SURGICAL-MANAGEMENT OF INFRAINGUINAL ARTERIAL PROSTHETIC GRAFT INFECTIONS - REVIEW OF A 35-YEAR EXPERIENCE

Purpose: The purpose was to determine the early and late mortality and morbidity rates associated with infrainguinal arterial prosthetic gra ft infection (IAPGI) and to identify optimal methods of management. Me thods: The study included 53 men and 14 women (mean age, 61 years) in whom a total of 68 IAPGIs developed in the years 1959 to 1993. IAPGI i nvolved 58 femoropopliteal grafts (85%), six femorodistal grafts (9%), and four other grafts or synthetic patches (6%). Graft material was d acron in 36 (53%), polytetrafluoroethylene in 28 (41%), and human umbi lical vein in four (6%). Sixteen IAPGIs (24%) involved limbs that had required amputations before IAPGI was diagnosed. Twenty-six (38%) of t he 68 grafts were thrombosed, and 14 (88%) of the 16 amputeed had occl uded grafts. Results: Staphylococcal organisms were isolated from 34 ( 58%) of the 59 IAPGIs for which culture data were available. The media n intervals until IAPGI was diagnosed were 3 months after implantation and 1 month after the last procedure involving the original graft. In itial management consisted of local measures only in 13 (19%), partial removal or:in situ graft replacement in 15 (22%), and total graft exc ision in 40 (59%). Total excision was performed in 15 (94%) of the 16 patients with prior amputations and in only 25 (48%) of the 52 intact limbs. The overall postoperative mortality rate was 18%; seven (58%) o f the 12 early deaths were related to sepsis, and all 12 occurred with in the group of 51 patients (24%) for whom limb salvage was still bein g attempted (p = 0.056). IAPGI ultimately led to amputations in 21 (40 %) of 52 intact limbs within the first year. Twenty-three (82%) of the 28 IAPGIs managed with incomplete graft removal required subsequent o perations for continued sepsis, compared with five (13%) of the 40 tre ated with complete excision (p < 0.001). The cumulative 5-year surviva l rate (77%) for 53 patients who survived operation was less than that (89%) for the normal, age-matched U.S. male population. Conclusions: IAPGI is associated with substantial early mortality and amputation ra tes. Complete excision of infected graft material results in a signifi cant reduction in the incidence of recurrent sepsis.