Obturator or "lateral" bypass in the management of infected vascular prostheses at the groin

• Published in: Srpski arhiv za celokupno lekarstvo Vol. 130; no. 1-2; pp. 27 - 32
• Main Authors: Davidovic, Lazar, Kuzmanovic, Ilija, Kostic, Dusan, Cinara, Ilijas, Cvetkovic, Slobodan, Ristic, Miljko, Velimirovic, Dusan, Jadranin, Dragica
• Format: Journal Article
• Language: English
• Published: Serbian Medical Society 2002
• Subjects: Bypass; groin; infected prostheses; lateral; obturator
• ISSN: 0370-8179; 2406-0895
• DOI: 10.2298/SARH0202027D

The infection of the previously implanted vascular graft at the groin, is associated with great mortality and morbidity rate [1]. The authors present a retrospective study in which they analyzed management of infected vascular prostheses at the groin, using obturator bypass in 26 cases, and "lateral" bypass in 15 cases. The indications for obturator bypass reconstructions included: 20 infections of aorto-femoral grafts, two infected pse udoaneurysms in the groin after RTA of the superficial femoral artery, and 4 infections of iliac-femoral grafts. The indications for lateral bypass reconstructions were: infections after aorto-femoral reconstructions - 8 cases; infection after femora-popliteal reconstructions - 4 cases; infection after iliac-femoral reconstruction - 2 patients, and one infected pseudoaneurysm in the groin after RTA of the superficial femoral artery. In 3 subjects obturator bypass was performed using extraperitoneal approach while in other 23 patients transperitoneal approach was done by donor's artery. The obturator bypass was performed using a PTFE graft in 3 cases and Dacron graft in 23. The donor's artery used for obturator bypass was a noninfected proximal part of aortofemoral graft in 20 cases, and iliac artery in 6 patients. The superfical femoral artery was recipient artery for obturator bypass in 3 cases, deep femoral artery in one case, and above the knee popliteal artery in 22 cases (Figure 1). In two patients transperitoenal approach to donors artery for "lateral" bypass has been used, and in 13 cases extraperitoneal. The proximal noninfected part of aorto femoral graft was used as a donor's artery for lateral bypass in 8 patients, while common iliac artery in 7 subjects. In 5 cases recon structions were performed using PTFE grafts, in 3 using autologous saphenous vein grafts, and in 7 using Dacron grafts. The recipient artery for "lateral" bypass was deep femoral in 8 cases, superficial femoral in three patients and above the knee popliteal artery in 4 subjects. After both types of reconstruction, extirpation of infected grafts from the groin was performed (Figure 2). The control examination was performed using physical and Doppler ultrasonographic examinations, one, 3, 6, 12 months, and then every year after the operation. In cases with suspected graft infection or thrombosis, control angography was also performed. One intraoperative perforation of the urinary bladder has been done accidentally during obturator bypass reconstruction. The mean follow-up period for patients with obturator bypasses was 2.3 years, while 2.1 years for patients with "lateral" bypasses. Comparing with "lateral" bypass, obturator bypass showed statistically significant lower (p < 0.05) 30- day mortality and early graft infection rate, as well as statistically significant better early and total limb salvage rate. There were no statistically significant differences (p > 0.05) between obturator and "lateral" bypass procedures having in mind, late graft infection rate, as well as early and late graft patency (Figures 3 and 4). In cases with infected vascular prostheses in the groin, the authors recommend obturator bypass comparing with "lateral" bypass. Autori uporedjuju rezultate 26 opturacionih i 15 "lateralnih" bajpaseva u tretmanu infekcije, prethodno implantisane vaskularne proteze u preponi. Razlozi za opturacioni bajpas su bili: infekcija grafta posle aorto-femoralnog bajpasa (20 bolesnika); inficirana pseudoaneurizma u preponi posle politetrafluoretilenskog grafta (dva bolesnika); infekcija garfata posle ilijako-femoro bajpasa (cetiri bolesnika). Za novu rekonstrukciju kod tri bolesnika je koriscen politetrafluoretilenski, a kod 23 dakronski graft. Razlozi za "lateralni" bajpas su bili: infekcija garfta posle aorto-femoralnog bajpasa (osam bolesnika), infekcija grafta posle femoro-poplitealnog bajpasa (cetiri bolesnika); infekcija grafta posle ilijakofemoralnog bajpasa (dva bolesnika); inficirana pseudoaneurizma u preponi posle politetrafluoretilenskog grafta (jedan bolesnik). Kod pet bolesnika je koriscen politetrafluoretilenski, kod tri autovenski, a kod sedam dakronski graft. Bolesnici su kontrolisani posle 1, 3, 6 i 12 meseci i potom jednom godisnje fizikalnim i dopler-sonografskim pregledom, a u slucaju infekcije ili tromboze grafata i angiografijom. Statisticka obrada rezultata izvrsena je primenom Fiserovog testa. Kod jednog bolesnika s opturacionim bajpasom intraoperaciono je povredjena mokracna besika. Bolesnici s opturacionim bajpasom su prosecno nadgledani 2,3, a bolesnici s "lateralnim" bajpasom 2,1 godinu. Opturacioni bajpas je bio statisticki znacajno bolji od lateralnog bajpasa (? < 0,05) kada su u pitanju mortalitet tokom prvih 30 dana, rana infekcija novo implantisane proteze odnosno rano spasavanje i ukupno spasavanje ekstremiteta. U pogledu rane i kasne protocnosti, kao i kasne infekcije novoimplantisane proteze statisticke razlike izmedju ove dve hirurske intervencije nije bilo (? > 0,05). Kada je u pitanju tretman vaskularne proteze u preponi, autori daju prednost opturacionom u odnosu na lateralni bajpas.