Original papers Acta chir belg, 2007, 107, 37-44
Use of Vacuum Assisted Closure in Vascular Graft Infection Confined to the Groin T. Kotsis*, Chr. Lioupis** From the *Department of Vascular Surgery, 2nd Surgical Clinic, School of Medicine, Athens University, Aretaeion Hospital and the **Department of Vascular Surgery, Red Cross Hospital of Athens, Athens, Greece.
Key words. Vacuum assisted closure ; groin wounds ; wound healing complications ; vascular graft infection ; lymphatic fistula. Abstract. Purpose : In this report we share our experience with the use of the VAC system as a less invasive means of graft preservation and an effective alternative to routine muscle flap closure, in patients with groin wound healing complications following lower limb vascular procedures. We also review the English literature regarding the use of VAC therapy on infected groin wounds when the infection affects the prosthesis. Patients and Methods : eight patients treated with delayed healing of a groin incision following a femoral artery surgery. In six cases local exploration or CT examination showed evidence of graft involvement (Szilagyi grade III). Results : Mean duration of VAC use was 21.5 days (range, 10 to 45). The wounds were filled with granulation tissue by day 10 with no purulent-inflammatory exudates. At the end of VAC therapy, final closure was easily achieved by either healing by secondary intention or delayed primary closure. No patient required use of muscle flaps. There were no reinfections at 1 to 28 month follow-up (mean, 17.2 months/ one case lost to follow-up). Conclusion : Our initial experience with VAC therapy to treat non healing groin wounds following vascular reconstructions is very promising. Negative pressure therapy resulted in control lymph leakage, achieving healing and managing infection.
Introduction Lymphatic complications and wound infections are common and potentially serious events following lower limb arterial reconstructions. A lymphatic fistula is a persistent lymphatic clear discharge that complicates approximately 2% of groin incisions of vascular surgery. While the discharged lymph is initially sterile, in approximately 25% of patients cultures become positive ; and lymphatic fistulas may be potential causes of graft infection (1, 2). The presence of prosthetic material increases the likelihood of protracted lymphatic drainage (3) ; which in about 40% of cases results in an increased morbidity and hospital stay (4). The pathogenesis and management of this clinical problem remain unclear. In the case of infection of a groin incision, the entire reconstruction is endangered by the transmission of infection to the prosthetic material. The incidence of vascular prosthetic graft infection is low, ranging from 0.7% to 7% after lower limb bypass surgery. Any infected vascular graft may have devastating sequelae, including loss of either life or limb (5-7). The mortality asso-
ciated with infra-inguinal prosthetic infections has been reported to be about 10-25% ; mainly determined by the extent of the graft infection and by the underlying condition of the patient. Morbidity, which in general is represented by the necessity of subsequent amputation, is still higher than 20% (8). Despite the availability of multiple options for the treatment of infected inguinal grafts, an algorithm for rational selection among them has not been well defined (7, 9). Adequate treatment usually requires a lengthy period of hospitalization, which is often accompanied by multiple revision interventions. PICONY et al. hypothesized that if a deep wound infection near the prosthetic material, is recognized early enough, negative pressure treatment can be considered with an acceptable success rate (8). In this report we share our experience with the use of the VAC (Vacuum Assisted Closure) system as a less invasive means of graft preservation and an effective alternative to routine muscle flap closure, in patients with groin wound healing complications following lower limb vascular procedures. We also review the English literature regarding the use of VAC therapy on infected groin wounds, with exposure of the vascular graft.
38 Patients and methods It concerns a retrospective observational case-study of eighth patients treated by VAC for vascular graft infection at the level of the groin. From September 2003 to December 2006, eight patients presented with delayed healing of a groin incision following a femoral artery surgery (table I). Six patients were men and two women, with a mean age of 61.4 (range, 24 to 74). Four patients with delayed healing of groin incision presented with lymphatic fistulae while the remaining four had acute postoperative wound infection, evidenced by clinical signs (redness, swelling and purulent wound discharge). Six patients had symptomatic arterial occlusive disease and three patients were type II diabetics. Other comorbidities included : arterial hypertension, morbid obesity, pulmonary insufficiency, malignancies and renal failure (table 1). Three patients had polytetrafluoroethylene (PTFE) grafts implanted, one had a Dacron aortic graft and four patients had a synthetic patch placed on the common femoral artery. Wound infection was defined as a purulent discharge or leakage from the wound edges which showed a positive culture for pathogenic micro-organisms, with signs of inflammation. Description of groin infective complications is made according the Szilagyi’s grading system, that includes three grades of infection. When only the dermis was affected the infection was classified as Grade I ; if the infection extended into the subcutaneous region without invading the vascular graft was classified as Grade II ; and in the instances where the vascular graft was involved in the infection was classified as Grade III. In five cases local exploration or CT examination showed evidence of graft involvement (Szilagy grade III). During exploration, the infection was deemed affecting the prosthesis when suture material became visible on the bottom of the wound. Wound smears of the infected area close to the implant were taken in all patients. Low grade fever was present in three cases with Szilagy grade III infection. No improvement was seen after a short course of polyvidone iodine packing changed daily and intravenous administered antibiotics. The VAC system (V.A.C.TM System, Kinetic Concepts, Inc, San Antonio, TX) was applied one day after the initial debridement, after the wound was considered suitable to vacuum treatment according to the discretion of the treating physician. All wounds were debrided at bedside or in the operating theatre after local exploration. The polyurethane foam sponge was cut to match the size of the wound cavity and was placed within the wound area adjacent to the prosthetic material and together with the vacuum tubing. The construct was sealed with a transparent adhesive dressing (Fig. 1). The vacuum assisted closure (VAC) system was directly applied on part of the vessel wall or vascular graft with suction to 125 mmHg,
T. Kotsis and Chr. Lioupis but not in contact with exposed or uncovered anastomotic line. The frequency of dressing changes was determined based on the amount and appearance of the fluid collected in the reservoir, which was evaluated daily. In most patients, changing the dressing every 48 hours was appropriate. Laboratory diagnostics were carried out every third day to investigate systemic response to local inflammation. All patients were treated with culture-directed intravenous antibiotics during VAC application. Results Mean duration of VAC use was 21.5 days (range, 10 to 45). The mean length of hospital stay was 37.4 days (range, 18 to 64). Cultures revealed mixed infection in all but one cases. In four patients total wound closure was accomplished at the end of VAC use. In two more cases almost complete healing permitted patient’s transfer to a rehabilitation center with suggestions for dressing changes. In the last two cases, use of VAC system resulted in clear and well granulated wounds that were treated secondary with delayed primary closure. The wounds were filled with granulation tissue by day 10, with no purulent-inflammatory exudates. After the end of VAC therapy, final closure was easily achieved by either healing by secondary intention or delayed primary closure (Fig. 1, 2). No patient required use of muscle flaps. There were no re-infections with 1 to 28 months’ follow-up (mean, 17.2 months/one case lost to followup). None of the patients reported severe discomfort associated with negative pressure or with dressing changes. No bleeding or false aneurysm formation occurred despite of VAC application directly on femoral vessels and anastomotic sites. Distal blood flow was not affected neither. However, one patient developed deep vein thrombosis at the site of VAC application, documented with Colour Duplex examination, and an episode of pulmonary embolism five days after negative pressure initiation. Appropriate anticoagulation was started and VAC treatment was interrupted allowing continution of wound healing by secondary intention. Discussion Our experience with VAC therapy to treat non-healing infected groin wounds following vascular reconstructions is very promising. We used the VAC system in patients who were poor candidates for graft removal or muscle flap closure. Negative pressure therapy resulted in pausing lymph drainage, achieving rapid granulation and eradicating infection in all cases.It has become the only modality utilized for wound closure in our departement. Acceptability by the patients was very good, while the system imposed few constraints on the caregivers.
hypertension, morbid obesity,
diabetes mellitus II, morbid obesity,
pulmonary insufficiency, morbid obesity,
65
68
55
6
7
8
Aorto-bifemoral bypass
angioplasty R femoral
femoral-femoral bypass
12
10
13
7
angioplasty R femoral
diabetes mellitus II, malignancy
5
71
61
4
15
10
hepatitis C
24
3
EVAR, femoralfemoral bypass
6
hypertension, renal R femoral-popliteal failure bypass
hypertension, diabetes mellitus II, renal failure
73
2
embolectomy L femoral
Time from initial Procedure (days)
30
hypertension, morbid obesity,
74
1
Vascular procedure
R femoral artery & vein injury after gunshot
Medical History
Age (yr)
Patient
Table I
Staphylococcus aureus, Proteus, Pseudomonas aeruginosa.
Coagulase negative Staphylococcus, E.coli, E.faecalis, Streptococcus viridans, Bacteroides,
enterococcus faecalis, proteus mirabilis, Staphylococcus aureus, Providencia rustigianii
Streptococcus viridans, Proteus, Klebsiela
Staphylococcus aureus, Corynebacterium
MRSA, Streptococcus viridans, E. coli, E.faecalis, Candida
Staphylococcus aureus, Klebsiella, Escherichia coli.
Staphylococcus epidermidis
Culture
45
12
37
19
18
10
19
12
Grade III
Grade III
Grade III
Grade III
Grade III
Grade II
Grade III
Grade II
Duration of Infection VAC use staging (days) according to Szilagyi
Vascular procedures resulting in wound lymphatic complications or infection
L inguinal area
R inguinal area
R inguinal area
R inguinal area
R inguinal area
Almost complete granulation
Almost complete granulation
Wound closure
Wound closure
Wound closure
Almost complete granulation
Wound closure
Inguinal bilateral R inguinal area
Clearance/ improved granulation
Outcome
L inguinal area
Position of VAC placement
64
35
50
26
28
44
34
18
Hospital length of stay (days)
1/no
26/no
1/no
20/no
20/no
–
14/no
25/no
Follow up (months)/ reinfection
VAC Therapy of Vascular Surgical Wounds 39
40
T. Kotsis and Chr. Lioupis
Fig. 1 (a) Infection of right groin wound following femoralfemoral bypass ; (b) VAC system application on both groins for thirty-seven days ; (c) wound closure at the end of therapy.
Postoperative complications in groin area such as lymphatic fistulae are worrisome because they have been associated with an increased risk of infection of underlying grafts (3). Risk of infection has motivated several approaches to treatment once lymph leakage is noted. Leg elevation to lessen lymph flow by reducing capillary hydrostatic pressure, in combination with the use of antibiotics, has been recommended (10). Pressure dressing over the groin to interrupt flow and permit healing has also been proposed, but thrombosis of the grafts placed in the groin during the period of pressure application is a great concern (11). Moreover, KWAAN et al. reported that three of seven patients with conservatively treated lymphorrhea developed serious wound infection, resulting in amputation in one of these cases (1). Eastcott has treated lymphorrhea with success by reopening the incision, placing suction drains beneath the skin and resuturing the wound (12). A policy of early exploration and direct ligature of damaged lymphatics has been advocated by many authors (1, 3, 13). GORDON et al. suggested that in the case of fluid leaking through an incision, wounds should be explored as soon as feasible and reclosed if possible (3). Recent reports have documented benefit from early operative re-exploration with the use of isofluran blue, in conjunction with operative exploration that allows rapid and accurate oversewing of the injured lymphatics (14). However, this non-selective approach can possibly lead to unnecessary exploration of some superficial lymphatic fistulas that one would expect to close spontaneously. Moreover, the extensive dissection required to remove the lymphatic capsule of the lymphocoel, exposes adjacent lymphatics to injury and may be the cause of a recurrence following dye-assisted ligation (14). It is also very important that the typical fragile elderly patient with many comorbidities may not be a suitable candidate for early surgical re-
Fig. 2 (a) Infected right groin wound following femoralfemoral bypass, after surgical debridement in the operating theatre ; (b) infected left groin wound with graft and suture material visible on the bottom of the wound (arrow) ; (c) VAC system application on both groins for nineteen days ; (d) delayed primary closure after eradication of infection and fill of wound with granulation tissue. No re-infections during fourteen months’ followup.
intervention. The controversy regarding optimal treatment, opposing nonoperative therapy versus early reoperation and direct control of the leak, prompted some authors to search new treatment modalities such as VAC therapy, to deal with early lymphatic complications. Management of inguinal wound infections following vascular graft placement depends on degree of graft involvement. If no graft involvement is apparent (Szilagyi grade I or II), then wound debridement or drainage with culture-directed antibiotic administration is considered to be adequate. If, in contrast, direct graft sepsis is present (Szilagyi grade III), then further management is more controversial. Traditionally, complete graft excision has been recommended followed by immediate revascularization via extra-anatomical routes (7). However, many drawbacks have been associated to extra-anatomic bypass including low patency, lengthy procedure time, relatively high amputation rate, significant risk of rupture of the aortic suture line(aortic stump blow-out), and difficulty of extra-anatomic routing in the inguinal region (15). These drawbacks lead to the question of whether extra-anatomic bypass should remain the gold standard for treatment of infected vascular grafts. In situ reconstruction has been attempted in
VAC Therapy of Vascular Surgical Wounds appropriately selected patients using various conduits, including autogenous veins, cryopreserved allografts, and synthetic prostheses that are either rifampicin-bonded or silver-coated. Recently, O’CONNOR et al. demonstrated in a meta-analysis of treatments of aortic graft infections, that in situ reconstruction is a safe and effective alternative in the treatment of selected patients (15, 16). There are, however, disadvantages associated with in situ reconstructions, including lengthier operative time in case of vein harvesting and contraindication in patients with previous deep vein thrombosis ; high complication rates of cryopreserved allografts and lack of availability in emergent cases ; or the limited risk of reinfection of rifampicin-bonded prostheses. It must be stressed, that in situ reconstructions are associated with a greater surgical stress than extra-anatomic bypasses, which is an important consideration for fragile patients in life-threatening situations. Moreover, the available evidence is mainly restricted to aortic graft infections associated with microorganisms of low virulence. The literature on infected infra-inguinal grafts is scarce. Use of a muscle flap to cover exposed native vessels or to salvage prosthetic material used in arterial reconstruction has also been advocated in a selected group of patients (9). Graft preservation is considered to be feasible when the graft is patent and the anastomosis is intact, the whole graft is not involved by the infection, the patient has no systemic signs of sepsis and the offending organism is not a virulent strain of bacteria, especially MRSA and Pseudomonas aeruginosa (19, 20). The feasibility of using local muscle flaps, providing a source of richly vascularized tissue to promote wound healing and vascular graft salvage has been well documented (2123). However, this approach constitutes a second operation on a fragile, multi-operated patient with many comorbidities, that may worsen outcome. Indeed, ILLIG et al. reported a very high mortality rate (24.4%) in a series of 41 patients treated with muscle flap coverage of deep but localized groin infections ; however the percentages of successful groin wound healing were excellent (90% of flaps healed primarily without problems) (18). Furthermore re-infection may occur in as many as 35% of patients after radical debridement and muscle flap closure (25). CALLIGARO et al. (1994), challenged management approaches of infected groin wounds using muscle flaps and developed the concept that complete infected graft preservation can be achieved without using muscle flaps. Complete graft preservation was achieved successfully in approximately three quarters of 51 patients with infected prosthetic grafts (the site of infection was in the groin in the majority of the cases) with an acceptable mortality and amputation rates (12% and 4%, respectively). The patients were successfully managed by repeated, operative wound debridement and antibiotic or povidone-iodine-soaked
41 dressing changes until the wounds healed by delayed secondary intention. Long-term wound healing was successfully accomplished in 71% of the patients. Compared with other series of infected grafts treated by routine grafts excision, this approach resulted in an improved amputation rate without increased mortality rates. Thus, the authors suggested that placement of a muscle flap is not essential to achieve successful graft preservation, though it may shorten hospital stay (20). Recently VAC therapy has been reported as an adjunctive measure after groin infections involving exposed bypass grafts or as a definite treatment approach to deal with such lesions. GIOVANNINI et al. used VAC therapy for treating a patient in poor general condition, presenting with purulent groin wound dehiscence and vascular patch exposure following a common femoral artery revascularization procedure (26). After 19 days of treatment, the vascular prostheses was covered with granulation tissue, wound size had decreased substantially and the patient’s condition improved. PICONY et al. treated 24 patients with periprosthetic infection (grade III according Szilagyi) by the insertion of a PVAvacuum sponge system (8). They used a modified treatment protocol lasting 14 days with sponge exchange after 7 days and closure of the wound by vertical mattress suture and continuous suction by means of a vacuum fluid removal system connected to the Redon drain, with the achieved vacuum fluctuating between 400 and 600 mmHg. All wounds were definitely closed after 14 days and the authors concluded that deep wound infections in the vicinity of underlying prosthetic material in the groin can be successfully and cost-effectively treated by application of a PVA-vacuum sponge system. DEMARIA et al. evaluated the efficacy and safety of VAC therapy in four patients who suffered severe local complications (tissue defect, diffuse haematoma and abscess) with evidence of systemic infection following emergency femoral vessel surgery (27). Dramatic local improvements were observed in all four patients and after a mean of 2 weeks, the defects were entirely covered and filled by granulation tissue, allowing use of a simple surgical skin-closure technique. STEENVOORDE et al. treated successfully a patient with VAC therapy for a dehiscent groin wound with a high lymphatic output fistula after an ilioinguinal node dissection for a locally metastasized melanoma (28). There were no complications and the wound responded very well to the treatment. GREER et al. have presented two more cases of groin lymphocutaneous fistulas after vascular surgery treated successfully with negative pressure therapy (29). More recently DOSLUOGLU et al. used the VAC system after wound debridement in four patients with fully exposed synthetic bypass grafts who were too unstable or risky for further operative interventions (19). Mean duration of VAC use was 22.8 days with mean time to
42 total wound closure of 41 days. Nonadherent dressing or silver antimicrobial perforated sheet (Silvasorb) were used to keep the sponge from coming in direct contact with the anastomoses. All patients were kept on culturedirected intravenous antibiotics for 6 to 24 weeks, depending on the extent of the exposure of the anastomoses and the virulence of the cultured bacteria. There were no reinfections during a 11 to 25 months followup. The authors suggested that for high-risk surgical patients with a fully exposed infected prosthetic vascular graft, VAC therapy along with aggressive debridement and antibiotic therapy may be an effective alternative to current management strategies. Perhaps the most impressive data have been reported recently from MAYER et al. who applied the VAC system directly on the vessel wall or vascular graft in 29 patients with 36 perivascular infection sites or lymphatic fistulae (30). The VAC system (with suction-force of 50 to 125 mmHg) was applied mainly to groin, the technical success rate was 100% and no vascular erosion or bleeding occurred. Bacterial swabs were negative after 4 to 56 days of VAC application and wounds healed after a mean time of 19.5 days. The authors concluded that the direct application of VAC system on native vessels and/or grafts is safe ; wound-infections otherwise requiring daily revision in the theatre, could be treated every 3 to 10 days using VAC therapy on the ward ; and extra-anatomic bypasses were avoided. Finally, COLWELL et al. have used the VAC system as an adjunctive treatment in four of nine patients with groin infections adjacent to vascular bypass grafts after initial debridement, for 3 to 14 days, before a muscle flap was used to cover the graft (31). The time to flap closure was 5 days shorter in the patients with VAC use, although the difference was not significant because of the small sample size. We share the impression of GREER et al. that VAC therapy is as effective as any other treatment modality for management of lymphocutaneous fistulas (29). Of course, successful surgical ligation is a faster option than VAC therapy ; however VAC therapy is less invasive, and provides the added benefit of promoting granulation tissue and healing in the wound surrounding the lymphatics. It also removes the liquified debris and decreases the bacterial count. Moreover, it is thought that when VAC is applied to lymphocutaneous fistulas, the leaking lymphatics are sealed by the surrounding rapid proliferation of granulation tissue. In the case of frank groin infection affecting a synthetic vascular graft, the VAC therapy may be used as a bridge to muscle flap closure or as a definite treatment. Our goal is to intervene in these patients early, before an initially serous drainage turns purulent. In general, graft removal is suggested in cases of Pseudomonas aeruginosa graft infection. However, in
T. Kotsis and Chr. Lioupis one case we decided to treat a patient with such infection of the left groin (III° according to Szilagyi), using the VAC system, since the patient was too unstable to sustain an operation of aorto-bifemoral graft removal. We observed excellent results after six weeks of VAC therapy.The wound almost completely granulated, while the patient was in good condition, with no clinical or biochemical evidence of infection. Of course, we cannot recommend this treatment option (VAC) based upon only a month of follow-up and certainly, there is the potential of re-infection in the long-term. From our experience from treating successfully eight patients with groin lymph drainage and/or infection using the VAC system, we conclude that VAC treatment may speed the process of granulation and has a favorable effect on the bacterial balance. However, MOUES et al. could not find any significant effect of VAC therapy on the total amount of bacteria (32). These results differ from earlier clinical VAC studies in which a trend toward reduction of bacterial load was reported using semiquantitative superficial swabs (8, 33). They are also in contrast with the results of an animal study in which a significant decrease in the number of bacteria was found in tissue biopsies (34). The difference in outcome between clinical studies might be explained by the differences in sampling method (superficial swabs vs. biopsies) and/or method of analysis (semiquantitative vs. quantitative). WEED et al. retrospectively reviewed 25 patient-charts of wound VAC therapy with serial quantitative cultures and found that there is not a consistent effect of bacterial clearance with the wound VAC (35). Despite this finding, the beneficial effects of VAC treatment on wound healing were noted in most cases. Alltogether it should be noted that VAC therapy seems to have a similar effect on bacterial load to conventional therapy, despite the fact that in VAC therapy no local antimicrobial agents are used (32). The only event of possible concern was the occurrence of deep vein thrombosis on the side of VAC therapy in one patient. It is a possible that the negative pressure, applied over the femoral vein, collapsed this low pressure vessel, impairing venous return and increasing the risk of thrombosis. DEMARIA (27) suggested reasonable precautions including effective anticoagulation throughout the treatment and routine Doppler examination of the deep leg veins on the site of VAC device. Our observation of deep vein thrombosis on the site of VAC system placement complicated with pulmonary embolism is the second case reported in the English literature (the other is the case-report by Demaria). Because of the negative pressure to vein blood flow, protection of femoral and saphenous veins in the groin using relatively rigid dressings is strongly recommended. Another concern with the use of VAC system on exposed grafts is the closeness of the sponge to the arte-
VAC Therapy of Vascular Surgical Wounds rial anastomosis, to the artery or to the vein graft itself. Recently, WHITE et al. reported an erosion and hemorrhage of a left anterior tibial artery associated with a vacuum-assisted closure device (36). This report represents the first arterial erosion associated with a vacuum-assisted closure device. Based on this complication, the authors believe that great care should be taken when placing a vacuum-assisted closure device adjacent to an exposed artery. Other reported complications with VAC therapy include bleeding from hypervascular healing tissue and tissue ingrowth into the sponge. Probably in the infected-inflamed environment of the groin, arterial erosion and hemorrhage is a risk, especially when VAC therapy is combined with anticoagulation. Currently, there is no ideal treatment modality for managing lymphatic and/or infective groin complications following a femoral arterial reconstruction. Many studies have contributed to the conceptual framework of “conservative management” with or without the use of muscle flaps and provided the basis for new treatment options in this area. Negative pressure therapy is a new promising treatment modality. The current clinical evidence supporting the use of VAC therapy on infected groin wounds or lymphatic fistulae following vascular reconstructions has been largely based on clinical experience, case series and small cohort studies. Our short case-series cannot pretend to provide convincing and reliable arguments for routine use of VAC system in the management of infected vascular grafts at the level of the groin. Further evaluation is needed to see if use of the VAC system results in healing of infected groin wounds with longstanding eradication of infection from the tissues and the prosthetic materials. References 1. KWAAN J. H., BERNSTEIN J. M., CONNOLLY J. E. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg, 1979, 114 : 1416-8. 2. MURPHY J. L., COLE C. W., WHITE P. M. et al. Lymphatic fistula after vascular reconstruction : a case-control study. Can J Surg, 1991, 34 : 76-8. 3. GORDON I. L., POUSTI T. J., STEMMER E. A. et al. Inguinal wound fluid collections after vascular surgery : management by early reoperation. South Med J, 1995, 88 : 433-6. 4. SKUDDER P. A. Jr., GEARY J. Lymphatic drainage from the groin following surgery of the femoral artery. J Cardiovasc Surg (Torino), 1987, 28 : 460-3. 5. GRAHAM R. G., OMOTOSO P. O., HUDSON D. A. The effectiveness of muscle flaps for the treatment of prosthetic graft sepsis. Plast Reconstr Surg, 2002, 109 : 108-13, discussion 114-5. 6. NEWINGTON D. P., HOUGHTON P. W., BAIRD R. N. et al. Groin wound infection after arterial surgery. Br J Surg, 1991, 78 : 888. 7. KIMMEL R. M., MURPHY R. X. Jr, CHOWDARY R. P. Optimal management of inguinal vascular graft infections. Ann Plast Surg, 1994, 32 : 623-9. 8. PICONY J., ALBES J. M., WICKE C. et al. Treatment of periprosthetic soft tissue infection of the groin following vascular surgical procedures by means of a polyvinyl alcohol-vacuum sponge system. Wound Repair Regen, 2003, 11 : 104-9.
43 9. MORASCH M. D., SAM A. D. 2nd, KIBBE M. R. et al. Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery. J Vasc Surg, 2004, 39 : 1277-83. 10. DEWEESE J. A. Complications of arterial reconstruction distal to the inguinal ligament. In : BEEBE H. G. (ed.). Complications in Vascular Surgery. Philadelphia : Lippincott, 1973, 19 : 155-9. 11. SETHI G. K., SCOTT S. M., TAKARO T. Persistent lymphatic fistula. Unusual complication of femoro-femoral arterial bypass. J Cardiovasc Surg (Torino), 1978, 19 : 155-9. 12. EASTCOTT H. H. G. Complications of aorto-iliac reconstructions for occlusive disease. In : BERNHARD V., TOWNE J. (eds.). Complications in Vascular Surgery. New York City : Grune and Stratton, 1980, 41-64. 13. SMELLIE G. D., WALLACE J. R. Lymph fistulas and lymphocysts after peripheral vascular surgery. J R Coll Surg Edinb, 1981, 26 : 78-81. 14. SCHWARTZ M. A., SCHANZER H., SKLADANY M. et al. A comparison of conservative therapy and early selective ligation in the treatment of lymphatic complications following vascular procedures. Am J Surg, 1995, 170 : 206-8. 15. O’CONNOR S., PETER ANDREW P., MICHEL BATT M., BECQUEMIN J. P. A systematic review and meta-analysis of treatments for aortic graft infection. J Vasc Surg, 2006, 44 : 38-45. 16. ODERICH G. S., BOWER T. C., CHERRY K. J. et al. Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center. J Vasc Surg, 2006, 43 : 1166-74. 17. TAYLOR S. M., MILLS J. L., FUJITANI R. M. et al. The influence of groin sepsis on extraanatomic bypass patency in patients with prosthetic graft infections. Ann Vasc Surg, 1992, 6 : 80-84. 18. ILLIG K. A., ALKON J. E., SMITH A. et al. Rotational muscle flap closure for acute groin wound infections following vascular surgery. Ann Vasc Surg, 2004, 18 : 661-8. 19. DOSLUOGLU H. H., SCHIMPF D. K., SCHULTZ R. et al. Preservation of infected and exposed vascular grafts using vacuum assisted closure without muscle flap coverage. J Vasc Surg, 2005, 42 : 989-92. 20. CALLIGARO K. D., VEITH F. J., SALES C. M. et al. Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts. Ann Vasc Surg, 1994, 8 : 31-7. 21. MIXTER R. C., TURNIPSEED W. D., SMITH D. J. Jr. et al. Rotational muscle flaps : a new technique for covering infected vascular grafts. J Vasc Surg, 1989, 9 : 472-8. 22. MCKENNA P. J., LEADBETTER M. G. Salvage of chronically exposed Gore-Tex vascular access grafts in the hemodialysis patient. Plast Reconstr Surg, 1988, 82 : 1046-51. 23. PERLER B. A., VANDER KOLK C. A., DUFRESNE C. R. et al. Can infected prosthetic grafts be salvaged with rotational muscle flaps ? Surgery, 1991, 110 : 30-4. 24. MAHONEY J. Salvage of the infected groin vascular graft with muscle flaps. Ann Plast Surg, 1989, 22 : 252-6. 25. TAYLOR S. M., WEATHERFORD D. A., LANGAN E. M. 3rd, LOKEY J. S. Outcomes in the management of vascular prosthetic graft infections confined to the groin : a reappraisal. Ann Vasc Surg, 1996, 10 : 117-22. 26. GIOVANNINI U. M., DEMARIA R. G., CHAPTAL P. A. et al. Negative pressure for the management of an exposed vascular dacron polyester patch. Ann Plast Surg, 2001, 47 : 577-8. 27. DEMARIA R. G., GIOVANNINI U. M., TEOT L. et al. Topical negative pressure therapy. A very useful new method to treat severe infected vascular approaches in the groin. J Cardiovasc Surg (Torino), 2003, 44 : 757-61. 28. STEENVOORDE P., SLOTEMA E., ADHIN S. et al. Deep infection after ilioinguinal node dissection : vacuum-assisted closure therapy? Int J Low Extrem Wounds, 2004, 3 : 223-6. 29. GREER S. E., ADELMAN M., KASABIAN A. et al. The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin. Br J Plast Surg, 2000, 53 : 484-7. 30. MAYER D. O., ENZLER M., INDERBITZI R. et al. (2005) Vacuumassisted closure system with direct contact to native arteries and/or vascular grafts to improve the outcome of perivascular infection. (only abstract) Available from : http://www.veithsymposium. org/pdf2005/87.pdf. Accessed (4 May 2006)
44 31. COLWELL A. S., DONALDSON M. C., BELKIN M. et al. Management of early groin vascular bypass graft infections with sartorius and rectus femoris flaps. Ann Plast Surg, 2004, 52 : 49–53. 32. MOUES C. M., VOS M. C., VAN DEN BEMD G. J. et al. Bacterial load in relation to vacuum-assisted closure wound therapy : a prospective randomized trial. Wound Repair Regen, 2004, 12 : 11-7. 33. DEVA A. K., BUCKLAND G. H., FISHER E. et al. Topical negative pressure in wound management. Med J Aust, 2000, 173 : 12831. 34. LIEKWEG W. G., GREENFIELD L. J. Vascular prosthetic infections collected experience and results of treatment. Surgery, 1977, 81 : 335–342. 35. WEED T., RATLIFF C., DRAKE D. B. Quantifying bacterial bioburden during negative pressure wound therapy : does the wound VAC
T. Kotsis and Chr. Lioupis enhance bacterial clearance? Ann Plast Surg, 2004, 52 : 276-9, discussion 279-80. 36. WHITE R. A., MIKI R. A., KAZMIER P. et al. Vacuum-assisted closure complicated by erosion and hemorrhage of the anterior tibial artery. J Orthop Trauma, 2005, 19 : 56-9.
Dr Thomas Kotsis, M.D., Ph.D. Aretaeion Hospital, University of Athens Vas. Sophias 76 115 28 Athens, Greece Tel. : 0030210 7286-126/273 E-mail :
[email protected] 