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December 23, 2005
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Stephen Kolakowski, Jr., MD, Matthew J. Dougherty, MD, Keith D. Calligaro, MD.
Pennsylvania Hospital, Philadelphia, PA, USA.
OBJECTIVE: The purpose of this study was to compare the incidence and characteristics of graft infection in patients who underwent early vs. late revisional surgery of lower extremity arterial bypass grafts.
METHODS: Between 1992 and July 2005, 500 revisional procedures were performed on 198 lower extremity bypass grafts. Revision groups were defined as early (less than 30 days after the primary bypass (ER, N= 99)), or late (more than 30 days after bypass (LR, N= 99)). Infection was defined as cellulitis with graft exposure or purulence in continuity with a graft, requiring antibiotics and operation for infection control. Mean follow-up was 60 months. Groups were compared using the student t-test.
RESULTS: The ER group included 66 autogenous and 33 prosthetic grafts. The LR group consisted of 53 autogenous and 46 prosthetic grafts. Of the 500 revisional procedures performed, a total of 17 graft infections occurred (3.4%). Twelve (70.6%) were prosthetic grafts and five (29.4%) were autogenous grafts (p=0.004). Defining the infection rate per graft rather than per revisional procedure, the ER group had a significantly higher graft infection rate (11/99, 11.1%) compared to the LR group (6/99, 6.1%, p=0.012). Within the ER group, there was a significantly higher risk of infection for prosthetic grafts compared with autogenous grafts (9/33, 27.3% vs. 2/66, 3.1% respectively; p=0.0001). Three vein graft and three prosthetic grafts developed infection in the LR group (p=ns.) For prosthetic graft revisions only, infection risk was 9/33 (27.3%) in the ER group and 3/46 (6.5 %) in the LR group (p=.005). The most common cultured pathogen was Methicillin Resistant Staphylococcus Aureus (ER = 6/11 vs. LR = 3/6 (p = ns)). Within the ER group there was a significantly higher prevalence of Pseudomonas Aeruginosa compared to the LR group (3/11, 27.3% vs. 0/6, 0%; p = 0.04).
CONCLUSIONS: Early revision of lower extremity arterial bypass grafts carries a significantly higher risk of graft infection compared with revision later than one month after surgery. Approximately one quarter of prosthetic grafts reoperated early will develop infection. If feasible, re-operation should be delayed beyond one month for prosthetic grafts needing revision. Endovascular or extra-anatomic interventions should be considered if early revision is mandated in this group.
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Infection Associated with Re-operation of Lower Extremity Bypass Grafts: When is the worst time to re-operate?
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Stephen Kolakowski, Jr., MD, Matthew J. Dougherty, MD, Keith D. Calligaro, MD.
Pennsylvania Hospital, Philadelphia, PA, USA.
OBJECTIVE: The purpose of this study was to compare the incidence and characteristics of graft infection in patients who underwent early vs. late revisional surgery of lower extremity arterial bypass grafts.
METHODS: Between 1992 and July 2005, 500 revisional procedures were performed on 198 lower extremity bypass grafts. Revision groups were defined as early (less than 30 days after the primary bypass (ER, N= 99)), or late (more than 30 days after bypass (LR, N= 99)). Infection was defined as cellulitis with graft exposure or purulence in continuity with a graft, requiring antibiotics and operation for infection control. Mean follow-up was 60 months. Groups were compared using the student t-test.
RESULTS: The ER group included 66 autogenous and 33 prosthetic grafts. The LR group consisted of 53 autogenous and 46 prosthetic grafts. Of the 500 revisional procedures performed, a total of 17 graft infections occurred (3.4%). Twelve (70.6%) were prosthetic grafts and five (29.4%) were autogenous grafts (p=0.004). Defining the infection rate per graft rather than per revisional procedure, the ER group had a significantly higher graft infection rate (11/99, 11.1%) compared to the LR group (6/99, 6.1%, p=0.012). Within the ER group, there was a significantly higher risk of infection for prosthetic grafts compared with autogenous grafts (9/33, 27.3% vs. 2/66, 3.1% respectively; p=0.0001). Three vein graft and three prosthetic grafts developed infection in the LR group (p=ns.) For prosthetic graft revisions only, infection risk was 9/33 (27.3%) in the ER group and 3/46 (6.5 %) in the LR group (p=.005). The most common cultured pathogen was Methicillin Resistant Staphylococcus Aureus (ER = 6/11 vs. LR = 3/6 (p = ns)). Within the ER group there was a significantly higher prevalence of Pseudomonas Aeruginosa compared to the LR group (3/11, 27.3% vs. 0/6, 0%; p = 0.04).
CONCLUSIONS: Early revision of lower extremity arterial bypass grafts carries a significantly higher risk of graft infection compared with revision later than one month after surgery. Approximately one quarter of prosthetic grafts reoperated early will develop infection. If feasible, re-operation should be delayed beyond one month for prosthetic grafts needing revision. Endovascular or extra-anatomic interventions should be considered if early revision is mandated in this group.
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