MUSCLE-FLAP COVERAGE FOR INFECTED PERIPHERAL VASCULAR PROSTHESES

Infection in a peripheral vascular prosthesis continues to be a serious complication in arterial reconstructive surgery and threatens the patient with loss of either limb or life. Infection rates at major centers are now low, ranging from 1 to 6 percent; however, limb loss and mortality rates for this complication range from 25 to 75 percent depending on the location of the graft and the extent of the infection. The use of muscle flaps in the management of acute wounds, infection-prone wounds, exposed orthopedic hardware, and osteomyelitis is now commonplace. Transposed muscle has been shown to be well-vascularized tissue that improves healing time and decreases local wound bacterial counts. After considering the preceding facts, we used muscle flaps for coverage of infected peripheral vascular prostheses in a highly select group of patients. These patients were ''end of the line,'' and last-ditch efforts were made to salvage life or limb. Twenty-four infected vascular grafts in 20 patients have been analyzed. Ages ranged from 52 to 87 years. All patients had grade 3, stage I, II, or III peripheral graft infections, as previously defined by Szilagyi and modified by vonDongen. Aortofemoral reconstruction was the most common initial bypass procedure (14), followed by femoral popliteal (6), axillofemoral (2), iliofemoral (1), and subclavian/subclavian bypass (1). Staphylococcus aureus was the most common infecting organism. Muscles used for coverage were the rectus femoris (13), the sartorius (9), the rectus abdominis (1), and the pectoralis major (1). The graft material was composed of Dacron in 16 instances and polytetrafluoroethylene in 8. The 24 graft infections were treated by extensive debridement, muscle-flap transposition, and closed-suction irrigation system with dilute povidone-iodine. Sixteen (66.7 percent) were successful with a mean follow-up of 41 months. There were eight failures, and three patients required amputation. Two patients died of septic and vascular complications secondary to central aortic graft infection and/or necrotizing fasciitis of the extremities. This procedure can be successful in patients with well-localized peripheral graft infections not extending to the aortoiliac system.