AVOIDING INFRAINGUINAL BYPASS WOUND COMPLICATIONS IN PATIENTS WITH CHRONIC RENAL-INSUFFICIENCY - THE ROLE OF THE ANATOMIC PLANE

Objective: To study the factors leading to wound problems in patients with chronic renal insufficiency (CRI) with emphasis on subcutaneous v s. deep placement of grafts. Methods: The outcomes of patients undergo ing an infrainguinal bypass with preoperative CRI (serum creatinine gr eater than or equal to 2.0 mg/dl) were reviewed. Surgical site infecti on (SSI) was classified as superficial or deep according to the Centre s for Disease Control standards. Results: Forty-two patients underwent a total of 47 infrainguinal bypasses for ischaemic rest pain or tissu e loss. The graft location was partially or predominantly subcutaneous in 21 limbs (Group I) and 26 grafts were positioned in the anatomic o r subfascial planes (Group II). In Group I, seven early (<30 days post operative), one intermediate (4-6 weeks postoperative), and one late ( >6 weeks postoperative) SSI's were found (9/21, 43%). In three of thes e patients the graft was exposed and two required removal. In contrast , only two early and one intermediate SSI's (3/26, 12%) were noted in Group II (p = 0.02). A logistic regression analysis, with twelve possi ble covariables to wound healing, confirmed the subcutaneous location to be the only controllable factor significantly predicting SSI (relat ive risk = 11.6, p = 0.01). Conclusions: The infrainguinal bypass in p atients with CRI is associated with a high incidence of wound complica tions. In our retrospective series, the presence of a vascular conduit in the subcutaneous plane was connected with a higher rate of SSI. De spite the glowing trend toward the use of the in situ bypass, CRI may represent a circumstance where deeply placed grafts should be used pre ferentially.