SURGICAL-MANAGEMENT OF INFRAINGUINAL ARTERIAL PROSTHETIC GRAFT INFECTIONS - REVIEW OF A 35-YEAR EXPERIENCE

Purpose: The purpose was to determine the early and late mortality and morbidity rates associated with infrainguinal arterial prosthetic graft infection (IAPGI) and to identify optimal methods of management. Methods: The study included 53 men and 14 women (mean age, 61 years) in whom a total of 68 IAPGIs developed in the years 1959 to 1993. IAPGI involved 58 femoropopliteal grafts (85%), six femorodistal grafts (9%), and four other grafts or synthetic patches (6%). Graft material was dacron in 36 (53%), polytetrafluoroethylene in 28 (41%), and human umbilical vein in four (6%). Sixteen IAPGIs (24%) involved limbs that had required amputations before IAPGI was diagnosed. Twenty-six (38%) of the 68 grafts were thrombosed, and 14 (88%) of the 16 amputeed had occluded grafts. Results: Staphylococcal organisms were isolated from 34 (58%) of the 59 IAPGIs for which culture data were available. The median intervals until IAPGI was diagnosed were 3 months after implantation and 1 month after the last procedure involving the original graft. Initial management consisted of local measures only in 13 (19%), partial removal or:in situ graft replacement in 15 (22%), and total graft excision in 40 (59%). Total excision was performed in 15 (94%) of the 16 patients with prior amputations and in only 25 (48%) of the 52 intact limbs. The overall postoperative mortality rate was 18%; seven (58%) of the 12 early deaths were related to sepsis, and all 12 occurred within the group of 51 patients (24%) for whom limb salvage was still being attempted (p = 0.056). IAPGI ultimately led to amputations in 21 (40%) of 52 intact limbs within the first year. Twenty-three (82%) of the 28 IAPGIs managed with incomplete graft removal required subsequent operations for continued sepsis, compared with five (13%) of the 40 treated with complete excision (p < 0.001). The cumulative 5-year survival rate (77%) for 53 patients who survived operation was less than that (89%) for the normal, age-matched U.S. male population. Conclusions: IAPGI is associated with substantial early mortality and amputation rates. Complete excision of infected graft material results in a significant reduction in the incidence of recurrent sepsis.