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Infected Arteriovenous Graft Requiring Extensive Debridement and Coverage with Fasciocutaenous Flap: A Case Report
Juan B. Umana-Pizano, MD, Hunter M. Ray, MD, Stuart A. Harlin, MD.
University of Texas Health Science Center at Houston, Houston, TX, USA.

DEMOGRAPHICS: A 62-year-old male patient with end-stage renal disease on hemodialysis, had undergone a left brachial to axillary vein arteriovenous graft (AVG) placement 3 weeks prior.
HISTORY: He was admitted to the hospital complaining of two days of progressive pain and drainage from the antecubital left arm wound.The wound was dehiscent and the AVG was exposed.
PLAN: A decision was made with Plastic Surgery to perform a wound debridement, AVG excision, brachial artery ligation and bypass with concomitant fasciocutaneous pedicle flap rotation for coverage. Under general anesthesia, an incision was made proximal and distal to the previous antecubital wound and the brachial artery was dissected proximal and distal to the infection. A tunnel was created between the incisions and an arterial bypass with a saphenous vein graft created. The previous surgical wound was open and the brachial artery was ligated proximally and distally. The AVG was excised. A 3 by 4 centimeter full-thickness soft tissue defect remained in the antecubital fossa. Debridement was completed with copious pulsatile irrigation. A 5 by 12 centimeter fasciocutaneous flap extending to the distal forearm overlying the brachioradialis muscle was harvested protecting the vascular pedicle, and was rotated over the wound. The donor proximal and distal zones were closed and the medial zone covered with a fenestrated skin graft harvested from the anterior thigh.
DISCUSSION: Patients on hemodialysis are at high risk of mortality from sepsis. The antecubital fossa infections can be devastating and require coverage with vascularized tissue; a fasciocutaneous graft rotation from the forearm is an option. This novel surgical approach allows for outstanding coverage for this difficult anatomical defect with vascularized tissue.


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