Groin lymphatic complications after arterial reconstruction

Does fibrin glue reduce complications after femoral artery surgery? A randomised trial

OBJECTIVES

to determine whether application of fibrin glue before closure of inguinal wounds reduces the incidence of lymphatic complications.

DESIGN

we a prospective randomised trial.

MATERIALS AND METHODS

224 consecutive patients were enrolled. The wounds were randomly assigned to standard closure (group A, n = 134) or closure with application of fibrin glue (group B, n = 132). The incidence of local lymphatic and non-lymphatic complications, the amount of lymphatic fluid collected, and the time to drain removal were compared in the groups.

RESULTS

the incidence of lymphatic complications was 19% in group A and 10% in group B (p = 0.027). The average drain output and the time to drain removal did not differ in the two groups. The total incidence of non-lymphatic local complications was 10% and did not differ in the two groups.

CONCLUSIONS

fibrin glue application is associated with a significant reduction in lymphatic complications.

Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study

Lymphoceles and lymph fistulas are common complications after exposure of the common femoral artery in the Scarpa triangle because of operative transsection of overlying lymphatics. The purpose of this prospective randomized study was to determine the incidence of groin lymphatic complications and to assess the impact of routine application of fibrin glue on lymphatic structures and subcutaneous tissue prior to closure. All patients undergoing exposure of the common femoral artery in the Scarpa triangle were included in this study. They were divided into two groups according to closure technique. In group A, closure was performed without fibrin glue. In Group B, fibrin glue was applied to lymphatic structures prior to closure. The efficacy of fibrin glue application was estimated on the basis of two criteria: incidence of local complications and amount of lymphatic fluid in the Redon drain. The preliminary findings suggest that application of fibrin glue leads to a significant reduction in the incidence of lymphatic complications after femoral artery exposure in the Scarpa triangle.

Lymphoscintigraphy in the diagnosis of lymphatic leak after surgical repair of femoral artery injury

PURPOSE

Technetium-99m-labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity.

METHODS

Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed.

RESULTS

The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection.

CONCLUSIONS

Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.

The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin

Groin lymphorrhea is an uncommon but serious complication of vascular and cardiac surgery as well as interventional procedures that cannulate the femoral vessels. Treatment options are somewhat controversial. For lymphocutaneous fistulas, a commonly used current modality is early surgical ligation with the assistance of blue-dye staining of the lymphatic anatomy. The purpose of this case series is to give the first description of a new, less invasive, approach using subatmospheric pressure dressing therapy for the treatment of the challenging problem of lymphocutaneous fistulas of the groin.

The value of the oblique groin incision for femoral artery access during endovascular procedures

Groin incisions for access to femoral vessels are typically made in a vertical fashion extending across the groin crease. Significant morbidity can be associated with these incisions, including lymphoceles, lymph fistulae and infections, as documented in the infrainguinal revascularization literature. We have adopted an oblique groin incision for femoral artery access during endovascular graft reconstruction of the aorta because of the potential for reduced wound morbidity. In this study we report our experience with this technique and compare it with the existing literature to determine its usefulness. From June 1998 to May 1999, 98 consecutive patients received endovascular exclusion of aortic aneurysms at The Mount Sinai Medical Center, New York. Patients were treated with aortoaortic (24), aortouniiliac with femorofemoral crossover bypass (41), or bifurcated endografts (33) and were prospectively studied for wound complications. Aortoaortic procedures required one inguinal incision whereas aortouniiliac with femorofemoral crossover bypass and bifurcated procedures employed bilateral inguinal wounds. Wound complications were defined as cellulitis, subcutaneous purulence, femorofemoral graft infection, lymphocele, or lymphocutaneous fistulae. The oblique groin incision allows adequate exposure to the femoral arteries and is associated with low wound morbidity. We suggest that this approach may be the preferred technique for access to femoral arteries during endovascular procedures, and should be considered for infrainguinal arterial reconstructions.

A multicenter, phase I evaluation of cryopreserved venous valve allografts for the treatment of chronic deep venous insufficiency

PURPOSE

A phase I feasibility study was conducted to determine whether cryopreserved venous valved segments would remain patent/competent in a short-term period (6 months).

METHODS

The target group consisted of 10 patients (C(4-6), E, A(D), P(R)). The exclusion criteria included untreated superficial/perforator venous disease, significant venous or arterial obstruction, hypercoagulability or coagulopathy, and significant preexisting medical conditions. Required preoperative tests were venous duplex, ascending/descending venography, and a physiologic study (eg, APG, blood typing, an ankle/brachial index, and if post-thrombotic, a hypercoagulability work-up). A single-valve transplant was placed below all reflux, aided by anticoagulation with or without a distal arteriovenous fistula. Postoperative assessment included duplex scanning/clinical examination (at 1, 3, and 6 months), descending venogram (at 1 month), and physiologic study (at 1 and 6 months). The primary end point was valve patency/competence, with clinical outcome as a secondary end point. Adverse events were recorded.

RESULTS

After eliminating protocol violations, nine patients with superficial femoral (5) or popliteal (4) vein valve transplants were studied. Six-month actuarial results show a patency rate of 67% +/- 16% and 78% +/- 13%, respectively, a primary and secondary competency rate of 56% +/- 17% and 67% +/- 16%, respectively, and a 100% patient survival rate. Clinical outcome averaged 1.1, with healing and/or freedom from ulcer recurrence, in six of nine patients. A postoperative risk of seroma formation (3) and cellulitis (1) exists.

CONCLUSION

In patients with few remaining therapeutic options, one can achieve a 6-month assisted patency and competency rate of 78% and 67%, respectively, with an improved clinical outcome.

Thigh isosulfan blue injection in the treatment of postoperative lymphatic complications

Postoperative lymphatic complications after infrainguinal revascularization are troublesome and potentially serious complications. Vital dye injection into the web spaces of the foot has been recommended as a simple and reliable method to identify lymphatic channel disruption before groin exploration. Such distal injections, however, are not always successful. We describe a modified technique using a proximal thigh injection with isosulfan blue, which is faster and more useful than the distal web space method.

A novel therapy for lymphedema complicated by lymphorrhea

Lymphorrhea is a rarely described complication of chronic lymphedema, in which the disrupted flow through diseased lymphatic channels gives rise to the external drainage of lymph, often heralded by the presence of an enlarging lymphocele. This report documents the applicability of the Reid sleeve, a novel, conservative form of therapy, in an unusually severe and protracted example of lymphorrhea.

A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique

Venovenous bypass minimizes the hemodynamic alterations during the anhepatic phase of liver transplantation. A new technique for the percutaneous placement of the bypass cannulae is described and compared to the cut-down ("open") technique. The records of 81 patients who underwent 94 liver transplants between August 1991 and April 1994 were reviewed for indications for transplant, United Network for Organ Sharing status, mean age, body surface area, bypass technique and time, flow rates, cardiac output, mean arterial pressure and central venous pressure during bypass, the development of deep venous thrombophlebitis, and lymphoceles. Femoral flow rates were higher in the open group (2054 +/- 74 mL/min), compared with the percutaneous group (1726 +/- 74 mL/min) (p = 0.003). Total flow rates in the open (2238 +/- 58 mL/min) and percutaneous (2197 +/- 67 mL/min) groups were not different. Maximum cardiac outputs (L/ min) were higher in the open (10.1 +/- 0.6) versus percutaneous group (7.0 +/- 0.5) (p < 0.0002). Similarly, minimum cardiac outputs (L/min) were higher in the open (8.9 +/- 0.7) versus percutaneous group (5.8 +/- 0.5) (p = 0.003). Other hemodynamic parameters (mean arterial pressure, central venous pressure) were not different between groups. Venous thrombosis occurred in 1/50 (2.0%) and 4/34 (11.8%) patients in the open and percutaneous groups, respectively (p = 0.153). Nineteen lymphoceles occurred in 102 (18.6%) at-risk sites in the open group, whereas no lymphoceles occurred in 66 at-risk sites in the percutaneous group (p < 0.001). Groin lymphoceles occurred in 7/50 (14%) and 0/34 at-risk sites in the open and percutaneous groups, respectively (p = 0.039). Axillary lymphoceles occurred in 12/52 (23.1%) and 0/32 at-risk sites in the open and percutaneous groups, respectively (p = 0.0031). Operative repair of a lymphocele was required in 11/16 (69%) patients. The percutaneous placement of catheters for venovenous bypass has the advantage of comparable flow rates with satisfactory hemodynamics without the lymphatic complications of the cut-down technique.

Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost

BACKGROUND

Wound complications after lower extremity arterial reconstruction can range from a minor lymphatic leak that causes minimal disability to a severe infection that jeopardizes the limb and life of the affected patient. This study was designed to define more clearly the incidence, severity, and the cost of these complications.

METHODS

During a 1-year period the infrainguinal incisions of all patients undergoing lower limb arterial reconstruction were evaluated prospectively. One hundred fifty-six infrainguinal incisions were monitored serially for the presence of infection, hematoma, seroma, serous leak, necrosis, or wound dehiscence. The need for additional treatment or services related to these complications and the cost of these services were determined.

RESULTS

Complications occurred in 10% of 77 infrainguinal incisions that were isolated to the groin (groin incisions) e.g., after aortobifemoral bypass, femoral endarterectomy). In only one of these patients was significant cost related to treatment of a complication. Complications occurred in 44% of 79 incisions used for femoral popliteal/tibial and pedal bypasses (distal incisions). In this latter group independent predictors of any complication were age (p=0.02) and obesity (p=0.05); predictors of in-hospital infection were preoperative evidence of venous stasis (p=0.01) and preoperative infection in the same extremity (p=0.08). Fifteen distal wound complications provided additional expense related to reoperation, extended hospitalization or rehospitalization, and rehabilitation or visiting nurse services, with a mean cost per patient undergoing reconstruction of $688.

CONCLUSIONS

After lower limb arterial reconstruction, infrainguinal wound complications in isolated groin incisions produce minimal morbidity and cost, whereas complications in incisions after distal bypass are both frequent and associated with significant additional expense.