Brachial Artery Ligation and Total Graft Excision is a Safe and Expeditious Approach to Prosthetic Arteriovenous Graft Infections

OBJECTIVE:
While autogenous arteriovenous access is preferred, prosthetic arteriovenous grafts(AVG) are still required in a large number of patients. Infection of AVGs occurs frequently and may cause life-threatening bleeding or sepsis. Multiple treatment strategies have been advocated(ranging from graft preservation to excision with complex concomitant reconstructions) indicating a lack of consensus on appropriate management. We undertook this study to evaluate if brachial artery ligation accompanied by total graft excision(BAL) is safe and effective.
METHODS:
All prosthetic arteriovenous graft infections managed by a single surgeon between 1995 and 2006 were reviewed retrospectively. Patients were identified from a computerized vascular registry and data was obtained via patient charts and the electronic medical record.
RESULTS:
We identified 45 AVG infections in 43 patients, of which 21(47%) demonstrated arterial anastomotic involvement and were treated with BAL; these form the cohort for this analysis. Patient mean age was 53.2(SD 9.5) years. The primary etiologies for ESRD were hypertension(29%), HIV(24%), and diabetes(19%). An upper arm AVG was present in all patients(95%) except one who had a forearm AVG(5%). The majority of grafts were PTFE(90%). Follow-up was 100% at 1 month, 86% at 3 months, and 67% at 6 months. No ischemic or septic complications occurred in the 21 patients that underwent BAL.
CONCLUSIONS:
BAL is a relatively easy and expeditious method to deal with an infected arm AVG in frequently critically ill patients with densely scarred wounds. In the short term, BAL appears to be well tolerated without resulting ischemic complications. Further study with longer follow-up is necessary to ascertain whether this method is definitive or a temporizing technique from which patients may ultimately manifest ischemic changes and require additional intervention.