Prophylactic Transversely Hemisected Sartorius Flap for High-Risk Groin Dissections in Vascular Surgery-A Case Series.

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.

Systematic review of groin incision surgical site infection preventative measures in vascular surgery.

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.

Utility of Closed Suction Drains in Groin Incisions after Femoral Artery Exposure.

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.

Meta-analysis of prophylactic closed-incision negative pressure wound therapy for vascular surgery groin wounds.

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.

Vasculink iPhone Application and Risk Prediction Model for Groin Complication in Vascular Surgery.

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.

A multicenter, prospective randomized trial of negative pressure wound therapy for infrainguinal revascularization with a groin incision.

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.

Contemporary management and outcomes of complex vascular surgical groin wound infections.

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.

Editor's Choice - Systematic Review and Meta-Analysis of Wound Adjuncts for the Prevention of Groin Wound Surgical Site Infection in Arterial Surgery.

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.

Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair.

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.

Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery.

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.

Clinical efficacy and safety of the PRO-glide device as a sUture-mediated ClosurE in Thoracic EndoVascular Aortic Repair in patients with previous groin intervention (from the PRODUCE-TEVAR Trial).

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.

Use of Femostop device in the setting of life threatening inguinal bleeding.

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.

A systematic review and meta-analysis of randomized controlled trials for the reduction of surgical site infection in closed incision management versus standard of care dressings over closed vascular groin incisions.

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.

Meta-analysis and trial sequential analysis of prophylactic negative pressure therapy for groin wounds in vascular surgery.

BACKGROUND: Negative pressure therapy has been proposed as a prophylactic measure to promote surgical wound healing and reduce surgical site complications. METHODS: We conducted a systematic review of the literature to identify randomized controlled trials (RCTs) comparing prophylactic negative pressure therapy with standard practice in closed groin incisions in vascular surgery. We calculated the pooled odds ratio (OR) or risk difference and 95% confidence interval (CI) with the use of the fixed-effect model. To control the risk of type I error, we adjusted the thresholds for the Z-values with the use of the O'Brien-Fleming α-spending function, and the risk of type II error was controlled with the use of the ß-spending function and futility boundaries. RESULTS: We selected six RCTs reporting on a total of 733 groin wounds. Patients with negative pressure wound therapy had a lower risk of developing surgical site infection (OR, 0.36; 95% CI, 0.24-0.54; P < .001), a lower risk of revision surgery (OR, 0.44; 95% CI, 0.22-0.88; P = .02) and a shorter hospital stay (weighted mean difference, -2.14; 95% CI, -3.78 to 0.49; P = .01). There was no difference in in-hospital mortality (risk difference, 0.01; 95% CI, -0.02 to 0.05; P = .53) or readmission (OR, 0.46; 95% CI, 0.17-1.29; P = .14). The Z-curve for surgical site infection crossed the O'Brien-Fleming significance boundaries for superiority (before the required information size was reached). CONCLUSIONS: Prophylactic negative pressure wound therapy confers improved outcomes in patients undergoing arterial surgery via a groin incision compared with standard surgical wound care.

Lateral femoral bypass for prosthetic arterial graft infections in the groin.

OBJECTIVE: Prosthetic arterial graft infections (PAGIs) in the groin pose significant challenges in terms of revascularization options and risk of limb loss as well as associated morbidities. Although obturator canal bypass (OCB) has been suggested for revascularization of the extremity in these cases, moderate success rates and technical challenges have limited widespread use. Our study analyzed lateral femoral bypass (LFB) as an alternative approach for the treatment of groin PAGIs. METHODS: This is a retrospective review of a prospectively maintained database of patients who underwent LFB for groin PAGIs at a single center from 2000 to 2017. Patients' data including demographics, comorbidities, perioperative complications, graft patency, and need for reintervention were used. Patients were observed after LFB with duplex ultrasound surveillance in an accredited noninvasive vascular laboratory every 3 months during the first year, followed by every 6 months for the second year and yearly thereafter. After isolation of the infected wound with sterile dressings, remote proximal and distal arterial exposure incisions were made. LFBs were tunneled under the inguinal ligament and lateral to the infected wound from an uninvolved inflow artery or bypass graft to an uninvolved outflow vessel. RESULTS: A total of 19 LFBs were performed in 16 patients (mean age, 69 ± 12.6 years). Three LFBs were performed urgently for acute bleeding. Choice of conduit included 6 (31.6%) autogenous vein grafts, 10 (52.6%) cadaveric grafts, 2 (10.5%) rifampin-soaked Dacron grafts, and 1 (5.3%) polytetrafluoroethylene graft. Average follow-up was 33 months (range, 0-103 months). Major adverse events occurring within 30 days of the operation included one (5.3%) death and one (5.3%) graft excision for pseudoaneurysm. Primary patency and primary assisted patency at 12 and 24 months were 73% and 83%, respectively. One patient required an amputation 17 months after surgery after failure of repeated revascularization attempts. Overall limb salvage was 93.8% during this follow-up period. CONCLUSIONS: In this series, LFB for management of groin PAGIs demonstrated higher patency and limb salvage rates compared with previous reports of OCB. Diligent postoperative duplex ultrasound surveillance is critical to the achievement of limb salvage and maintenance of graft patency. These results suggest that LFB, which is technically less complex than OCB, should be considered the first choice for revascularization in select cases of PAGIs involving the groin.

Variation in timing and type of groin wound complications highlights the need for uniform reporting standards.

BACKGROUND: Groin wound infections represent a substantial source of patients' morbidity and resource utilization. Definitions and reporting times of groin infections are poorly standardized, which limits our understanding of the true scope of the problem and potentially leads to event under-reporting. Our objective was to investigate the timing and variation of groin wound complications after vascular surgery. METHODS: We reviewed all patients who underwent vascular surgery with a groin incision at our institution during 2013 (N = 256; 32% female; mean age, 68.8 years). We analyzed patient- and procedure-level variables. Our primary outcome was any groin complication within 180 days. We classified groin-related events as major (hospital readmission or reoperation for groin wound) or minor (wound opened in clinic, initiation of antibiotics specifically for a groin wound, or new groin hematoma or wound drainage). RESULTS: The Kaplan-Meier estimated rate of groin complications at 180 days was 23% (n = 53/256); 29 (54%) were major and 24 (46%) were minor. The Kaplan-Meier 30-day event rate was 13% for any complication and only 3% for major complications, indicating that most events occurring within the first 30 days did not require readmission or reoperation. By 180 days, the overall complication rate rose to 23% and the major event rate to 14%, indicating that nearly all complications occurring after 30 days required readmission or reoperation. Those with a groin complication more commonly had tissue loss (23% vs 12%; P = .05), underwent infrainguinal bypass (42% vs 22%; P=.004), had a redo incision (32% vs 18%; P = .03), and had a longer operation (77% vs 65% surgery >200 minutes; P = .07). There were no significant differences in patients' comorbidities, skin closure, dressing type, prosthetic implants, hemostatic agents, or discharge status. CONCLUSIONS: Whereas >20% of patients suffered a groin complication, nearly half of these events occurred after 30 days. Standardized reporting measures limited to 30-day events or infection definitions that are limited to the need for antibiotic use may misrepresent the true infection rate and thus highlight the need for uniform reporting standards.

Preoperative risk score for access site failure in ultrasound-guided percutaneous aortic procedures.

OBJECTIVE: The factors associated with access site failure after ultrasound-guided percutaneous access for aortic endograft procedures remain poorly characterized. We developed a prediction model to risk stratify patients for access site failure. METHODS: We performed a retrospective institutional review of consecutive patients who underwent endovascular aneurysm repair (EVAR), fenestrated EVAR (FEVAR), or thoracic endovascular aortic repair (TEVAR) from 2014 to 2016. We excluded patients undergoing direct aortic access through sternotomy and patients treated with physician-modified endografts, given reporting restrictions. Our primary outcome was groin access site failure, which included bleeding and thrombosis. An 8-point risk model was created for access site failure using multivariable fractional polynomials and internally validated using bootstrapping. RESULTS: We identified 469 femoral arteries from 247 patients undergoing endovascular aortic repair procedures (EVAR, 75%; FEVAR, 8.0%; TEVAR, 17%). Surgeons performed percutaneous access in 97.2% of the femoral arteries, with 99.6% ultrasound use. Twenty-seven (5.9%) access site failures occurred (17 bleeding, 10 thrombosis), all treated with groin cutdown, for a successful percutaneous femoral artery access rate of 94%. Of the 215 patients with attempted bilateral percutaneous access, 90% had successful bilateral access. However, FEVAR had lower rates of successful bilateral access (FEVAR, 78%; EVAR, 91%; TEVAR, 94%; P = .03). Factors independently associated with percutaneous access site failure were femoral artery outer wall diameter (per millimeter increase: odds ratio [OR], 0.003 [0.0002-0.1]; P < .001), femoral artery stenosis >50% (OR, 22.3 [2.7-183.2]; P < .01), and urgent/emergent intervention (OR, 3.6 [1.2-11.0]; P = .03). A risk prediction model based on these criteria produced a C statistic of 0.89, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of 0.04. Excluding treatment for ruptured aneurysms, cutdown for access failure and planned initial groin cutdown resulted in longer postoperative lengths of stay and higher rates of access-related readmission, return to operating room, groin infection, and myocardial infarction compared with successful percutaneous access. There was no difference in major adverse events between planned initial groin cutdown and cutdown after failure; however, the small number of patients in these two comparison groups limits the statistical power to detect a difference. CONCLUSIONS: Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures, but access site failures do occur. This risk score can help users select patients with high likelihood of success, identify patients who need close scrutiny with postclosure femoral duplex ultrasound, and provide patient guidance about risk of unplanned groin cutdown.

Rotational Atherectomy Plus Drug-Coated Balloon Angioplasty for the Treatment of Total In-Stent Occlusions in Iliac and Infrainguinal Arteries.

PURPOSE: To analyze the long-term outcomes of a hybrid treatment method combining rotational atherectomy with drug-coated balloon (DCB) angioplasty in patients with total in-stent occlusion in the iliac and/or infrainguinal arteries. MATERIALS AND METHODS: Between April 2014 and June 2017, 74 consecutive patients (mean age 66.7±9.7 years; 49 men) with total occlusion of a previously implanted stent underwent endovascular recanalization using the Rotarex system and DCB angioplasty. Half (37, 50%) of the patients had critical limb ischemia (CLI), and 30 (41%) of the procedures were performed in emergency. Mean lesion length was 22±15 cm. RESULTS: Overall procedure success was achieved in 73 (98.6%) patients. Six (8.1%) CLI patients developed distal embolism that responded to thrombolysis. Three (4.1%) dissections did not require treatment, while 1 (1.4%) perforation necessitated stent-graft implantation. In all, 33 (44.6%) patients had an additional stent implanted, mainly due to a suboptimal outcome (n=28) or complications (n=5 including the stent-graft). The restenosis rate assessed by duplex ultrasound at 12 months was 20.5% (15/73); 4 (5.5%) patients underwent target lesion revascularization. Recurrent restenosis was more frequent in patients with Rutherford category 5 ischemia (p=0.005), in emergency procedures (p=0.021), after extensive procedures involving 3 independent vessel segments (p=0.016), and if a complication arose during the procedure (p<0.001). In multivariate analysis, only occurrence of a procedural complication was an independent predictor of recurrent restenosis at 1 year (OR 63.3, 95% CI 5.7 to 701.5). CONCLUSION: These findings imply that rotational atherectomy and DCB angioplasty may provide satisfactory outcomes in the treatment of total in-stent occlusion, with a satisfactory recurrent restenosis rate at 12 months.

In situ Reconstruction of Infected Groin Pseudoaneurysms in Drug Abusers With Biological Grafts.

OBJECTIVES: The aim of this study was to evaluate outcomes after in situ reconstruction using biological grafts in infected groin pseudoaneurysms in drug abusers. METHODS: This was a single centre retrospective analysis of all patients undergoing in situ reconstruction with biological vascular grafts for infected groin pseudoaneurysms in drug abusers from 2000 to 2017. Outcome measures included wound healing problems, re-infection, graft patency, lower limb amputation, and mortality. RESULTS: Twenty-two patients (14 male) with a median age of 39 years (range 27-49) were identified. Fifteen patients (68%) underwent urgent in situ reconstruction with a xenograft, five patients (23%) with a homograft, and two patients (9%) with an autologous vein. There were no in hospital deaths, in hospital re-infections, or early major limb amputations. Four (18%) patients developed wound healing complications requiring re-operation. During a median follow up of 56 months (range 13-180 months), six patients (27%) developed re-infection requiring complete graft replacement with a new biological graft. Thereafter, three (14%) had re-re-infection. Seven patients (32%) had graft occlusions: two were treated endovascularly, two underwent re-operation, and three were treated conservatively. Two patients (9%) had patent grafts but significant stenosis: one had successful angioplasty and another one was left untreated. One patient required above knee amputation, resulting in an overall major amputation rate of 4%. Estimated primary patency was 87% after one year and 40% after five years. Six patients (27%) died during follow up from non-vascular causes. CONCLUSIONS: In situ reconstruction using biological grafts of infected groin pseudoaneurysms in drug abusers can be achieved with no peri-operative graft related complications, although rates of wound complications may be high. In the longer term, a significant number of patients develop re-infection, graft occlusion, or stenosis, although the amputation rate remains low. The management of this demanding group of patients remains a major challenge.

Trans-Iliac Bypass Grafting for Vascular Groin Complications.

OBJECTIVES: Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience. METHODS: A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival. RESULTS: Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related. CONCLUSIONS: Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting.