Results of Lateral Femoral Bypass for Prosthetic Arterial Graft Infections in the Groin
Nicholas Madden, DO, Matthew Dougherty, MD, Keith Calligaro, MD, Hong Zheng, DO, Douglas Troutman, DO.
Pennsylvania Hospital, Philadelphia, PA, USA.
Objective- Prosthetic arterial graft infections (PAGIs) in the groin pose significant challenges in terms of revascularization, limb loss, and associated morbidities. Although obturator canal bypass (OCB) has been suggested as an alternative to revascularize a threatened extremity in these cases, moderate success rates and technical challenges have limited its widespread adoption. Our results using lateral femoral bypass (LFB) as an alternative approach for the treatment of groin PAGIs suggest this is a viable option.
Methods- This is a retrospective review of our prospectively maintained database of patients who underwent LFB for groin PAGIs at our institution from 2000-2017. The data set includes patient demographics, comorbidities, peri-operative complications, patency, and need for re-intervention. Patients were followed with aggressive duplex ultrasound (DU) surveillance in our accredited non-invasive vascular laboratory every three months for the first year followed by every six months thereafter. After isolating the infected wound with sterile dressings, LFBs were tunneled under the inguinal ligament lateral to the infected wound from a sterile inflow iliac artery or aortobifemoral graft limb to an uninvolved outflow superficial femoral artery, deep femoral artery, or outflow graft.
Results- A total of 19 LFBs were performed in 16 patients (mean age, 69 + 12.6 years); 3 LFBs were performed urgently for acute bleeding. Choice of conduit included 6 (31.6%) autogenous vein grafts, 10 (52.6%) cadaveric grafts, 2 (10.5%) rifampin-soaked Dacron grafts, and 1 (5.3%) PTFE grafts. Average follow-up was 33 + 35.5 months (range 0 - 103 months). Major adverse events (MAE) included one (5.3%) death and one (5.3%) graft excision for pseudoaneurysm, both within 30 days of the operation. Primary and assisted primary patency at 12 and 24 months was 73% and 83%, respectively. One (6.2%) surviving patient required an amputation 17 months after surgery despite attempts at repeated revasculariation. Overall limb salvage was 93.8% during this follow-up period.
Conclusions- In this series, LFB for management of groin PAGIs demonstrated superior patency and limb salvage rates compared to previous reports of OCB. Diligent postoperative DU surveillance is critical to achieve limb salvage and maintain graft patency. LFB also confers the advantage of being less technically challenging than OCB. Our results suggest that LFB should be considered the first choice of revascularization in the management of groin PAGIs.
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