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Removal of infected arteriovenous grafts is morbid and many patients do not receive a new access within 1 year.
J Vasc Surg. 2018 Dec 24;:
Authors: Cheng TW, Farber A, Eslami MH, Kalish JA, Jones DW, Rybin D, Siracuse JJ
Abstract
OBJECTIVE: Infection of a prosthetic arteriovenous graft (AVG), in patients who have many comorbidities and limited access options, is a feared complication. Our objective was to investigate our contemporary series of infected AVG operations and analyze perioperative and long-term outcomes.
METHODS: We performed a retrospective analysis of AVGs removal, in the setting of infection, from 2005 to 2017 at a single institution. Procedures were classified as total excision if all graft material was removed, subtotal excision if small cuffs remained, and revision if a segment was removed and the graft was revised. Demographics, medical history, perioperative details, and follow-up data were collected.
RESULTS: There were 47 patients who underwent an operation for an infected AVG-forearm (27.7%), upper arm (63.8%), and femoral (8.5%). The mean age was 57.7 years and 59.6% were male. The average time from AVG placement to operation for infection was 20.4 months and 85.1% of grafts were placed at our institution. There were 33 patients (70.2%) who had a previous access before the infected graft. Patients with infected AVGs presented with bacteremia (57.4%), sepsis (36.2%), purulent drainage (55.3%), and bleeding at the graft site (31.9%). The majority of grafts (61.7%) were patent on presentation. There were patients 17 (36.2%) who had a fistulogram and 16 (34%) underwent an endovascular intervention within 90 days of graft excision. With regard to procedure type, 40.4%, 38.3%, and 21.3% of AVGs were treated with total excision, subtotal excision, and revision, respectively. Bacterial growth was present in 84.8% of specimens with the most common bacterial species being any Staphylococcus aureus (53.2%), methicillin-resistant S aureus (17%), coagulase-negative S species (10.6%), and Pseudomonas aeruginosa (8.5%). Postoperative intensive care unit admission occurred in 21.3% of cases. There were 25 postoperative complications that occurred in 17 patients (36.2%). The most frequent postoperative complications were nongraft site infections (28%) followed by graft-related events (16%). Mortality at 90 days and 1 year were 2.1% and 12.8%, respectively. Readmissions at 30 and 90 days were 30% and 55%, respectively. Reoperation for infection in the index limb occurred in 10.6% of patients-40% from those who had subtotal excision and 60% from those who underwent revision. New access was placed in 52% of eligible patients at 1 year.
CONCLUSIONS: Removal of an infected AVG is associated with high morbidity and resource use. Many eligible patients do not receive a definitive access within the first year of graft excision. Close follow-up is necessary to allow opportunities in reassessing for potential new access creation.
PMID: 30591289 [PubMed - as supplied by publisher]