Prosthetic patch remnants to treat infected arterial grafts

Purpose: Our previous experience with the traditional management of infecte d prosthetic arterial grafts, which included graft excision and vein,patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic,gra fts with subtotal graft excision and oversewing of small graft remnants. Methods: During the last 20 years, we treated 53 wounds involving 45 infect ed prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2-to 3-mm graft remnant (patch) at an intact arte rial anastomosis. This technique was selectively used to maintain patency o f small-diameter arteries (41 common femoral, five deep femoral, three axil lary, two iliac, and two popliteal), which were critical for limb salvage o r amputation healing. This strategy avoided difficult dissection of the und erlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cas es and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing change s were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedure s were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1: to 218 months). Results: No complications were directly attributable to prosthetic patch re mnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died duri ng hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 m onths after surgery, and two wounds failed to heal. Sixteen secondary bypas s grafting procedures were necessary to achieve limb salvage. Patch oversew ing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when se condary revascularization was not possible. Conclusion: Prosthetic patch remnants are a useful adjunct-that simplify ma nagement of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.