Kolakowski Stephen, Dougherty Matthew J, Calligaro Keith D
Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA.
J Vasc Surg. 2007 Jan;45(1):60-4. doi: 10.1016/j.jvs.2006.09.007. Epub 2006 Nov 21.
This study compared the incidence and characteristics of graft infection in patients who underwent early vs late revisional surgery of lower extremity arterial bypass grafts.
Between 1992 and July 2005, 500 revisional procedures were performed on 198 lower extremity bypass grafts. Patients whose revisions were performed <30 days after the primary bypass were in the early revision (ER) group (n = 99), and those done >30 days after bypass were in the late revision (LR) group (n = 99). Infection was defined as cellulitis with graft exposure or purulence in continuity with a graft that required antibiotics and operation for infection control. Mean follow-up was 60 months (range, 2 to 60 months). Groups were compared using Student's t test.
The ER group included 66 autogenous and 33 prosthetic grafts. The LR group consisted of 53 autogenous and 46 prosthetic grafts. Of the 500 revisional procedures performed, 17 graft infections occurred (3.4%). Twelve (70.6%) were prosthetic grafts and five (29.4%) were autogenous grafts (P = .004). Defining the infection rate per graft rather than per revisional procedure, the ER group had a significantly higher graft infection rate at 11% (11/99) compared with 6.1% in the LR group (6/99; P = .012). The risk of infection for prosthetic grafts was significantly higher within the ER group at 27.3% (9/33) compared with autogenous grafts at 3.1% (2/66; P = .0001). Infection developed in three vein grafts and three prosthetic grafts in the LR group (P = NS). For prosthetic graft revisions only, infection risk was 27.3% (9/33) in the ER group and 6.5% (3/46) in the LR group (P = .005). The most common cultured pathogen was methicillin resistant Staphylococcus aureus (ER, 6/11 vs LR, 3/6; P = NS). Within the ER group, the prevalence of Pseudomonas aeruginosa was significantly higher at 27.3% (3/11) compared with 0% (0/6) in the LR group (P = .04).
Early revision of lower extremity arterial bypass grafts has a significantly higher risk of graft infection compared with revision >1 month after surgery. Infection will develop in approximately 25% (9/33) of prosthetic grafts that are reoperated on early. If feasible, reoperation should be delayed >1 month for prosthetic grafts needing revision. Endovascular or extra-anatomic interventions should be considered if early revision is mandated in this group.
本研究比较了接受下肢动脉搭桥移植早期翻修手术与晚期翻修手术患者的移植物感染发生率及特征。
1992年至2005年7月期间，对198例下肢搭桥移植物进行了500次翻修手术。初次搭桥术后<30天进行翻修的患者纳入早期翻修（ER）组（n = 99），术后>30天进行翻修的患者纳入晚期翻修（LR）组（n = 99）。感染定义为伴有移植物外露的蜂窝织炎或与移植物相连的脓性分泌物，需要使用抗生素并进行手术以控制感染。平均随访时间为60个月（范围2至60个月）。采用学生t检验对两组进行比较。
ER组包括66例自体移植物和33例人工移植物。LR组由53例自体移植物和46例人工移植物组成。在进行的500次翻修手术中，发生了17例移植物感染（3.4%）。其中12例（70.6%）为人工移植物，5例（29.4%）为自体移植物（P = 0.004）。以每个移植物而非每次翻修手术来定义感染率，ER组的移植物感染率显著高于LR组，分别为11%（11/99）和6.1%（6/99；P = 0.012）。ER组人工移植物的感染风险显著高于自体移植物，分别为27.3%（9/33）和3.1%（2/66；P = 0.0001）。LR组有3例静脉移植物和3例人工移植物发生感染（P = 无显著性差异）。仅对于人工移植物翻修，ER组的感染风险为27.3%（9/33），LR组为6.5%（3/46）（P = 0.005）。最常见的培养病原体是耐甲氧西林金黄色葡萄球菌（ER组6/11例，LR组3/6例；P = 无显著性差异）。在ER组中铜绿假单胞菌的患病率显著高于LR组，分别为27.3%（3/11）和0%（0/6）（P = 0.04）。
与术后>1个月进行翻修相比，下肢动脉搭桥移植物的早期翻修有显著更高的移植物感染风险。早期再次手术的人工移植物中约25%（9/33）会发生感染。如果可行，对于需要翻修的人工移植物，再次手术应推迟>1个月。如果该组患者必须进行早期翻修，应考虑血管腔内或解剖外干预措施。
