Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study

The Utility of Prevena Negative Pressure Wound Therapy on Groin Incisions for Critical Limb-Threatening Ischemia: A Single Institution Experience

BACKGROUND

Incisional negative pressure wound therapy (iNPWT) is an adjunctive treatment that uses constant negative pressure suction to facilitate healing. The utility of this treatment modality on vascular operations for critical limb-threatening ischemia (CLTI) has yet to be elucidated. This study compares the incidence of postoperative wound complications between the Prevena Incision Management System, a type of iNPWT, and standard wound dressings for vascular patients who also underwent plastic surgery closure of groin incisions for CLTI.

METHOD

We performed a retrospective cohort study of 40 patients with CLTI who underwent 53 open vascular surgeries with subsequent sartorius muscle flap closure. Patient demographics, intraoperative details, and wound complications were measured from 2015 to 2018 at the University of California San Francisco. Two cohorts were generated based on the modality of postoperative wound management and compared on wound healing outcomes.

RESULTS

Of the 53 groin incisions, 29 were managed with standard dressings, and 24 received iNPWT. Patient demographics, comorbidities, and operative characteristics were similar between the 2 groups. Patients who received iNPWT had a significantly lower rate of infection (8.33% vs 31.0%, P = 0.04) and dehiscence (0% vs 41.3%, P < 0.01). Furthermore, the iNPWT group had a significantly lower rate of reoperation (0% vs 17.2%, P = 0.03) for wound complications within 30 days compared with the control group and a moderately reduced rate of readmission (4.17% vs 20.7%, P = 0.08).

CONCLUSIONS

Rates of infection, reoperation, and dehiscence were significantly reduced in patients whose groin incisions were managed with iNPWT compared with standard wound care. Readmission rates were also decreased, but this difference was not statistically significant. Our results suggest that implementing iNPWT for the management of groin incisions, particularly in patients undergoing vascular operations for CLTI, may significantly improve clinical outcomes.

Prediction Models for Forecasting Risk of Development of Surgical Site Infection after Lower Limb Revascularization Surgery: A Systematic Review

BACKGROUND

Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures.

METHODS

After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability.

RESULTS

Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

CONCLUSIONS

Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.

Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review

BACKGROUND

Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base.

METHODS

We conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map.

RESULTS

We identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described.

CONCLUSION

The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.

Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery.

BACKGROUND

SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all).

CONCLUSIONS

Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.

Systematic Review of Groin Incision Surgical Site Infection Preventative Measures in Vascular Surgery

OBJECTIVE

Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention techniques including: prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy and adhesive drapes METHODS: This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic review was conducted utilizing the Google Scholar ©, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1,371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics.

RESULTS

The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are: - We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin. [Grade 2C] - We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention. [Grade 2C] - Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use. - We suggest closed-incision negative pressure wound therapy be utilized in groin surgical incisions at high risk for SSI. [Grade 2B] - Given the paucity of data regarding adhesive drapes, such as Ioban ®, no recommendation can be made regarding its use.

CONCLUSIONS

This review highlights the effects of various preventative techniques and their potential benefit in prevention of SSI in the groin. However, there is a glaring deficit in the available data emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. While the use of endovascular techniques continues to increase thus limiting the amount of open arterial procedures and the potential for further studies to be conducted. In order to provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.

The Safety and Efficacy of the Anterior Approach Total Hip Arthroplasty as per Body Mass Index

BACKGROUND

Obesity is associated with component malpositioning and increased revision risk after total hip arthroplasty (THA). With anterior approaches (AAs) becoming increasingly popular, the goal of this study was to assess whether clinical outcome post-AA-THA is affected by body mass index (BMI).

METHODS

This multicenter, multisurgeon, consecutive case series used a prospective database of 1,784 AA-THAs (1,597 patients) through bikini (n = 1,172) or standard (n = 612) incisions. Mean age was 63 years (range, 20-94 years) and there were 57.5% women, who had a mean follow-up of 2.7 years (range, 2.0-4.1 years). Patients were classified into the following BMI groups: normal (BMI < 25.0; n = 572); overweight (BMI: 25.0-29.9; n = 739); obese (BMI: 30.0-34.9; n = 330); and severely obese (BMI ≥ 35.0; n = 143). Outcomes evaluated included hip reconstruction (inclination/anteversion and leg-length, complications, and revision rates) and patient-reported outcomes including Oxford Hip Scores (OHS).

RESULTS

Mean postoperative leg-length difference was 2.0 mm (range: -17.5 to 39.0) with a mean cup inclination of 34.8° (range, 14.0-58.0°) and anteversion of 20.3° (range, 8.0-38.6°). Radiographic measurements were similar between BMI groups (P = .1-.7). Complication and revision rates were 2.5% and 1.7%, respectively. The most common complications were fracture (0.7%), periprosthetic joint infection (PJI) (0.5%), and dislocation (0.5%). There was no difference in dislocation (P = .885) or fracture rates (P = .588) between BMI groups. There was a higher rate of wound complications (1.8%; P = .053) and PJIs (2.1%; P = .029) among obese and severely obese patients. Wound complications were less common among obese patients with the 'bikini' incision (odds ratio 2.7). Preoperative OHS was worse among the severely obese (P < .001), which showed similar improvements (Change in OHS; P = .144).

CONCLUSION

AA-THA is a credible option for obese patients, with low dislocation or fracture risk and excellent ability to reconstruct the hip, leading to comparable functional improvements among BMI groups. Obese patients have a higher risk of PJIs. Bikini incision for AA-THA can help minimize the risk of wound complications.

Surgical treatment of femoral artery bifurcation without material. Technique and follow up

INTRODUCTION

Complete eversion of the femoral tripod is interesting to reduce clinical consequences of wound infection, in particular for patients at high risk (eg: obese, diabetics, cancer). Experience and follow up of this technique are scarce. The different technical possibilities and results are reported here.

METHODS

Single center prospective study including patients operated on for femoral occlusive lesions using eversion of the common femoral artery and its bifurcation. Clinical and imaging preoperative data, surgical technique and follow up are detailed.

RESULTS

Thirty-five patients (37 limbs) have been included between June 2014 and April 2016. Mean Rutherford index was 3.6 and 65% of the patients were claudicants. Lesions were limited to the common femoral artery in 14 (38%) of the cases and spread to the superficial femoral artery in 2 (7%) and to the three branches in 21 (57%) of the cases, respectively. Postoperatively, one death, one major amputation and 3 reinterventions were noted, resulting in a 8% rate of major complications. The mean follow up was 37 months. At this time, 11 MACE, 9 deaths and no additional major amputation were noted. The mean Rutherford index was 1.7 (P<.001) and 3 reinterventions were necessary (1 for septic occlusion at 3 months and 2 for restenosis at 12 and 42 months), translating into a primary and secondary patency rates of 93.3% and 96.1%.

CONCLUSION

This work further confirms that eversion of the femoral tripod is safe and effective. This experience adds to the existing body of the literature and describe alternative techniques of eversion. The technique should be considered when treating patients at high risk of postoperative infection.

Comparison of transverse versus longitudinal skin incisions for femoral endarterectomy and patchplasty

INTRODUCTION

Access to the femoral artery for a femoral endarterectomy and patchplasty (CFE) can be undertaken either through transverse (TI) or longitudinal incision (LI). LIs have been shown in previous studies to have higher groin complications though these were undertaken in multiple types of vascular procedures. We looked at wound complications for patients undergoing elective CFE procedures only with or without angioplasty via TI or LI.

METHODS

All patients who had undergone CFE were retrospectively analysed from a prospective database. Length of stay, wound complications and readmission rates were recorded. Factors for wound complication were looked at using logistic regression with backward elimination.

RESULTS

122 CFE procedures were performed (30 TI) over the study period. 92 (76.7%) of patients had a prosthetic patch used, whilst 57 (46.7%) patients underwent an adjunctive endovascular procedure, namely, iliac angioplasty and stenting. Median length of stay was 3 days for both groups. The wound complication rate was 6.7% in the TI group and 22.6% in the LI group. 85.6% of the wound complications were identified after discharge. 6/122 (4.9%) were readmitted for intravenous antibiotics, whilst others were managed in the outpatient setting. TI (aOR = 0.15; 95% 0.03-0.75) and combined open FE with endovascular revascularisation (aOR = 0.33; 95% 0.11-0.95) had protective effects on wound complications. Type of the patch used was not associated with any wound complications (p = 0.07).

CONCLUSION

Compared to traditional LI, TI for CFE and OTA have lower risk of wound complications and reduced readmission rates in our series. We advocate adopting TI as the standard for femoral artery procedures rather than LI.

Nonoperative Management of a Recurrent Postoperative Inguinal Lymphatic Leak via Negative-Pressure Wound Therapy: A Case Report

ABSTRACT

Lymphatic leaks are common following common femoral vessel exposure for cardiac surgical procedures. The management of this complication can be difficult and is often uncomfortable for the patient. This case report describes the successful nonoperative treatment of a recurrent lymphatic leak from an inguinal surgical wound via negative-pressure wound therapy. Negative pressure may be considered a minimally invasive, effective, and acceptable way to treat postoperative lymphatic leaks at the groin.

Gentamicin-Containing Collagen Implant May Reduce Surgical Site Infections After Open Infrainguinal Arterial Revascularization

BACKGROUND

Deep-space surgical site infections carry significant morbidity and mortality. The evidence for gentamicin-containing collagen implants at reducing surgical site infections in open infrainguinal arterial surgery is limited. This study examined whether gentamicin-containing collagen implants reduces 30-day surgical site infections and their severity following open infrainguinal arterial surgery.

METHODS

A retrospective observational cohort study that included all patients undergoing infrainguinal arterial bypass or endarterectomy between November 2015 and March 2019 at a single tertiary vascular unit. Patients with contaminated/infected surgical fields, surgical wounds treated with negative pressure therapy, or the usage of antimicrobial implants and dressings other than Collatamp G^Ⓡ (Aralez Pharmaceuticals, Canada) were excluded. Patients with gentamicin-containing collagen implants placed abutting vasculature were compared against patients without gentamicin-containing collagen implants. Outcomes included the rate of surgical site infections and their severity within 30 days after the operation.

RESULTS

In 159 procedures (mean age 67.7 years, 74.8% male, 33.3% diabetic, 16.4% chronic renal failure, 25.2% anticoagulated postoperatively, 32.7% with prosthetic implants), 55 (34.6%) procedures received gentamicin-containing collagen implants. There were significantly more males (85.5% vs. 69.2%; P = 0.025), higher rates of obesity (41.8% vs. 26.0%; P = 0.041), and hyperlipidemia (65.5% vs. 49.0%; P = 0.048) in the gentamicin-containing collagen implant group. In total, 6 (3.8%) procedures developed deep-space surgical site infections (1 with gentamicin-containing collagen implant, 5 without) and 13 (8.2%) had severe surgical site infections that required re-intervention (1 with gentamicin-containing collagen implant, 12 without). On logistic regression analysis, the absence of gentamicin-containing collagen implants statistically significantly increased the odds of overall surgical site infections (OR = 2.50; 95% CI 1.01 - 6.19; P = 0.047). There was no statistically significant difference in the odds of deep-space surgical site infections or the severity and need for reintervention of surgical site infections.

CONCLUSIONS

This is the first study that examined the effect of gentamicin-containing collagen implants on the severity of surgical site infections in vascular surgery. Gentamicin-containing collagen implants may reduce the odds of overall surgical site infections. It did not reduce the odds of deep-space surgical site infections or the severity and reintervention rate of surgical site infections following infrainguinal arterial revascularization. Larger studies are required to achieve adequate power to assess for these outcomes.

Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage

Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.

Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta-analysis

BACKGROUND

A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes.

RESULTS

We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P = 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P = 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P = 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P = 0.08) were similar.

CONCLUSIONS

A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.

Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery

Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.

Assisting Vascular Surgery with Smartphone Augmented Reality

Background Augmented reality is a technology that expands on image-guided surgery to allow intraoperative guidance and navigation. Augmented reality-assisted surgery (ARAS) has not been implemented in the vascular field yet. The wealth of sensors found on modern smartphones make them a promising platform for implementing vascular ARAS. However, current smartphone augmented reality platforms suffer from tracking instability, making them unsuitable for precise surgery. Novel algorithms need to be developed to tackle the stability and performance limitations of mobile phone augmented reality. Aim The primary aim was to develop an ARAS system utilizing low-cost smartphone hardware for vascular surgery. The second aim was to assess its performance by evaluating the stability of its tracking algorithms. Methods We designed an ARAS system utilizing standard optical tracking (SOT) and developed a novel tracking algorithm: hybrid gyroscopic and optical tracking (HGOT) for improved tracking stability. We evaluated the stability of both tracking algorithms using a phantom model and calculated tracking errors using root mean square error (RMSE).  Results The novel augmented reality system displayed a three-dimensional (3D) guidance model fused with the patient's anatomy on a smartphone in real-time. The rotational tracking RMSE was 3.12 degrees for SOT and 0.091 degrees for HGOT. Positional tracking RMSE was 3.3 mm for SOT compared to 0.03 mm for HGOT. Comparing the stability of both tracking techniques showed HGOT to be significantly superior to SOT (p = 0.004). Conclusion We have developed a novel augmented reality system for vascular procedures. The development of HGOT has significantly increased the stability of a low-cost handheld augmented reality solution.

Transverse versus vertical groin incision for femoral artery approach

BACKGROUND

Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.

OBJECTIVES

To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures.

DATA COLLECTION AND ANALYSIS

Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE.

MAIN RESULTS

We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain.

AUTHORS' CONCLUSIONS

In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.

Total Hip Arthroplasty Through the Direct Anterior Approach Using a Bikini Incision Can Be Safely Performed in Obese Patients

BACKGROUND

Direct anterior approach (DAA) total hip arthroplasty can be performed through a traditional vertical incision or a horizontal (bikini) incision. The purpose of this study is to compare the 2 approaches, performed by a single surgeon past the learning curve, in terms of (1) overall wound complications and (2) patient-reported esthetics at the 6-month follow-up.

METHODS

A case-control retrospective study was conducted. Eighty-six bikini DAA patients were matched 3:1 to 230 conventional DAA patients for gender, age, body mass index (BMI), and American Society of Anesthesiologists score. Outcomes evaluated included wound complications, acute periprosthetic joint infection, transfusion, length of surgery, and dysesthesia. A subgroup analysis was also performed on obese patients, BMI greater than 30 kg/m². Furthermore, the patients rated cosmesis of the incision at 6 months using a Patient Scar Assessment Scale and the Vancouver Scar Assessment Scale.

RESULTS

Bikini patients had lower rates of delayed wound healing compared to conventional incision (2.3% vs 6.1%, P = .087). This difference was statistically significant (0% vs 16.6%, P < .05) in obese patients. There was no difference in terms of incision cosmesis between the 2 incision types.

CONCLUSION

Our study demonstrates that the DAA total hip arthroplasty can be performed safely through an alternative horizontal bikini incision with complication rates equivalent to conventional incision DAA and to those in other approaches when performed by surgeons in a high volume, efficient hip replacement institution. In patients whose BMI is >30, a potential benefit of the horizontal incision may be lower wound complications. This study design should be performed at other institutions and ideally at a multi-institution level to evaluate if results can be corroborated. Our opinion is that the horizontal bikini incision should be utilized but only after mastery of the DAA approach using the conventional vertical incision.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians

BACKGROUND

Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.

DISCUSSION

Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.

CONCLUSIONS

REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.

Negative-Pressure Wound Therapy for Managing Complicated Wounds at Extracorporeal Membrane Oxygenation Sites

OBJECTIVE

To evaluate the effectiveness of negative-pressure wound therapy (NPWT) for management of wound complications at extracorporeal membrane oxygenation (ECMO) removal sites.

METHODS

The authors retrospectively reviewed patients who underwent NPWT at ECMO removal sites followed by the development of wound complications including skin necrosis, lymphorrhea, and femoral vessel exposure. A nonadhesive bacteria-binding mesh was used as a wound contact layer of NPWT application. Patient characteristics and clinical outcomes were evaluated.

RESULTS

Nine patients underwent NPWT for complicated wounds at ECMO sites. The mean age of patients was 49.2 years (range, 14-64 years). All patients exhibited wound complications with lymphorrhea and skin necrosis. Seven of nine patients had wound cultures that were positive for microorganisms, but culture conversion to negative was achieved after NPWT application for a mean period of 21.2 days (range, 12-30 days). Lymphorrhea was successfully managed, and formation of fresh granulation tissue was observed in all patients. Wound healing either by primary closure, skin graft, or secondary healing was achieved without recurrence of wound complications. There were no cases of femoral vessel injury or aneurysm during NPWT application.

CONCLUSIONS

Negative-pressure wound therapy appears to be a safe and effective treatment option in the management of complicated wounds at ECMO sites.

Meta-analysis of negative pressure wound therapy of closed groin incisions in arterial surgery

BACKGROUND

Surgical-site infection (SSI) after groin incisions for arterial surgery is common and may lead to amputation or death. Incisional negative pressure wound therapy (NPWT) dressings have been suggested to reduce SSIs. The aim of this systematic review with meta-analysis was to assess the effects of incisional NPWT on the incidence of SSI in closed groin incisions after arterial surgery.

METHODS

A study protocol for this systematic review of RCTs was published in Prospero (CRD42018090298) a priori, with predefined search, inclusion and exclusion criteria. The records generated by the systematic research were screened for relevance by title and abstract and in full text by two of the authors independently. The selected articles were rated for bias according to the Cochrane risk-of-bias tool.

RESULTS

Among 1567 records generated by the search, seven RCTs were identified, including 1049 incisions. Meta-analysis showed a reduction in SSI with incisional NPWT (odds ratio (OR) 0·35, 95 per cent c.i. 0·24 to 0·50; P < 0·001). The heterogeneity between the included studies was low (I²  = 0 per cent). The quality of evidence was graded as moderate. Two studies had multiple domains in the Cochrane risk-of-bias tool rated as high risk of bias. A subgroup meta-analysis of three studies of lower limb revascularization procedures only (363 incisions) demonstrated a similar reduction in SSI (OR 0·37, 0·22 to 0·63; P < 0·001; I²  = 0 per cent).

CONCLUSION

Incisional NPWT after groin incisions for arterial surgery reduced the incidence of SSI compared with standard wound dressings. The risk of bias highlighted the need for a high-quality RCT with cost-effectiveness analysis.

Use of Closed-Incision Negative-Pressure Therapy: Cardiothoracic and Vascular Surgery

Vascular groin wound and median sternotomy infections are challenging complications that may lead to serious sequela. Traditional gauze dressings have poor bacteria barrier properties, and so there has been a recent enthusiasm for the use of closed-incision negative-pressure therapy as an effective closed environment, which controls exudate and helps hold the incision edges together. Studies suggest that it may reduce surgical site infection in cardiothoracic and vascular surgery.

Open Versus Endovascular Repair of Isolated Iliac Artery Aneurysms

PURPOSE:

Outcomes of open iliac artery repair (OIR) and endovascular iliac artery repair (EVIR) were compared at a tertiary referral vascular center.

METHODS:

From 2004 to 2015, all patients treated for isolated iliac artery aneurysms (IAAs) were retrospectively identified, and patient records and computed tomography (CT) scans were analyzed. The primary end point was overall survival; secondary end points were 30-day mortality and morbidity and freedom from reintervention. For follow-up, data from outpatient visits and CT scans following a standard surveillance protocol were used.

RESULTS:

A total of 106 IAAs in 94 patients were treated (mean follow-up: 35.7 months; 66 OIR; 40 EVIR). Six (15%) aneurysms from the EVIR group and 4 (6.1%) from open-operated IAA presented in the state of rupture. There was no difference in overall survival between EVIR and OIR ( P = .14). In multivariable analysis, higher risk of death was associated with ruptured IAA (rIAA; hazard ratio [HR]: 40.44, 95% confidence interval [CI]: 2.05-796.18; P = .02) and coronary heart disease (HR: 11.07, 95% CI: 1.94-63.36; P < .01). The 30-day mortality was 1.9% overall (0% OIR, 5.0% EVIR, P = .27), but there were no differences between OIR and EVIR in 30-day morbidity ( P = .11). Freedom from reintervention was higher for OIR than for EVIR ( P < .01). In multivariable analysis, a higher reintervention rate was seen in EVIR (HR: 10.80, 95% CI: 2.20-53.01; P < .01) and in rIAA (HR: 12.02, 95% CI: 1.31-111.11; P = .03).

CONCLUSION:

Iliac artery aneurysmss can be safely and effectively treated by EVIR or OIR regarding 30-day morbidity, mortality, and long-term survival, although freedom from reintervention is significantly lower after EVIR.

Evaluation of inguinal vascular surgical scars treated with closed incisional negative pressure wound therapy using three-dimensional digital imaging-A randomized controlled trial on bilateral incisions

PURPOSE OF THE INVESTIGATION

Scar formation is an important, permanent surrogate marker for wound healing. The main aim of this randomized trial was to evaluate the effects of incisional negative pressure wound therapy (iNPWT) on scar formation in uncomplicated wound healing with 3-dimensional (3D) digital imaging.

BASIC PROCEDURES

Patients undergoing bilateral inguinal incisions after vascular surgery were randomized to receive iNPWT and standard dressing on separate sides. The incisional scars were documented at a median time of 808 days (range 394-1194) after surgery with 3D photography, which were objectively evaluated by two plastic surgeons using the Stony Brook scar evaluation scale (SBSES) and a 10-point graded numeric ranking scale (NRS10). Subjective evaluation was performed with the patient observer scar assessment scale (POSAS). Patients with surgical site infection or other wound complications were excluded to minimize bias. The p-values were calculated using McNemar's and Wilcoxon signed-rank test for paired nominal and paired continuous data, respectively.

MAIN FINDINGS

Among 33 patients, 32 patients had undergone endovascular aortic repair (EVAR) and 31 patients had transverse inguinal incisions. Objective and subjective scar evaluation showed no difference between iNPWT and standard dressing. In objective scorings, 18.8 and 21.9% received the highest possible SBSES total score in the iNPWT and standard dressing groups, while 43.8 and 37.5% received the highest possible NRS10 score, respectively. The inter-rater reliability between the two assessors for SBSES total score and NRS10 showed an intra-class correlation (ICC) of 0.78 and 0.68 for NPWT and 0.70 and 0.77 for traditional dressing, respectively.

PRINCIPAL CONCLUSION

The present randomized trial showed that iNPWT and standard dressings on closed transverse inguinal incisions after EVAR resulted in equal subtle scar formation. Objective scar evaluation with 3D images showed good inter-rater agreement.

Reduction of groin wound complications in vascular surgery patients using closed incision negative pressure therapy (ciNPT): a prospective, randomised, single-institution study

Groin wound infections in patients undergoing vascular procedures often cause a lengthy process of wound healing. Several clinical studies and case reports show a reduction of surgical site infections (SSIs) in various wound types after using closed incision negative pressure therapy (ciNPT). The aim of this prospective, randomised, single-institution study was to investigate the effectiveness of ciNPT (PREVENA™ Therapy) compared to conventional therapy on groin incisions after vascular surgery. From 1 February to 30 October 2015, 100 patients with 129 groin incisions were analysed. Patients were randomised and treated with either ciNPT (n = 58 groins) or the control dressing (n = 71 groins). ciNPT was applied intraoperatively and removed on days 5-7 postoperatively. The control group received a conventional adhesive plaster. Wound evaluation based on the Szilagyi classification took place postoperatively on days 5-7 and 30. Compared to the control group, the ciNPT group showed a significant reduction in wound complications (P < 0·0005) after both wound evaluation periods and in revision surgeries (P = 0·022) until 30 days postoperatively. Subgroup analysis revealed that ciNPT had a significant effect on almost all examined risk factors for wound healing. ciNPT significantly reduced the incidence of incision complications and revision procedures after vascular surgery.

Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients

OBJECTIVE

Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development.

METHODS

We conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome.

RESULTS

Median age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention.

CONCLUSIONS

Lymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.

Negative pressure wound therapy for high-risk wounds in lower extremity revascularization: study protocol for a randomized controlled trial

Background

Rates of surgical site infections (SSIs) following groin incision for femoral artery exposure are much higher than expected of a clean operation. The morbidity and mortality is high, particularly with the use of prosthetic grafts. The vascular surgery population is at an increased risk of SSIs related to peripheral vascular disease (PVD), diabetes, obesity, previous surgery and presence of tissue loss. Negative pressure wound therapy (NPWT) dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. We have not come across any randomized controlled trials to support the prophylactic use of negative pressure wound therapy in high-risk vascular patients undergoing lower limb revascularization.

Methods/design

In this single-center, prospective randomized controlled trial, patients scheduled for a lower limb revascularization requiring open femoral artery exposure who are at a high risk (BMI > 30 kg/m², previous femoral cutdown or Rutherford V or VI category for chronic limb ischemia) will be eligible for the study. A total of 108 groin incisions will be randomized to the use of a negative pressure wound device or standard adhesive gauze dressing. Patients will be followed in hospital and reassessed within the first 30 days postoperatively. The primary outcome is SSI within the first 30 days of surgery and will be determined using the intention-to-treat principle. Secondary outcomes include length of stay, emergency room visits, reoperation, amputation and mortality. A cost analysis will be performed.

Discussion

The trial is expected to define the role of NPWT in SSI prophylaxis for lower limb revascularization in high-risk vascular patients. The results of the study will be used to inform current best practice for perioperative care and the minimization of SSIs.

Trial registration

NCT02084017, March 2014

Incidence and relevance of groin incisional complications after aortobifemoral bypass grafting

BACKGROUND

Aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AIOD) is traditionally accompanied by substantial groin incisional morbidity, which poses a threat to an underlying prosthetic graft. We performed a study to investigate the frequency and define the clinical course and significance of such problems.

METHODS

One hundred twenty consecutive patients undergoing primary elective ABFB for AIOD were enrolled in a prospective study. The healing of groin wounds was systematically assessed, the occurrence of incisional complications of any type noted, and their clinical course and economic consequences documented and analyzed.

RESULTS

Early postoperative complications (30 days) affected 35 (15%) groin wounds in 29 (24.8%) patients. Lymph fistulas/lymphoceles were observed in 15 (6.4%), infection in 11 (4.7%), and noninfectious wound dehiscence in 9 (3.8%) of groin incisions. The only significant predictor of groin healing impairment was preoperative length of stay. Groin incision-related morbidity significantly increased the duration and cost of hospitalization. Sixty percent of groin healing problems were diagnosed after discharge and they represented the most common cause for early readmissions.

CONCLUSIONS

The incidence of groin wound complications after ABFB is considerable, their financial impact significant, and delayed onset frequent. Femoral incisional morbidity after ABFB still represents an unremitting nuisance, necessitating further improvements in preventive strategies and techniques and strict adherence to conventional ones, including the minimization of preoperative length of stay.

Surgical wound infections after peripheral vascular surgery

Surgical wound infection is one of the most common complications after peripheral vascular surgery. It increases the affected patient's risk for major amputation as well as mortality. Furthermore, surgical wound infection is an additional cost. Wound infections after vascular surgery are of multifactorial nature and generally result from the interplay of patient- and procedure-related factors. The use of systemic antibiotic prophylaxis may be the most important method in preventing surgical wound infections. In this review article, we report the current literature of surgical wound infections after peripheral vascular surgery.

Techniques in endovascular aneurysm repair

Endovascular repair of infrarenal abdominal aortic aneurysms (EVARs) has revolutionized the treatment of aortic aneurysms, with over half of elective abdominal aortic aneurysm repairs performed endoluminally each year. Since the first endografts were placed two decades ago, many changes have been made in graft design, operative technique, and management of complications. This paper summarizes modern endovascular grafts, considerations in preoperative planning, and EVAR techniques. Specific areas that are addressed include endograft selection, arterial access, sheath delivery, aortic branch management, graft deployment, intravascular ultrasonography, pressure sensors, management of endoleaks and compressed limbs, and exit strategies.