INFECTED LOWER-EXTREMITY EXTRAANATOMIC BYPASS GRAFTS - MANAGEMENT OF A SERIOUS COMPLICATION IN HIGH-RISK PATIENTS

To determine optimal management and outcome of infected extra-anatomic bypass grafts (EABG), we reviewed 28 patients (19 men and 9 women; me an age 70 years) treated over a 18-year period. Mean follow-up was 42 months. There were 16 axillofemoral (AF), 10 femorofemoral (FF), and t wo axillopopliteal (AP) grafts. Risk factors included previous prosthe tic graft infection in 13 patients, enterocutaneous fistula in two, an d mycotic aortic aneurysm in one. initial management involved complete graft excision in 12 patients, partial graft excision in 10, and nonr esectional therapy in six. Failure of nonresectional therapy and parti al excision in three patients each required further operative interven tion with graft excision. Reconstruction in patients eventually requir ing graft excision (n = 25) entailed placement of a new prosthetic AF or AP graft in eight, an autogenous FF graft in five, combined prosthe tic AF and autogenous FF bypass in two, autogenous iliofemoral bypass in one, obturator bypass in one, or no reconstruction in eight. Four a utogenous FF reconstructions thrombosed immediately postoperatively, a nd three prosthetic reconstructions became infected. The mortality rat e was 18% (FF = 20%, AF = 19%, AP = 0%). The amputation rate was 25% ( AP = 100%, AF = 25%, FF = 10%) and was higher without arterial reconst ruction (56% vs. 12%, p = 0.02). Two patients required hemipelvectomie s and one had bilateral hip disarticulation. We conclude that EABG inf ections can be successfully treated but carry significant morbidity an d mortality. Optimal management includes EABG resection and prompt rev ascularization, bearing in mind the risk of early thrombosis in autoge nous grafts and reinfection in prosthetic grafts.