Risk Factors And Consequences Of Graft Infection After Femoropopliteal Bypass: A 25-year Experience
Young Kim, MD, MS1, Charles DeCarlo, MD2, Shiv S. Patel2, Monica Majumdar, MD1, Samuel Jessula, MD1, Abhisekh Mohapatra, MD, MS1, Anahita Dua, MD, MS, MBA1.
1Massachusetts General Hospital, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA, MA, USA.
OBJECTIVES: Mitigation of risk factors associated with graft infection after femoropopliteal bypass is important for prevention of this highly morbid complication. This multi-institutional study aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post femoropopliteal bypass.
METHODS: A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures using CPT codes for the years 1995-2020. Chi-squared/T-test were utilized with univariable comparisons. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI) and Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk. Median follow-up was 2.89 years (IQR 0.75-6.55 years).
RESULTS: Over the 25-year study period, BGI was diagnosed in 34 of 1315 (2.6%) of total patients. Mean age was 68.4±12.0 years. Medical comorbidities were similar between BGI patients and all patients (p=NS each). Indications for surgery were similar between patients with BGI (32.4% rest pain, 38.2% tissue loss) and all patients (30.6% rest pain, 33.4% tissue loss) (p=NS). Popliteal bypass target was similar between groups (52.9% vs 38.4% above-knee) (p=NS). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%) and 30-day readmission rates (47.1% vs 21.3%) (p<0.05 each). BGI occurred between 9 days and 16.6 years postoperatively, with a median 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% CI, 1.4-3.1%) and 2.8% (95% CI, 1.9-3.9%), respectively. Most commonly isolated pathogens were Staphylococcus aureus (n=19, 55.9%) and polymicrobial cultures (n=5, 14.7%). Reoperation for BGI involved incision and drainage (n=7, 20.6%), graft excision without reconstruction (n=12, 35.3%), graft excision with in-line reconstruction (n=11, 32.4%), and graft excision with extra-anatomic reconstruction (n=2, 5.9%). Nine BGI patients (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR] 3.73 [1.64-8.51], p=0.002), postoperative hematoma (SHR 3.44 [1.23-9.61], p=0.018), and 30-day readmission (SHR 2.75 [1.27-5.44], p=0.010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9-65.7%) after BGI.
CONCLUSIONS: This is the largest series on femoropopliteal bypass graft infections to date. Prosthetic grafts and procedures complicated by hematoma or readmission are at increased risk for graft infection. Mitigation of these risk factors may decrease the risk of this highly morbid complication.
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