Removal of Infected Arteriovenous Grafts is Morbid and Few Patients get a New Access within One Year
Thomas Cheng, M.S., Alik Farber, M.D., Mohammad H. Eslami, M.D., Jeffrey Kalish, M.D., Douglas W. Jones, M.D., Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
Objective: Infected arteriovenous grafts (AVGs) are a feared complication. These patients have many comorbidities and limited access options. Our objective was to analyze our contemporary series of infected AVG removal and analyze perioperative and long-term outcomes.
Methods: A retrospective analysis was performed for excision of infected AVGs from 2005-2017 at a single institution. Excisions were classified as total if all graft material was removed, subtotal if small cuffs were left, and a revision if a segment was removed and the graft was revised. Demographics, medical history, perioperative details, and follow up data were collected.
Results: There were 45 patients who underwent excision of an infected AVG - forearm (28.9%), upper arm (62.2%), and femoral (8.9%). Mean age was 57.6 years and 57.8% were male. Median time from AVG placement to removal was 1 (0-18) years and 91.1% of grafts were placed at our institution. Patients with infected AVGs presented with bacteremia (55.6%), sepsis (35.6%), purulent drainage (37.8%), and bleeding (31.1%). The majority (60%) of grafts were patent on presentation. 15.6% of patients that had an endovascular intervention 30 days prior to graft removal. 37.8% of grafts underwent total excision with the majority had a venous patch repair of the artery. 22.2% of grafts underwent a revision, while the remainder had subtotal excision. A tourniquet was used in 15.6% of cases. The mean estimated blood loss was 155 ml and procedure time was 184 minutes. Bacterial growth was present in 82.2% of specimens: Staphylococcus aureus (45.9%), methicillin-resistant Staphylococcus aureus (18.9%), coagulase-negative Staphylococcus species (13.5%), and Pseudomonas aeruginosa (13.5%). Post-operative ICU admission occurred in 17.8% of cases. Post-operatively there were cardiac (13.3%), surgical site (13.3%), and pulmonary (4.4%) complications. Mortality at 90 days and 1 year were 4.4% and 13.3%. There were 33.3% readmissions at 30 days and 60% readmissions at 90 days. Reoperation occurred in 15.6% patients of which the majority (85.7%) originally had a subtotal excision. New access was placed in only 28.9% patients at 1 year.
Conclusions: Patients undergoing removal of an infected AV grafts have high morbidity and are resource intensive. The majority do not have a definitive access placed again within the first postoperative year. Infected AV graft should be considered an important quality measure at centers creating and maintaining dialysis access.
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