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Ravikumar S, Li R, Thompson J, Peshel EC, Recarey M, Amdur R, Lala S, Ricotta J, Sidawy A, Nguyen BN. Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications. World J Surg 2024. [PMID: 39019646 DOI: 10.1002/wjs.12296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. METHODS We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. RESULTS Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p = 0.03), especially deep incisional infection (4.9% vs. 2.4%; p = 0.04). CONCLUSION Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.
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Affiliation(s)
- Samyuktha Ravikumar
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Jamie Thompson
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Emanuela C Peshel
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Melina Recarey
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Richard Amdur
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Salim Lala
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - John Ricotta
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Anton Sidawy
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
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Ortiz-Fullana JL, Sánchez C, Pagán P, Mulero-Soto P, Dieppa-Barnes G, Santini-Domínguez R, Martinez-Trabal JL. Human gelatin thrombin matrix with rifampin for the treatment of prosthetic vascular graft infections. J Vasc Surg Cases Innov Tech 2024; 10:101365. [PMID: 38130367 PMCID: PMC10731601 DOI: 10.1016/j.jvscit.2023.101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/23/2023] [Indexed: 12/23/2023] Open
Abstract
We aim to describe and report on a novel graft preservation technique using a human gelatin thrombin matrix with rifampin for the treatment of vascular graft infections. Eight patients with vascular graft infections were included, one with bilateral infections, for a total of nine cases from January 2016 through June 2021. All the patients underwent wound exploration and placement of human gelatin thrombin matrix with rifampin. No deaths or allergic reactions had been reported at the 30-day follow-up, with only one major amputation. The graft and limb salvage rates were 77.8% at the 1-year follow-up. The mean time to a major amputation was 122 days, and the mean time to graft excision was 30 days.
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Affiliation(s)
| | - Cristina Sánchez
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Pedro Pagán
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Patricia Mulero-Soto
- Department of Vascular Surgery, San Luke's Memorial Hospital, Ponce, Puerto Rico
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Julian O, Wilcox K, Sharma D, Lamb K, Luo R, Zheng H, Sooppan R, Behnam A. Viability of the rectus femoris muscle flap for groin wound coverage after ligation of proximal inflow. J Surg Case Rep 2024; 2024:rjad306. [PMID: 38239382 PMCID: PMC10795896 DOI: 10.1093/jscr/rjad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/06/2023] [Indexed: 01/22/2024] Open
Abstract
Lower extremity revascularization via groin incisions can be complicated by wound dehiscence associated with infection, seroma and femoral vessel exposure. This may require additional surgical debridement and coverage of vascular structures and grafts. The pedicled rectus femoris muscle flap (RFF) has both bulk and a large arc of rotation, making it useful for reconstruction. Its main pedicle is the descending branch of the lateral femoral circumflex artery (DLFCA), a branch of the profunda femoris artery. One could anticipate that ligation of more proximal vasculature could lead to ischemia of the RFF. We present two patients who each underwent vascular surgery involving the common femoral artery and subsequent reconstruction utilizing a pedicled RFF. Both patients then required additional vascular procedures involving the ligation of inflow vessels proximal to the DLFCA. The flaps remained viable, demonstrating the rich collateralization of blood supply that occurs in vascular disease patients.
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Affiliation(s)
- Olivia Julian
- Drexel University College of Medicine, Philadelphia, PA, United States
| | - Kailyn Wilcox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Davek Sharma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Kathleen Lamb
- Division of Vascular Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Robert Luo
- Division of Vascular Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Hong Zheng
- Division of Vascular Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Renganaden Sooppan
- Division of Vascular Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
| | - Amir Behnam
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Reading Hospital, Tower Health System, West Reading, PA, United States
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Rajput S, Kuruoglu D, Salinas CA, Sen I, Kalra M, Moran SL. Flap management of groin wounds following vascular procedures: A review of 270 flaps for vascular salvage. J Plast Reconstr Aesthet Surg 2023; 78:38-47. [PMID: 36822101 DOI: 10.1016/j.bjps.2023.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Groin dehiscence following vascular procedures results in morbidity for patients with peripheral vascular disease. Controversy exists around the indications for flap coverage. We present an institutional experience with flap reconstruction of groin wounds after vascular procedures to identify predictors of beneficial outcomes. PATIENTS AND METHODS A retrospective review of patients who had flap coverage for infected/nonhealing groin wounds following a vascular procedure between 1998 and 2021 was performed. Demographics and clinical characteristics, including flap and vascular graft type, were collected along with major complications. Univariate and multivariable logistic regression analyses were performed to assess the associations between procedures and major complications. RESULTS A total of 270 flaps were transferred to 237 patients. Thirty-three patients had bilateral wounds. The mean age and BMI were 67 ± 11 years and 27.9 ± 6.3 kg/m2, respectively. Flaps included rectus femoris (n = 142), sartorius (n = 118), rectus abdominis (n = 7), and gracilis (n = 3). Covered vascular grafts included prosthetic materials (n = 200) and autografts (n = 70). The median length of hospital stay after surgery was 10 days (interquartile range=12), and the mean follow-up was 29.1 ± 39.2 months. The major complication rate was 38.5% with wound infection being the most common. Flaps successfully prevented the infection-related removal of the grafts in 98.9% of cases. Multivariable analysis revealed no significant associations between variables and having a major complication. CONCLUSIONS Flap coverage of the inguinal vessels can be performed safely with favorable limb salvage. Wound complications were high, but graft salvage was excellent. Rectus femoris and sartorius muscle flaps were the most common flaps, yielding comparable outcomes.
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Affiliation(s)
| | - Doga Kuruoglu
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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Geber B, Landscheidt K, Goertz O, Hernekamp JF. Die gestielte DIEP-Lappenplastik zur Weichteilrekonstruktion eines großen Leistendefektes nach komplikativer gefäßchirurgischer Vorversorgung. GEFÄSSCHIRURGIE 2022. [DOI: 10.1007/s00772-022-00948-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Grogan GM, Benedict KC, Hoppe IC. Use of Rectus Femoris Muscle Flap in Patients With Absent Profunda Femoris Vascular Flow. EPLASTY 2022; 22:e42. [PMID: 36212605 PMCID: PMC9516764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The rectus femoris (RF) muscle flap is an excellent choice for soft tissue coverage of complex wounds of the groin because of its reliable vascular anatomy and sufficient bulk allowing coverage of vascular anastomoses. The muscle receives its blood supply from the descending branch of the lateral femoral circumflex artery (dLFCA), which originates from the profunda femoris artery (PFA) in the proximal thigh. This case series reports 3 patients on whom pedicled RF muscle flaps were performed successfully despite known occlusion of the PFA preoperatively. METHODS All 3 patients had a history of peripheral vascular disease (PVD) and underwent femoral-popliteal bypass. This was complicated by pseudoaneurysm in 2 patients and exposure of the polytetrafluorethylene graft in the third patient. Computed tomography angiography (CTA) or traditional angiography was obtained for each patient, showing occlusion of the PFA. After adequate debridement and confirming flow through the pedicle, vascular graft coverage at the groin was performed using a pedicled RF muscle flap, followed by split thickness skin grafting (n = 2) or primary skin closure (n = 1). RESULTS The 3 patients included in this report had successful coverage of exposed vascular bypass grafts in the groin utilizing pedicled RF muscle flaps despite known occlusion of the PFA preoperatively. Follow-up at 3 months postoperatively showed healthy flaps with well-healed overlying skin graft or closure for all patients. CONCLUSIONS The pedicled RF muscle flap may be successfully used for coverage of complex groin wounds in patients with occlusion of the PFA. This flap is useful in complex groin wounds related to vascular interventions, particularly when other local options have been exhausted. This case report presents 3 successful cases of groin wound coverage using pedicled RF muscle flap despite known preoperative occlusion of the PFA.
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Affiliation(s)
- Graham M Grogan
- University of Mississippi Medical Center Division of Plastic and Reconstructive Surgery, Jackson, MS
| | - Katherine C Benedict
- University of Mississippi Medical Center Division of Plastic and Reconstructive Surgery, Jackson, MS
| | - Ian C Hoppe
- University of Mississippi Medical Center Division of Plastic and Reconstructive Surgery, Jackson, MS
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Hernekamp JF, Lauer H, Goertz O, Weigang E, Kneser U, Kremer T. Soft tissue reconstruction of complex infra-inguinal wounds following revisionary vascular surgery. Ann Vasc Surg 2022; 88:108-117. [PMID: 36029947 DOI: 10.1016/j.avsg.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/07/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Large, full thickness infra-inguinal wounds following revision revascularization procedures of the lower extremity are a challenging complication for reconstructive surgery. Frequently, these patients present with various comorbidities and after several previous reconstructive attempts and therefore no straightforward soft tissue reconstruction is likely. METHODS Patients who presented with large, complex inguinal wounds for soft tissue reconstruction were analyzed retrospectively in terms of flap choice, outcome and complication rates. A focus was set on the reconstructive technique and a subgroup analysis was assessed. RESULTS 19 patients (11 men, 8 women) who received 19 flaps (17 pedicled, two free flaps) were included in this retrospective study. Average patient age was 73.3 years (range: 53-88 years). 10 fascio-cutaneous flaps (ALT, 52.6%) and 9 muscle flaps (47.4%) were applied. Among muscle flaps, 3 pedicled gracilis flaps, 4 pedicled rectus abdominis flaps and two free latissimus dorsi flaps were used. No flap losses were observed except one case of limited distal flap necrosis (gracilis group). Body Mass Index (BMI) ranged from 19 to 37, mean 26.8. Mean surgery time in all patients was 165.9 minutes (range: 105-373 minutes). Revision surgery due to local wound healing problems averaged 1.6 in all patients. In all cases sufficient soft tissue reconstruction was achieved and bypasses were preserved. Lengths of stay averaged 27.2 (14 to 59 days). Mortality was considerably (10.5%) due to systemic complications (One patient died due to a heart attack 4 weeks postoperatively, another patient died due to an extensive pulmonary embolism two weeks postoperatively). CONCLUSION Soft tissue reconstruction of complex inguinal wounds after revision vascular surgery is challenging and wound-healing problems are expectable. In addition to the rectus abdominis flap the pedicled ALT flap is feasible in a broad variety of medium to large wounds. Free flap reconstruction is recommended for very large defects. A structured interdisciplinary approach is required for the management of complex wounds after vascular surgery to prevent and to deal with complications and perioperative morbidity.
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Affiliation(s)
- J-Frederick Hernekamp
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther Hospital Berlin, Berlin, Germany; Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.
| | - Henrik Lauer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther Hospital Berlin, Berlin, Germany
| | - Ole Goertz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther Hospital Berlin, Berlin, Germany
| | - Ernst Weigang
- Department of Vascular Surgery and endovascular Therapy, Hubertus Hospital Berlin, Berlin, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Kremer
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, Burn Trauma Center, St. Georg Hospital, Leipzig, Germany
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8
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Shimbo K, Kawamoto H, Koshima I. Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2022; 56:401-407. [PMID: 35050812 DOI: 10.1177/15385744211068342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Groin wound infections in vascular surgery are still a common complication and challenging problem. This systematic review aimed to establish a complete view of patient characteristics and clinical outcomes for infected groin wounds following vascular surgery reconstruction using muscle flaps and to evaluate the differences in outcomes between the sartorius muscle flap (SMF), rectus femoris muscle flap (RFF), and gracilis muscle flap (GMF). METHODS PubMed, Scopus, and Web of Science were systematically searched from inception to April 2021. Random-effects meta-analysis for comorbidities and outcomes and subgroup analyses for outcomes were performed. RESULTS Thirty studies were included in qualitative and quantitative syntheses. Overall pooled data showed the following outcome rates: 4.5% muscle flap necrosis (95% confidence interval [CI], -3.4-12.3%; I2 = 0%), 21.8% overall complications (95% CI, 15.8-27.7%; I2 = 0%), 8.0% limb loss (95% CI, 1.9-14.1%; I2 = 0%), 15.4% graft loss (95% CI, 5.0-25.3%; I2 = 37.9%), and 7.4% 30-day mortality (95% CI, -.9-15.6%; I2 = 0%). The rates of overall complications were 20.3% (95% CI, 12.1-28.2%; I2 = 0%), 23.2% (95% CI, 11.2-34.5%; I2 = 10.2%), and 18.0% (95% CI, -3.537.8%; I2 = 0%) for the SMF, RFF, and GMF, respectively. The rate of limb loss was highest for the GMF (17.2%; 95% CI, -4.237.2%; I2 = 0%). The rate of graft loss for the RFF was the highest (20.7%; 95% CI, .6-39.1%; I2 = 53.9%). The rate of 30-day mortality was the lowest for the SMF (5.3%; 95% CI, -6.1-16.6%; I2 = 0%). CONCLUSIONS The effectiveness and safety of muscle flap reconstruction for infected groin wounds following vascular surgery are clearly positive. This review indicated a tendency for lower complication rates with the SMF than with other muscle flaps.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, 37102Hiroshima Prefectural Hospital, Hiroshima, Japan.,International Center for Lymphedema, 68272Hiroshima University Hospital, Hiroshima, Japan
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9
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Calligaro KD. Vascular surgeons should learn how to perform rectus femoris muscle flaps. J Vasc Surg 2020; 72:1058. [PMID: 32829762 DOI: 10.1016/j.jvs.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/07/2019] [Indexed: 10/23/2022]
Affiliation(s)
- Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
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