prepared by first dissolving poly(D,L)-lactide-co-glycolide and vancomycin in 1,1,1,3,3,3-hexafluoro-2-propanol. The solution was then electrospun into nanofibers onto the surface of vascular prostheses. The in vitro release rates of the pharmaceutical from the nanofiber-loaded prostheses was characterized using an elution method and a high-performance liquid chromatography assay. Experimental results indicated that the drug-eluting prosthetic grafts released high concentrations of vancomycin in vitro (well above the minimum inhibitory concentration) for more than 30 days. In addition, the in vivo release behavior of the drug-eluting grafts implanted in the subcutaneous pocket of rabbits was also documented. The drug-eluting grafts developed in this work have potential applications in assisting the treatment of vascular prosthesis infection and resisting reinfection when an infected graft is to be exchanged.

Contribution of 18fluoro-deoxyglucose PET/CT for the diagnosis of infectious diseases.

The diagnosis of some infectious diseases is sometimes difficult to make and new diagnostic tools have been regularly assessed to that end. 18fluoro-deoxyglucose ((18)FDG) positron-emission tomography (PET) coupled with computed tomography (CT) is one of these new procedures. It has been evaluated for numerous infectious diseases with uneven results. A literature review allowed drawing some conclusions. First, (18)FDG-PET/CT is not currently a first-line procedure for infectious diseases. Second, it has proved useful for the evaluation of patients presenting with fever of unknown origin (FUO). Its negative predictive value is 100%: the symptoms of patients experiencing FUO with negative first-line investigations and a negative (18)FDG-PET/CT will almost always spontaneously disappear. Third, (18)FDG-PET/CT also seems to be contributive for the diagnosis of vascular prosthesis infections or osteomyelitis. Fourth, it has promising results for patients presenting with infective endocarditis, especially for secondary infectious foci, or for patients presenting with suspected infection of pacemakers or implanted defibrillator; but results are still preliminary and must be confirmed. Finally(18)FDG-PET/CT cannot be recommended yet for other infectious diseases due to lack of published data.