1
|
Kim Y, Weissler EH, Cui CL, Johnson AP, Seidelman JL, Coleman DM, Southerland KW. Impact of Wound Closure Technique on Surgical Site Infection After Lower Extremity Bypass Surgery. Ann Vasc Surg 2024; 109:424-432. [PMID: 39098728 DOI: 10.1016/j.avsg.2024.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/06/2024] [Accepted: 06/29/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Surgical site infections (SSIs) are among the most common complications after lower extremity bypass (LEB). Both patient and hospital-related factors have been associated with SSI after LEB; however, the impact of surgical closure technique on SSI incidence remains unclear. METHODS Institutional electronic medical records (EMRs) were retrospectively queried for all LEB procedures performed from 2018 to 2022. Data were collected on patient demographics, medical comorbidities, operative details, wound closure techniques, and postoperative outcomes. Closure techniques included skin staples, absorbable monofilament (Monocryl), nonabsorbable monofilament (Nylon), or left open to heal by secondary intention. Logistic regression analysis was utilized to identify risk factors and calculate adjusted odds ratios (ORs) for postoperative SSI. RESULTS A total of 517 patients underwent LEB surgery over the study period. SSI was diagnosed in 120 (23.2%) patients over a median follow-up period of 1.5 years. The most common SSI locations were groin incision (40.0%), saphenectomy (31.7%), and leg incision (19.2%). The median onset of SSI was 18.5 d (interquartile range [IQR] 11-28 d) post-LEB surgery. Patients with SSI had higher body mass index (BMI) (28.2 [IQR 24.2-33.5] vs. 26.6 [23.1-31.5] kg/m2, P = 0.03) compared with non-SSI patients. Patient age, sex, and medical comorbidities were otherwise similar between groups. There were no differences in closure technique (79.2% vs. 78.1% staples, 18.3% vs. 19.7% Monocryl, 0.8% vs. 1.8% Nylon, 1.7% vs. 0.5% open; P = 0.53) in SSI versus non-SSI groups. On multivariate analysis, patient BMI (OR 1.04 per unit, 95% confidence interval [CI] 1.01-1.08, P = 0.02), reoperative field (OR 1.81, 95% CI 1.00-3.25, P = 0.03), and active smoking (OR 2.72, 95% CI 1.12-6.59, P = 0.048) were independently associated with increased SSI incidence. Postoperative SSI resulted in prolonged hospital length of stay (LOS) (7 vs. 6 days, P = 0.04), unplanned hospital readmission (49.2% vs. 12.3%, P < 0.001), and reoperation rates (64.7% vs. 8.1%, P < 0.001). Bypass graft infection rates were also higher among patients suffering postoperative SSI (9.2% vs. 0.0%, P < 0.001). On subset analysis of patients at increased risk of postoperative SSI, as found on multivariate modeling, there were no differences in closure technique between SSI and no SSI groups. CONCLUSIONS This study provides insights on wound closure techniques and postoperative SSI made available through granular, operative data that are not found in large database analyses. Surgical wound closure technique was not associated with postoperative SSI after LEB surgery, even among patients at increased risk of infection. These data support individualization of wound closure techniques among patients undergoing LEB surgery.
Collapse
Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC.
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Adam P Johnson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Jessica L Seidelman
- Division of Infectious Disease, Department of Medicine, Duke University, Durham, NC
| | - Dawn M Coleman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| |
Collapse
|
2
|
Chaney M, Joshi G, Serrato JC, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. Morbidity and mortality of common femoral endarterectomy. J Vasc Surg 2024; 80:199-203. [PMID: 38360191 DOI: 10.1016/j.jvs.2024.01.211] [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: 12/19/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Common femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. METHODS Consecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. RESULTS A total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). CONCLUSIONS Although commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.
Collapse
Affiliation(s)
- Michael Chaney
- Homer Stryker School of Medicine, Western Michigan University, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammad Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health Systems, Evanston, IL.
| |
Collapse
|
3
|
Rezk F, Åstrand H, Svensson-Björk R, Hasselmann J, Nyman J, Butt T, Bilos L, Pirouzram A, Acosta S. Multicenter parallel randomized trial evaluating incisional negative pressure wound therapy for the prevention of surgical site infection after lower extremity bypass. J Vasc Surg 2024; 79:931-940.e4. [PMID: 38042513 DOI: 10.1016/j.jvs.2023.11.043] [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: 10/16/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Incisional negative pressure wound therapy (iNPWT) applied over all incisions after lower extremity bypass in the prevention of surgical site infections (SSIs) is unclear. The primary and secondary aims of this study were to investigate if prophylactic iNPWT after the elective lower extremity bypass prevents SSI and other surgical wound complications. METHODS This was a multicenter, parallel, randomized controlled trial. Patients undergoing elective lower extremity bypass in 3 hospitals were randomized to either iNPWT or standard dressings. SSIs or other wound complications were assessed within the first 90 days by wound care professionals blinded to the randomized result. The validated Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) score was used to objectively assess the wounds. ASEPSIS score ≥21 is defined as an SSI. Unilateral and bilateral groups were analyzed with the Fisher exact test and the McNemar test, respectively. RESULTS In the unilateral group (n = 100), the incidence of SSI in the iNPWT group was 34.9% (15/43), compared with 40.3% (23/57) in the control group, according to the ASEPSIS score (P = .678). In the bilateral group (n = 7), the SSI rate was 14.3% (1/7) in the iNPWT group compared with 14.3% (1/7) in the control group (P = 1.00). In the unilateral group, there was a higher wound dehiscence rate in the control group (43.9%) compared with the iNPWT group (23.3%) (P = .0366). No serious iNPWT-related adverse events were recorded. CONCLUSIONS There was no reduction of SSI rates in leg incisions with iNPWT compared with standard dressings in patients undergoing elective lower extremity bypass, whereas iNPWT reduced the incidence of wound dehiscence.
Collapse
Affiliation(s)
- Francis Rezk
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Surgery, Region Jönköping County, Jönköping, Sweden.
| | - Håkan Åstrand
- Department of Surgery, Region Jönköping County, Jönköping, Sweden
| | | | | | - Johan Nyman
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Linda Bilos
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Artai Pirouzram
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
4
|
Tresson P, Quiquandon S, Rivoire E, Boibieux A, Vanhems P, Bordet M, Long A. American Society of Anesthesiologists-Physical Status Classification As An Independent Risk Factor of Surgical Site Infection After Infra-Inguinal Arterial Bypass. Ann Surg 2023; 277:e1157-e1163. [PMID: 35417113 DOI: 10.1097/sla.0000000000005182] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The present study aimed to assess whether high-risk American Society of Anesthesiologists (ASA)-Physical Status was an independent risk factor for the development of surgical site infection (SSI) after infra-inguinal lower extremity bypass (LEB). SUMMARY OF BACKGROUND DATA The ASA-Physical Status Classification System assesses the overall physical status preoperatively. ASA-Physical Status is associated with postoperative morbidity and mortality. However, limited data are available on how ASA-Physical Status Class affects the development of SSI after infra-inguinal LEB. METHODS Patients who had undergone infra-inguinal LEB from January 1, 2015 to December 31, 2018, for obliterative arteriopathy or popliteal aneurysm at our university hospital were included. SSI risk factors were identified using multivariable logistic regression. The length of hospital stay, major limb events (MALE), major adverse cardiovascular events (MACE), and all-cause mortality were compared for patients with SSI versus those without SSI 3 months and 1- year of follow-up after the index surgery. RESULTS Among the 267 patients included, 30 (11.2%) developed SSI during the 3-month period and 32 (12%) at 1 year. ASA-Physical Status ≥3 [odds ratio (OR): 3.7, 95% confidence interval CI) 1.5-11.1], emergency surgery (OR: 2.7, 95% CI 1.2-6.0), general anesthesia (OR: 2.8, 95% CI 1.3-6.1), and procedure performed by a junior surgeon (OR: 2.7, 95% CI 1.3-6.0) were independently associated with SSI. At 3 months and 1 year, SSI was significantly associated with MALE (including surgical wound debridement, subsequent thrombectomy, major amputation), length of hospital stay, and all-cause mortality. CONCLUSION The ASA-Physical Status should be considered in medical management when an infra-inguinal LEB is considered in frail patients, to prevent surgical complications.
Collapse
Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France
- Centre rHodANien d'isChemie intEStinale (CHANCES Network), Hospices Civils de Lyon, France
| | - Samuel Quiquandon
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Emeraude Rivoire
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - André Boibieux
- Centre de Référence des Infections Vasculaire Complexes (CRIVasc Network), Lyon, France
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses Lyon cedex, France
| | - Philippe Vanhems
- Hospices Civils de Lyon, Hopital Edouard Herriot, Service d'Hygiéne, Epidémiologie et Prévention, Lyon cedex, France
- CIRI, Centre International de Recherche en Infectiologie, Laboratoire des Pathogénes Emergents-Fondation Mérieux, Université Lyon, Inserm, ENS de Lyon, France
| | - Marine Bordet
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Anne Long
- Centre rHodANien d'isChemie intEStinale (CHANCES Network), Hospices Civils de Lyon, France
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
- Univ Lyon, University Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
| |
Collapse
|
5
|
Zhang H, Li Z, Li J, Zhu B, Xu Q. Comparison of Pedicled Adductor Longus and Pedicled Sartorius Flap in Inguinal Reconstruction, a Fresh Cadaver Study. J Pers Med 2023; 13:jpm13010143. [PMID: 36675804 PMCID: PMC9860770 DOI: 10.3390/jpm13010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Reconstruction surgeries in the inguinal area are challenging for vascular surgeons, oncologists, orthopedists, and others. The pedicled sartorius flap is the most commonly used flap for reconstruction. The pedicled adductor longus is reported as a new method to reconstruct the inguinal region. The related anatomic study is rare. This work aims to make a comparison of pedicled adductor longus and pedicled sartorius on cadavers for better use. Out of the 12 thighs in the 6 cadavers analyzed, the author compares two surgical methods in terms of surgical details, exposure of vascular and nerve pedicle, flap harvesting, flap transposition and flap volume, etc. Through the course of this study, it is showed that the adductor longus flap had a sizable advantage over the sartorius flap in terms of exposure, harvesting, and flap volume.
Collapse
Affiliation(s)
- Hong Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Zhenfeng Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Jianmin Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Binghong Zhu
- Department of Gynecology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan 250014, China
| | - Qingjia Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan 250012, China
- Correspondence: ; Tel.: +86-18560082691
| |
Collapse
|
6
|
Seyferth ER, Itkin M, Nadolski GJ. Intranodal Glue Embolization for Postoperative Lymphatic Leaks in the Groin and Pelvis: Comparison with Sclerotherapy. J Vasc Interv Radiol 2022; 34:600-606. [PMID: 36563935 DOI: 10.1016/j.jvir.2022.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To compare the effectiveness of and adverse events related to intranodal glue embolization (IGE) with those of intracavitary sclerotherapy for the treatment of postoperative groin and pelvic lymphatic leaks. MATERIALS AND METHODS From November 2015 to July 2021, IGE for postoperative pelvic or groin lymphocele or lymphorrhea was performed in 33 patients. From January 2010 to July 2021, 28 patients with postoperative pelvic or groin lymphocele were treated with sclerosis alone. Clinical success was defined as resolution of drainage within 3 weeks of the last intervention performed without recurrence. Patients presenting >1 year after surgery or with <30 days of follow-up were excluded. Patients with lymphorrhea treated with IGE were not statistically compared with those in the sclerosis group because they were not eligible for sclerosis. RESULTS Clinical success was similar between the groups (lymphocele IGE, 15/18, 83.3%, vs sclerosis, 15/23, 65.2% [P = .29]; lymphorrhea IGE, 8/9, 88.9%). The mean number of interventions performed to successfully treat a lymphocele was significantly higher in the sclerosis group (2.5 for sclerosis vs 1.3 for IGE; P = .003; lymphorrhea IGE, 1.0). The mean time to resolution was significantly longer for sclerosis than for IGE (27 vs 7 days; P = .002; 4 days for lymphorrhea IGE). There were no sclerosis-related adverse events and 2 IGE-related adverse events: (a) 1 case of mild lymphedema and (b) 1 case of nontarget embolization resulting in deep vein thrombosis. CONCLUSIONS For treatment of postoperative pelvic and groin lymphoceles, IGE results in faster resolution with fewer interventions compared with sclerosis. IGE is also an effective treatment for postoperative groin lymphorrhea.
Collapse
Affiliation(s)
- Elisabeth R Seyferth
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maxim Itkin
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory J Nadolski
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Joshi GS, Zhang SM, Wang K, El Khoury R, Cataneo J, Jacobs CE, White JV, Schwartz LB. Predictors of Amputation-free Survival after Endovascular Intervention for Chronic Limb-Threatening Ischemia in the Modern era. Ann Vasc Surg 2022; 86:268-276. [PMID: 35595207 DOI: 10.1016/j.avsg.2022.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/12/2022] [Accepted: 04/26/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival (AFS) in a contemporary cohort treated with endovascular recanalization and assess its predictors. METHODS Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was AFS; a P-value < 0.05 was used for univariate screening and inclusion in a multivariable model. RESULTS A total of 137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (P = 0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%), although 26% were multilevel. Percutaneous atherectomy, stenting, and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16 months (interquartile range IQR = 4-29 months), significant independent predictors of reduced AFS included nonWhite race (HR = 2.96 [1.42-6.17]; P = 0.004) and WIfI stage 4 wounds (HR = 2.23 [1.10-4.52]; P = 0.026). At one year following successful revascularization, only 59% ± 1% of patients were alive with their limb intact. CONCLUSIONS Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.
Collapse
Affiliation(s)
- Gaurang S Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL.
| | - Suyue M Zhang
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Kathy Wang
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jose Cataneo
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| |
Collapse
|
8
|
Majumdar M, Lella S, Hall RP, Sumetsky N, Waller HD, McElroy I, Sumpio B, Feldman ZM, Kim Y, DeCarlo C, Warner M, Nuzzolo K, Kirshkaln A, Dua A. Utilization of Thromboelastography with Platelet Mapping to Predict Infection and Poor Wound Healing in Postoperative Vascular Patients. Ann Vasc Surg 2022; 87:213-224. [PMID: 35339591 DOI: 10.1016/j.avsg.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE/AIM Postoperative infection and wound dehiscence rates are higher than expected in peripheral artery disease and contribute significantly to limb loss and mortality. Microvascular pathology characterized by microthrombi and increased platelet aggregation have been cited as contributing factors to poor wound healing and infection. The emergence of viscoelastic assays, such as thromboelastography with platelet mapping (TEG-PM), have been utilized to identify prothrombotic states and may provide insight into a patient's microvascular coagulation profile. This prospective, observational study aimed to determine if TEG-PM could predict poor wound healing or infection following lower extremity revascularization. METHODS All patients undergoing revascularization between December 2020 and January 2022 were prospectively included and followed for wound complications or non-surgical site infections of the index limb. TEG-PM metrics at the first postoperative follow-up in the nonevent group was compared to the TEG-PM sample preceding the diagnosis of infection/dehiscence in the event group. Cox proportional hazards regression was used to model the predictive value of viscoelastic parameters. Cut-point analysis to determine high-risk groups was determined by performing receiver operating characteristic (ROC) curve analysis. RESULTS Of the 102 patients, 18.6% experienced infection/dehiscence. The TEG-PM sample analyzed in the event group was, on average, 19.5 days prior to the diagnosis of an event. The event group had significantly higher maximum clot amplitude (MA) [47.3mm±16.0 vs. 30.6mm±15.3, p<0.01], higher platelet aggregation [71.3%±27.7 vs. 31.2%±24.0, p<0.01] and lower platelet inhibition [28.7%±27.7 vs. 68.7%±24.1, p<0.01]. Cox PH analysis identified platelet aggregation as an independent and consistent predictor of infection [HR=1.04, 95% CI 1.03-1.06, p<0.01]. An optimal cut-point of >33.2mm MA, >46.6% platelet aggregation or <55.8% platelet inhibition identifies those with infection/dehiscence with 79.0-89.5% sensitivity. CONCLUSIONS These are the first data to provide a quantitative link between prothrombotic viscoelastic coagulation profiles with the development of infection/dehiscence. Based on the cut-points of >33.2mm MA, >46.6% platelet aggregation or <55.8% platelet inhibition, we recommend consideration of an enhanced antimicrobial or antithrombotic approach for these high risk groups.
Collapse
Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Ryan P Hall
- Department of Surgery, Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Natalie Sumetsky
- Department of Epidemiology, University of Pittsburg, Pittsburg, PA
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Mary Warner
- Department of Surgery, Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA.
| |
Collapse
|
9
|
Amato B, Compagna R, De Vivo S, Rocca A, Carbone F, Gentile M, Cirocchi R, Squizzato F, Spertino A, Battocchio P. Groin Surgical Site Infection in Vascular Surgery: Systemic Review on Peri-Operative Antibiotic Prophylaxis. Antibiotics (Basel) 2022; 11:antibiotics11020134. [PMID: 35203737 PMCID: PMC8868080 DOI: 10.3390/antibiotics11020134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Surgical site infections (SSIs) in lower extremity vascular surgeries, post-groin incision, are not only common complications and significant contributors to patient mortality and morbidity, but also major financial burdens on healthcare systems and patients. In spite of recent advances in pre- and post-operative care, SSI rates in the vascular surgery field remain significant. However, compliant antibiotic therapy can successfully reduce the SSI incidence pre- and post-surgery. Methods: In October 2021, we conducted a systematic literature review using OVID, PubMed, and EMBASE databases, centered on studies published between January 1980 and December 2020. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta Analyses checklist. Inclusion/exclusion criteria have been carefully selected and reported in the text. For analyses, we calculated 95% confidence intervals (CI) and weighted odds ratios to amalgamate control and study groups in publications. We applied The Cochrane Collaboration tool to assess bias risk in selected studies. Results: In total, 592 articles were identified. After the removal of duplicates and excluded studies, 36 full-texts were included for review. Conclusions: The review confirmed that antibiotic therapy, administered according to all peri-operative protocols described, is useful in reducing groin SSI rate in vascular surgery.
Collapse
Affiliation(s)
- Bruno Amato
- Department of Public Health, University Federico II of Naples, 80131 Naples, Italy;
- Correspondence: ; Tel.: +39-3403604022
| | - Rita Compagna
- Division of Vascular Surgery, Ospedale Pellegrini, 80100 Naples, Italy; (R.C.); (S.D.V.)
| | - Salvatore De Vivo
- Division of Vascular Surgery, Ospedale Pellegrini, 80100 Naples, Italy; (R.C.); (S.D.V.)
| | - Aldo Rocca
- Deparment of Medicine and Health Sciences “V. Tiberio”, University of Campobasso, 86100 Campobasso, Italy;
| | - Francesca Carbone
- Department of Public Health, University Federico II of Naples, 80131 Naples, Italy;
| | - Maurizio Gentile
- Department of Clinical Medicine and Surgery, University Federico II of Naples, 80131 Naples, Italy;
| | - Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, 05100 Terni, Italy;
| | - Francesco Squizzato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, 35100 Padova, Italy; (F.S.); (A.S.); (P.B.)
| | - Andrea Spertino
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, 35100 Padova, Italy; (F.S.); (A.S.); (P.B.)
| | - Piero Battocchio
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, 35100 Padova, Italy; (F.S.); (A.S.); (P.B.)
| |
Collapse
|
10
|
Gwilym BL, Bosanquet DC. Re: "Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin". Ann Vasc Surg 2021; 79:e1-e2. [PMID: 34648851 DOI: 10.1016/j.avsg.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/01/2022]
|
11
|
Roberts DJ, Nagpal SK, Stelfox HT, Brandys T, Corrales-Medina V, Dubois L, McIsaac DI. Risk Factors for Surgical Site Infection After Lower Limb Revascularization Surgery in Adults With Peripheral Artery Disease: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2021; 10:e28759. [PMID: 34161251 PMCID: PMC8485188 DOI: 10.2196/28759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are common, costly, and associated with increased morbidity and potential mortality after lower limb revascularization surgery (ie, arterial bypass, endarterectomy, and patch angioplasty). Identifying evidence-informed risk factors for SSI in patients undergoing these surgeries is therefore important. OBJECTIVE The aim of this study is to conduct a systematic review and meta-analysis of prognostic studies to identify, synthesize, and determine the certainty in the cumulative evidence associated with reported risk factors for early and delayed SSI after lower limb revascularization surgery in adults with peripheral artery disease. METHODS We will search MEDLINE, Embase, the seven databases in Evidence-Based Medicine Reviews, review articles identified during the search, and included article bibliographies. We will include studies of adults (aged ≥18 years) with peripheral artery disease that report odds ratios, risk ratios, or hazard ratios adjusted for the presence of other risk factors or confounding variables and relating the potential risk factor of interest to the development of SSI after lower limb revascularization surgery. We will exclude studies that did not adjust for confounding, exclusively examined certain high-risk patient cohorts, or included >20% of patients who underwent surgery for indications other than peripheral artery disease. The primary outcomes will be early (in-hospital or ≤30 days) SSI and Szilagyi grade I (cellulitis involving the wound), grade II (infection involving subcutaneous tissue), and grade III (infection involving the vascular graft) SSI. Two investigators will independently extract data and evaluate the study risk of bias using the Quality in Prognosis Studies tool. Adjusted risk factor estimates with similar definitions will be pooled using DerSimonian and Laird random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. Finally, we will use the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to determine certainty in the estimates of association between reported risk factors and the development of SSI. RESULTS The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews). We will execute the peer-reviewed search strategy on June 30, 2021, and then complete the review of titles and abstracts and full-text articles by July 30, 2021, and September 15, 2021, respectively. We will complete the full-text study data extraction and risk of bias assessment by November 15, 2021. We anticipate that we will be able to submit the manuscript for peer review by January 30, 2022. CONCLUSIONS This study will identify, synthesize, and determine the certainty in the cumulative evidence associated with risk factors for early and delayed SSI after lower limb revascularization surgery in patients with peripheral artery disease. The results will be used to inform practice, clinical practice statements and guidelines, and subsequent research. TRIAL REGISTRATION PROSPERO International Prospective Register of Systematic Reviews CRD42021242557; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242557. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/28759.
Collapse
Affiliation(s)
- Derek J Roberts
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tim Brandys
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Luc Dubois
- Department of Surgery, Western University, London, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
12
|
Wallace AB, Piper ML, Holland M, Lee S, Orringer M, Eichler C, Kim EA, Hansen SL. Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin. Ann Vasc Surg 2021; 78:77-83. [PMID: 34433093 DOI: 10.1016/j.avsg.2021.05.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. METHODS A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. RESULTS A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups. CONCLUSIONS In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.
Collapse
Affiliation(s)
- Adam B Wallace
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Merisa L Piper
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA.
| | - Michael Holland
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Solomon Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Matthew Orringer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Charles Eichler
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Scott L Hansen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA
| |
Collapse
|
13
|
Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review. Arch Plast Surg 2021; 48:404-409. [PMID: 34352953 PMCID: PMC8342245 DOI: 10.5999/aps.2020.02075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
Background To date, there are no consensus guidelines for management of lymphatic leak in groin vascular reconstruction patients. The goal of this study is to review the relevant literature to determine alternatives for treatment and to design an evidence-based algorithm to minimize cost and morbidity and maximize efficacy. Methods A systematic review of the literature was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two independent reviewers applied agreed-upon inclusion and exclusion criteria to eligible records. Studies that included patients who underwent groin dissection for oncologic diagnoses and level 5 data were excluded. Interventions were then categorized by efficacy using predetermined criteria. Results Our search yielded 333 records, of which eight studies were included. In four studies, the success of lymphatic ligation ranged from 75% to 100%, with average days to resolution ranging from 0 to 9. Conservative management in the form of elevation, compression, and bedrest may prolong time to resolution of lymphatic leak (14–24 days) and therefore cost. Conclusions The majority of patients should be offered early operative intervention in the form of lymphatic ligation with or without a primary muscle flap. If the patient is not an operative candidate, a trial of conservative management should be attempted before other nonsurgical interventions.
Collapse
|
14
|
Gwilym BL, Ambler GK, Saratzis A, Bosanquet DC. Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction Models: Development, Internal Validation, and Comparison with Existing Risk Prediction Models Identified in a Systematic Literature Review. Eur J Vasc Endovasc Surg 2021; 62:258-266. [PMID: 34246547 DOI: 10.1016/j.ejvs.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study aimed to develop and internally validate risk prediction models for predicting groin wound surgical site infections (SSIs) following arterial intervention and to evaluate the utility of existing risk prediction models for this outcome. METHODS Data from the Groin wound Infection after Vascular Exposure (GIVE) multicentre cohort study were used. The GIVE study prospectively enrolled 1 039 consecutive patients undergoing an arterial procedure through 1 339 groin incisions. An overall SSI rate of 8.6% per groin incision, and a deep/organ space SSI rate of 3.8%, were reported. Eight independent predictors of all SSIs, and four independent predictors of deep/organ space SSIs were included in the development and internal validation of two risk prediction models. A systematic search of the literature was conducted to identify relevant risk prediction models for their evaluation. RESULTS The "GIVE SSI risk prediction model" ("GIVE SSI model") and the "GIVE deep/organ space SSI risk prediction model" ("deep SSI model") had adequate discrimination (C statistic 0.735 and 0.720, respectively). Three other groin incision SSI risk prediction models were identified; both GIVE risk prediction models significantly outperformed these other risk models in this cohort (C statistic 0.618 - 0.629; p < .050 for inferior discrimination in all cases). CONCLUSION Two models were created and internally validated that performed acceptably in predicting "all" and "deep" groin SSIs, outperforming current existing risk prediction models in this cohort. Future studies should aim to externally validate the GIVE models.
Collapse
Affiliation(s)
- Brenig L Gwilym
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK.
| | - Graeme K Ambler
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Athanasios Saratzis
- NIHR Leicester Biomedical Research Centre, University of Leicester Department of Cardiovascular Sciences, Leicester, UK
| | - David C Bosanquet
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK
| | -
- Vascular and Endovascular Research Network (VERN), UK
| |
Collapse
|
15
|
Taylor ME, Ngaage LM, Wasicek P, Ha M, Nagarsheth K, Toursavadkohi SA, Karwowski J, Rasko YM. Vacuum-Assisted Incisional Closure Therapy After Groin Reconstruction With Muscle Flap. Cureus 2021; 13:e14954. [PMID: 34123651 PMCID: PMC8191421 DOI: 10.7759/cureus.14954] [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] [Indexed: 11/10/2022] Open
Abstract
Background Groin reconstruction with muscle flap coverage is associated with high wound complication rates. Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. We evaluated the impact of iVAC on postoperative outcomes in patients following groin reconstruction with muscle flap coverage. Methods We conducted a retrospective review of patients who underwent groin reconstruction with muscle flap coverage in 2012-2018. Patients were divided into those who received iVAC therapy and those who received standard sterile dressings (SSD). Results Of the 57 patients included, most received iVAC therapy (71%, n = 41) and the rest received SSD (28%, n = 16). The iVAC group had higher rates of diabetes, hypertension, coronary artery disease, and peripheral artery disease (p < 0.05). However, iVAC patients had comparable length of hospital stay (12 vs 8.5 days p = 0.0735), reoperations (34% vs 31%, p = 0.8415), and readmissions (32% vs 37%, p = 0.6801) with SSD patients. iVAC placement was less likely in prophylactic flaps (odds ratio 0.08, p = 0.0049). Conclusion Patients with a prophylactic flap were less likely to receive vacuum therapy, which may highlight a selection bias where surgeons pre-emptively use iVAC therapy in surgical candidates identified as high risk. The pre-emptive use of iVAC may minimize adverse postoperative outcomes in high-risk patients.
Collapse
Affiliation(s)
- Maryclare E Taylor
- Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Ledibabari M Ngaage
- Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Philip Wasicek
- General Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Michael Ha
- Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Khanjan Nagarsheth
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | | | - John Karwowski
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Yvonne M Rasko
- Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
16
|
Šuljagić V, Bajčetić M, Mioljević V, Dragovac G, Mijović B, Janićijević I, Đorđević Z, Krtinić G, Rakić V, Ćirković I, Nikolić V, Marković-Denić L. A nationwide assessment of the burden of healthcare-associated infections and antimicrobial use among surgical patients: results from Serbian point prevalence survey, 2017. Antimicrob Resist Infect Control 2021; 10:47. [PMID: 33676578 PMCID: PMC7936242 DOI: 10.1186/s13756-021-00889-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/05/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND As the only non-European Union (EU) country, Serbia participated in a second point prevalence survey of healthcare-associated infections (HAIs) and antimicrobial use (AMU) organized by the European Centre for Disease Prevention and Control (ECDC) in the EU countries. Here, we aimed to estimate the prevalence of HAI and AMU in patients who had recently undergone a surgery and to compare risk profile, HAI rates, and AMU among surgical patients and non-surgical patients. METHODS A national PPS was performed in 65 Serbian acute-care hospitals, in November 2017. In this paper, the data of 61 hospitals for adult acute-care were analyzed. To ensure the comparability of study design we used the Serbian translation of ECDC case definitions and ECDC PPS protocol. The trained infection control staff, led by a hospital coordinator, reviewed medical records to identify HAI active at the time of the survey and AMU. Only inpatients admitted to the ward before 8 a.m. on the day if the survey were included. RESULTS A total of 12,478 patients from 61 hospitals for adult acute-care were eligible for inclusion in this study. Significantly higher proportions of surgical patients were female, belonged to the 60-to-79 age group, and were less severely ill. Also, extrinsic factors (invasive devices, hospitalization at the ICU, and prior antibiotics therapy) were more frequent in surgical patients. Prevalence of HAIs was higher among surgical patients (261/3626; 7.2%) than among non-surgical patients (258/8852; 2.9%) (p < 0.0001). The highest prevalence of all HAIs was noted in patients who had kidney transplantation (4/11; 36.4%), while SSIs were the most prevalent among patients who had peripheral vascular bypass surgery (3/15; 20.0%). Non-surgical patients received treatment for community-acquired infections in significantly higher proportion (2664/8852; 64.3) (p < 0.001). Surgical prophylaxis for more than 1 day was applied in 71.4% of surgical patients. CONCLUSION We have provided an insight into the burden of HAIs and AMU among Serbia acute-care hospitals, and highlighted several priority areas and targets for quality improvement.
Collapse
Affiliation(s)
- Vesna Šuljagić
- Faculty of Medicine of Military Medical Academy, University of Defence, Belgrade, Serbia.
| | - Milica Bajčetić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Gorana Dragovac
- Institute of Public Health of Vojvodina, Novi Sad, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Biljana Mijović
- Faculty of Medicine, University of East Sarajevo, Foča, Bosnia and Herzegovina.,General Hospital of Čačak, Čačak, Serbia
| | | | | | | | - Violeta Rakić
- Institute of Public Health of Serbia, Belgrade, Serbia
| | - Ivana Ćirković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | | |
Collapse
|
17
|
Bertges DJ, Smith L, Scully RE, Wyers M, Eldrup-Jorgensen J, Suckow B, Ozaki CK, Nguyen L. A multicenter, prospective randomized trial of negative pressure wound therapy for infrainguinal revascularization with a groin incision. J Vasc Surg 2021; 74:257-267.e1. [PMID: 33548422 DOI: 10.1016/j.jvs.2020.12.100] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wound complications after open infrainguinal revascularization are a frequent cause of patient morbidity, resulting in increased healthcare costs. The purpose of the present study was to assess the effects of closed incision negative pressure therapy (ciNPT) on groin wound complications after infrainguinal bypass and femoral endarterectomy. METHODS A total of 242 patients who had undergone infrainguinal bypass (n = 124) or femoral endarterectomy (n = 118) at five academic medical centers in New England from April 2015 to August 2019 were randomized to ciNPT (PREVENA; 3M KCI, St Paul, Minn; n = 118) or standard gauze (n = 124). The primary outcome measure was a composite endpoint of groin wound complications, including surgical site infections (SSIs), major noninfectious wound complications, or graft infections within 30 days after surgery. The secondary outcome measures included 30-day SSIs, 30-day noninfectious wound complications, readmission for wound complications, significant adverse events, and health-related quality of life using the EuroQoL 5D-3L survey. RESULTS The ciNPT and control groups had similar demographics (age, 67 vs 67 years, P = .98; male gender, 71% vs 70%, P = .86; white race, 93% vs 93%, P = .97), comorbidities (previous or current smoking, 93% vs 94%, P = .46; diabetes, 41% vs 48%, P = .20; renal insufficiency, 4% vs 7%, P = .31), and operative characteristics, including procedure type, autogenous conduit, and operative time. No differences were found in the primary composite outcome at 30 days between the two groups (ciNPT vs control: 31% vs 28%; P = .55). The incidence of SSI at 30 days was similar between the two groups (ciNPT vs control: 11% vs 12%; P = .58). Infectious (13.9% vs 12.6%; P = .77) and noninfectious (20.9% vs 17.6%; P = .53) wound complications at 30 days were also similar for the ciNPT and control groups. Wound complications requiring readmission also similar between the two groups (ciNPT vs control: 9% vs 7%; P = .54). The significant adverse event rates were not different between the two groups (ciNPT vs control: 13% vs 16%; P = .53). The mean length of the initial hospitalization was the same for the ciNPT and control groups (5.2 vs 5.7 days; P = .63). The overall health-related quality of life was similar at baseline and at 14 and 30 days postoperatively for the two groups. Although not powered for stratification, we found no differences among the subgroups in gender, obesity, diabetes, smoking, claudication, chronic limb threatening ischemia, bypass, or endarterectomy. On multivariable analysis, no differences were found in wound complications at 30 days for the ciNPT vs gauze groups (odds ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .234). CONCLUSIONS In contrast to other randomized studies, our multicenter trial of infrainguinal revascularization found no differences in the 30-day groin wound complications for patients treated with ciNPT vs standard gauze dressings. However, the SSI rate was lower in the control group than reported in other studies, suggesting other practice patterns and processes of care might have reduced the rate of groin infections. Further study might identify the subsets of high-risk patients that could benefit from ciNPT.
Collapse
Affiliation(s)
- Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt.
| | - Lisa Smith
- Office of Clinical Trials Research, University of Vermont College of Medicine, Burlington, Vt
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Mark Wyers
- Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Bjoern Suckow
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Louis Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| |
Collapse
|
18
|
Rasheed H, Diab K, Singh T, Chauhan Y, Haddad P, Zubair MM, Vowels T, Androas E, Rojo M, Auyang P, McFall R, Gomez LF, Mohamed A, Peden E, Rahimi M. Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery. Ann Vasc Surg 2020; 72:578-588. [PMID: 33157243 DOI: 10.1016/j.avsg.2020.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Haroon Rasheed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Kaled Diab
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Tarundeep Singh
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Yusuf Chauhan
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Paul Haddad
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - M Mujeeb Zubair
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Travis Vowels
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Edward Androas
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Manuel Rojo
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Phillip Auyang
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ross McFall
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Luis Felipe Gomez
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ahmed Mohamed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Eric Peden
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Maham Rahimi
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX.
| |
Collapse
|
19
|
The association between preoperative length of stay and surgical site infection after lower extremity bypass for chronic limb-threatening ischemia. J Vasc Surg 2020; 73:1340-1349.e2. [PMID: 32889070 DOI: 10.1016/j.jvs.2020.08.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 08/01/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is an important complication of lower extremity bypass (LEB) and the rate of SSI after LEB varies widely in the existing literature, ranging from 4% to 31%. Prolonged length of stay (LOS) has been implicated in the occurrence of SSI across multiple surgical disciplines. The impact of preoperative LOS in patients with chronic limb-threatening ischemia (CLTI) undergoing LEB is unknown. We examined the association of preoperative LOS on SSI after LEB. METHODS A retrospective analysis of the Society for Vascular Surgery Vascular Quality Initiative Infrainguinal Bypass Registry identified patients undergoing elective LEB for chronic limb-threatening ischemia from 2003 to 2019. Patients undergoing LEB for acute limb ischemia, urgent/emergent procedures, aneurysm, or who had concomitant suprainguinal bypass were excluded. The primary outcome measure was postoperative SSI. Multivariable forward stepwise logistic regression was then performed including all variables with a P value of less than .10 in both matched and unmatched cohorts to evaluate for demographic and perioperative predictors of SSI. Propensity score matching was used to create matched cohorts of patients for each LOS group. RESULTS A total of 17,883 LEB procedures were selected for inclusion: 0 days (12,362 LEB), 1 to 2 days (1737 LEB), and 3 to 14 days (3784 LEB). Patients with the greatest preoperative LOS were more likely to have vein mapping (0 days preoperative LOS, 66.3%; 1-2 days, 65.2%; 3-14 days, 73.2%; P < .01) or computed tomography angiography/magnetic resonance angiography (0 days, 32.1%; 1-2 days, 34.4%; 3-14 days, 38.4%; P < .01). Patients with 3 or more days of preoperative LOS had longer procedure lengths (0 days, 244 minutes; 1-2 days, 243 minutes; 3-14 days, 255 minutes; P < .01) and were more likely to have completion angiogram (0 days, 27.1%; 1-2 days, 29.5%; 3-14 days, 31.6%; P = .02). Multivariable logistic regression demonstrated that preoperative LOS of 3 to 14 days was associated with increased rate of SSI (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.20-3.07; P = .01). Transfusion of 3 or more units (OR, 2.87; 95% CI, 1.89-4.36; P < .01) and prolonged procedure length (>220 minutes; OR, 1.86; 95% CI, 1.26-2.73; P < .01) were also significantly associated with postoperative SSIs. CONCLUSIONS Many factors including preoperative comorbidities and operative complexity covary with preoperative LOS as risk factors for SSI. However, when patients are matched based on comorbidities and factors that would predict overall clinical complexity, preoperative LOS remains important in predicting SSI.
Collapse
|
20
|
Böhme T, Noory E, Beschorner U, Macharzina R, Zeller T. The SELUTION SLR™ drug-eluting balloon system for the treatment of symptomatic femoropopliteal lesions. Future Cardiol 2020; 17:257-267. [PMID: 32815739 DOI: 10.2217/fca-2020-0085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Endovascular treatment has become first line therapy for the treatment of femoropopliteal disease. Drug-coated devices play a key role in maintaining vessel patency. In the past antiproliferative coating of drug-coated balloons (DCBs) exclusively consisted of paclitaxel. Use of limus drugs was limited by a short residency time in the vessel wall. Besides the drug, the SELUTION SLR™ drug-eluting balloon system consists of a coating formulation of four excipients. The first excipient is a biodegradable polymer (poly(lactic-co-glycolic acid)) that is intermixed with the sirolimus to form micro-reservoirs and regulates drug release via matrix degradation. This review summarizes the existing pre-clinical and clinical literature on treatment of femoropopliteal artery lesions with the SELUTION SLR DCB.
Collapse
Affiliation(s)
- Tanja Böhme
- Department of Angiology, Universitaets-Herzzentrum Freiburg, Bad Krozingen, Germany
| | - Elias Noory
- Department of Angiology, Universitaets-Herzzentrum Freiburg, Bad Krozingen, Germany
| | - Ulrich Beschorner
- Department of Angiology, Universitaets-Herzzentrum Freiburg, Bad Krozingen, Germany
| | - Roland Macharzina
- Department of Angiology, Universitaets-Herzzentrum Freiburg, Bad Krozingen, Germany
| | - Thomas Zeller
- Department of Angiology, Universitaets-Herzzentrum Freiburg, Bad Krozingen, Germany
| |
Collapse
|
21
|
Abstract
Post-operative wound complications after infrainguinal vascular surgery can lead to a significant decrease in a patient’s quality of life. The main complications are surgical site infection, wound dehiscence, seroma, hematoma, delayed healing and/or poor scarring. Closed-incision negative pressure therapy (ciNPT) in particular has recently been suggested as a method of prophylaxis against these surgical site complications when applied over a closed wound. In our unit, it has generally been used for long groin and abdominal surgical wounds. We describe here four relatively unusual cases of our experience using ciNPT. In our series, ciNPT has been used to good effect on small eccentrically shaped wounds and non-resolving groin hematomas. We have also used it in tandem with intra-cavity Vacuum Assisted Closure (VAC) (KCI, Acelity, San Antonio, TX) dressings for the management of partially closed wounds to reduce risk of infection and dehiscence. Additionally, it has shown good analgesic effects in our patient post-operatively. Hence, we suggest that the paradigm of ciNPT can be expanded to include these circumstances to improve wound healing and decrease risk of post-operative complications. Further research into the overall clinical benefits and cost-effectiveness will also be helpful.
Collapse
Affiliation(s)
- Sarah Huan
- Hand Surgery, Singapore General Hospital, Bukit Merah, SGP
| | - Luke Tay
- Vascular Surgery, Singapore General Hospital, Bukit Merah, SGP
| |
Collapse
|
22
|
Benrashid E, Youngwirth LM, Guest K, Cox MW, Shortell CK, Dillavou ED. Negative pressure wound therapy reduces surgical site infections. J Vasc Surg 2020; 71:896-904. [DOI: 10.1016/j.jvs.2019.05.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
|
23
|
Kronick M, Liem TK, Jung E, Abraham CZ, Moneta GL, Landry GJ. Experienced operators achieve superior patency and wound complication rates with endoscopic great saphenous vein harvest compared with open harvest in lower extremity bypasses. J Vasc Surg 2019; 70:1534-1542. [DOI: 10.1016/j.jvs.2019.02.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/19/2019] [Indexed: 10/26/2022]
|
24
|
Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
Collapse
Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
| |
Collapse
|
25
|
Use of Closed-Incision Negative-Pressure Therapy: Cardiothoracic and Vascular Surgery. Plast Reconstr Surg 2018; 143:31S-35S. [PMID: 30586101 DOI: 10.1097/prs.0000000000005310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
Collapse
|
26
|
Madden NJ, Calligaro KD, Dougherty MJ, Zheng H, Troutman DA. Lateral femoral bypass for prosthetic arterial graft infections in the groin. J Vasc Surg 2018; 69:1129-1136. [PMID: 30292617 DOI: 10.1016/j.jvs.2018.07.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Prosthetic arterial graft infections (PAGIs) in the groin pose significant challenges in terms of revascularization options and risk of limb loss as well as associated morbidities. Although obturator canal bypass (OCB) has been suggested for revascularization of the extremity in these cases, moderate success rates and technical challenges have limited widespread use. Our study analyzed lateral femoral bypass (LFB) as an alternative approach for the treatment of groin PAGIs. METHODS This is a retrospective review of a prospectively maintained database of patients who underwent LFB for groin PAGIs at a single center from 2000 to 2017. Patients' data including demographics, comorbidities, perioperative complications, graft patency, and need for reintervention were used. Patients were observed after LFB with duplex ultrasound surveillance in an accredited noninvasive vascular laboratory every 3 months during the first year, followed by every 6 months for the second year and yearly thereafter. After isolation of the infected wound with sterile dressings, remote proximal and distal arterial exposure incisions were made. LFBs were tunneled under the inguinal ligament and lateral to the infected wound from an uninvolved inflow artery or bypass graft to an uninvolved outflow vessel. RESULTS A total of 19 LFBs were performed in 16 patients (mean age, 69 ± 12.6 years). Three LFBs were performed urgently for acute bleeding. Choice of conduit included 6 (31.6%) autogenous vein grafts, 10 (52.6%) cadaveric grafts, 2 (10.5%) rifampin-soaked Dacron grafts, and 1 (5.3%) polytetrafluoroethylene graft. Average follow-up was 33 months (range, 0-103 months). Major adverse events occurring within 30 days of the operation included one (5.3%) death and one (5.3%) graft excision for pseudoaneurysm. Primary patency and primary assisted patency at 12 and 24 months were 73% and 83%, respectively. One patient required an amputation 17 months after surgery after failure of repeated revascularization attempts. Overall limb salvage was 93.8% during this follow-up period. CONCLUSIONS In this series, LFB for management of groin PAGIs demonstrated higher patency and limb salvage rates compared with previous reports of OCB. Diligent postoperative duplex ultrasound surveillance is critical to the achievement of limb salvage and maintenance of graft patency. These results suggest that LFB, which is technically less complex than OCB, should be considered the first choice for revascularization in select cases of PAGIs involving the groin.
Collapse
Affiliation(s)
- Nicholas J Madden
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | | | - Hong Zheng
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | | |
Collapse
|
27
|
Mirza AK, Stauffer K, Fleming MD, De Martino R, Oderich G, Kalra M, Gloviczki P, Bower T. Endoscopic versus open great saphenous vein harvesting for femoral to popliteal artery bypass. J Vasc Surg 2018; 67:1199-1206. [DOI: 10.1016/j.jvs.2017.08.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
|
28
|
Fewer Complications in the Obese Following Lower Extremity Endovascular Interventions. Ann Vasc Surg 2018; 49:17-23. [PMID: 29421418 DOI: 10.1016/j.avsg.2017.10.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/17/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The prevalence of obesity is increasing in the United States; however, its impact on adverse outcomes in patients with peripheral vascular disease is not well studied. Obesity is associated with higher rates of complications following open bypass surgery, but limited data are available on its effect on endovascular intervention. This study aimed to identify whether obese patients suffer the same complications when undergoing lower extremity endovascular interventions. METHODS All patients who underwent femoropopliteal or tibial endovascular interventions between 2011 and 2013 were identified in the Targeted Vascular Module of the National Surgical Quality Improvement Program. Patients were stratified into 5 groups based on their body mass index (BMI): underweight (<18.6), normal weight (18.6-24.9), overweight (25-29.9), obese (30-34.9), and morbidly obese (≥35). Those patients without a documented BMI or a defined target lesion were excluded. Baseline demographics, patient characteristics, operative details, and outcomes were compared using univariate analysis between the BMI groups. Multivariable logistic regression was used to account for patient demographics and operative details. RESULTS 3,246 patients underwent endovascular interventions (78% femoropopliteal and 22% tibial). Of these, 137 (4%) were underweight, 881 (27%) were normal weight, 1,193 (37%) were overweight, 647 (20%) were obese, and 388 (12%) were morbidly obese. There were no differences in 30-day mortality; however, surgical site infection (SSI) was higher in the morbidly obese (5% vs. normal weight: 2%, P = 0.02), whereas untreated patency loss was lower (morbidly obese: 0.5%, obese: 1%, normal weight: 2%, P = 0.02). Other important 30-day outcomes, including bleeding and amputation, were similar across the BMI groups. Following multivariate analysis, SSI remained more common in the morbidly obese (odds ratio [OR]: 2.6, 95% confidence interval [CI]: 1.4-5.0), whereas untreated patency loss remained lower in both overweight and morbidly obese patients (overweight: OR 0.5, 95% CI: 0.2-0.9 and morbidly obese: OR: 0.2, 95% CI: 0.05-0.85). Length of stay >1 day was significantly lower in the overweight, obese, and morbidly obese (OR 0.7, 95% CI: 0.6-0.8; OR 0.6, 95% CI: 0.5-0.7; and OR 0.7, 95% CI: 0.5-0.9, respectively). CONCLUSIONS Few major complications occur in the obese in the first 30 days following endovascular interventions, and obesity is not an independent predictor of 30-day mortality. Rates of postoperative SSIs are low overall, although they are highest in morbidly obese patients (5%, compared to 2% in normal weight patients). Given this knowledge, endovascular interventions are a prudent treatment option for this patient population.
Collapse
|
29
|
Parikh PP, Rubio GA, Patel K, Gupta K, Jones K, Rey J, Robinson H. Transverse versus Longitudinal Incisions for Femoral Artery Exposure in Treating Patients with Peripheral Vascular Disease. Ann Vasc Surg 2018; 47:143-148. [DOI: 10.1016/j.avsg.2017.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/30/2017] [Accepted: 08/03/2017] [Indexed: 12/01/2022]
|
30
|
Fernandes-Taylor S, Berg S, Gunter R, Bennett K, Smith MA, Rathouz PJ, Greenberg CC, Kent KC. Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery. J Surg Res 2017; 221:196-203. [PMID: 29229128 DOI: 10.1016/j.jss.2017.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/26/2017] [Accepted: 08/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery. METHODS We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis. RESULTS Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017). CONCLUSIONS Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.
Collapse
Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Stephen Berg
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca Gunter
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kyla Bennett
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - K Craig Kent
- The Ohio State University College of Medicine, Columbus, Ohio
| |
Collapse
|
31
|
Aziz F, Bohr T, Lehman EB. Wound Disruption after Lower Extremity Bypass Surgery is a Predictor of Subsequent Development of Wound Infection. Ann Vasc Surg 2017; 43:176-187. [DOI: 10.1016/j.avsg.2016.10.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/17/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
|
32
|
Comparison of perioperative complications of pedicled island flap in reconstruction of extremities. J Surg Res 2017; 220:94-104. [PMID: 29180217 DOI: 10.1016/j.jss.2017.06.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/31/2017] [Accepted: 06/29/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE The aim of this study was to analyze the differences in perioperative complications for pedicled island flaps in the reconstruction of extremities and to identify the factors contributing to pedicled island flap necrosis. Furthermore, the flap indications based on these outcomes are summarized. METHODS Based on the inclusion criteria, 228 skin flaps were included in this study. Univariate and multivariate analyses were used to identify the risk factors for pedicled island flap necrosis. Differences in perioperative complications between upper and lower extremities were analyzed using the chi-square test or Fisher's exact test. RESULTS The average age of the patients was 38 years. The overall complication rate was 21.93%, including partial flap necrosis (10.09%) and total flap necrosis (5.70%). The overall complication rate and flap necrosis rate in upper extremity reconstruction were significantly lower than the rates in lower extremity reconstruction. Flap area and postoperative wound infection were statistically significant risk factors for pedicled island flap necrosis in extremity reconstruction. Preoperative contamination of the wound bed was a statistically significant risk factor for postoperative wound infection. CONCLUSIONS The flap area and postoperative wound infection were both independent risk factors for pedicled island flap necrosis in extremity reconstruction. The causes contributing to the differences in perioperative complications between upper and lower extremities reconstruction included preoperative contamination of the wound bed, postoperative wound infection, and the flap area but were also related to anatomical factors of the skin flap. Pedicled island flaps are more suitable for small- and medium-sized soft tissue defects.
Collapse
|
33
|
Predictors of surgical site infection after open lower extremity revascularization. J Vasc Surg 2017; 65:1769-1778.e3. [PMID: 28527931 DOI: 10.1016/j.jvs.2016.11.053] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/19/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) after open lower extremity bypass (LEB) is a serious complication leading to an increased rate of graft failure, hospital readmission, and health care costs. This study sought to identify predictors of SSI after LEB for arterial occlusive disease and also potential modifiable factors to improve outcomes. METHODS Data from a statewide cardiovascular consortium of 35 hospitals were used to obtain demographic, procedural, and hospital risk factors for patients undergoing elective or urgent open LEB between January 2012 and June 2015. Bivariate comparisons and targeted maximum likelihood estimation were used to identify independent risk factors of SSI. Adjusted odds ratios (ORs) were calculated for patient demographics, comorbidities, operative details, and hospital-level factors. RESULTS Our study population included 3033 patients who underwent 703 femoral-femoral bypasses, 1431 femoral-popliteal bypasses, and 899 femoral-distal vessel bypasses. An SSI was diagnosed in 320 patients (10.6%) ≤30 days after the index operation. Adjusted patient and procedural predictors of SSI included renal failure currently requiring dialysis (OR, 4.35; 95% confidence interval [CI], 3.45-5.47; P < .001), hypertension (OR, 4.29; 95% CI, 2.74-6.72; P < .001), body mass index ≥25 kg/m2 (OR, 1.78; 95% CI, 1.23-2.57; P = .002), procedural time >240 minutes (OR, 2.95; 95% CI, 1.89-4.62; P < .001), and iodine-only skin preparation (OR, 1.73; 95% CI, 1.02-2.91; P = .04). Hospital factors associated with increased SSI included hospital size <500 beds (OR, 2.22; 95% CI, 1.09-4.55; P = .028) and major teaching hospital (OR, 1.66; 95% CI, 1.07-2.58; P = .024). SSI resulted in increased risk of major amputation and surgical reoperation (P < .01), but did not affect 30-day mortality. CONCLUSIONS SSI after LEB is associated with an increase in rate of amputation and reoperation. Several patient, operative, and hospital-related risk factors that predict postoperative SSI were identified, suggesting that targeted improvements in perioperative care may decrease complications and improve vascular patient outcomes.
Collapse
|
34
|
Arnaoutakis DJ, Scully RE, Sharma G, Shah SK, Ozaki CK, Belkin M, Nguyen LL. Impact of body mass index and gender on wound complications after lower extremity arterial surgery. J Vasc Surg 2017; 65:1713-1718.e1. [PMID: 28259578 DOI: 10.1016/j.jvs.2016.12.116] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Wound complications (WCs) after lower extremity arterial surgery (LEAS) are common, resulting in readmissions and reinterventions. Whereas diabetes and obesity are known risk factors for WCs, gender-specific variability in body fat distribution (android vs gynoid) may drive differential risks of WCs after LEAS. We analyzed the independent and synergistic effects of gender and body mass index (BMI) on WCs. METHODS We performed a retrospective review of prospectively collected data from a published, randomized, multicenter trial assessing the incidence of WCs (dehiscence, surgical site infections, seroma, and hematoma) after LEAS. Postoperative outcomes were compared between genders. A multivariable regression model assessed the impact of gender and BMI on WCs. Subanalysis focused on the synergy of gender and body habitus, groin-only incisions, and clinical outcomes. RESULTS There were 502 patients who underwent LEAS between October 2010 and September 2013. The cohort was elderly (67.6 ± 10.5 years), mostly male (72%), and overweight (BMI, 27.6 ± 5.7); 225 (45%) patients had a groin-only incision. In 171 patients (37.9%), a WC developed within 30 days, 85% of which were infectious in etiology. On multivariable regression, obesity (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.17-3.77), morbid obesity (OR, 2.87; 95% CI, 1.32-6.23), and female gender (OR, 1.17; 95% CI, 1.06-2.75) were independent predictors of infectious WCs at 30 days. When stratified by groin-only incision, BMI was no longer significant, but female gender (OR, 2.70; 95% CI, 1.24-5.87) was predictive of infectious WCs at 30 days. There was no synergistic effect of BMI and gender on WCs. CONCLUSIONS WCs are common after LEAS. BMI is an independent risk factor for the development of any WC. Female gender, a potential surrogate for high hip to waist ratio body habitus, is also an independent predictor of groin WCs, suggesting the clinical importance of gynoid vs android fat distribution.
Collapse
Affiliation(s)
- Dean J Arnaoutakis
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
| | - Rebecca E Scully
- Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Gaurav Sharma
- Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Samir K Shah
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| |
Collapse
|
35
|
Scaglioni MF, Franchi A, Giovanoli P. Pedicled chimeric sensitive fasciocutaneous anterolateral thigh (ALT) and vastus lateralis muscle (VLM) flap for groin defect reconstruction: A case report. Microsurgery 2017; 38:423-426. [DOI: 10.1002/micr.30157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/03/2017] [Accepted: 01/05/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Mario F. Scaglioni
- Department of Plastic and Hand Surgery; University Hospital Zurich; Zurich Switzerland
| | - Alberto Franchi
- Department of Plastic and Hand Surgery; University Hospital Zurich; Zurich Switzerland
| | - Pietro Giovanoli
- Department of Plastic and Hand Surgery; University Hospital Zurich; Zurich Switzerland
| |
Collapse
|
36
|
Endoscopic vein harvest does not negatively affect patency of great saphenous vein lower extremity bypass. J Vasc Surg 2016; 63:1546-54. [DOI: 10.1016/j.jvs.2016.01.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/08/2016] [Indexed: 11/23/2022]
|
37
|
Daryapeyma A, Hammar U, Wahlgren C. Incidence of Healthcare Associated Infections After Lower Extremity Revascularization Using Antibiotic Treatment as a Marker. Eur J Vasc Endovasc Surg 2016; 51:690-5. [DOI: 10.1016/j.ejvs.2015.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 12/12/2015] [Indexed: 01/08/2023]
|
38
|
Bennett KM, Levinson H, Scarborough JE, Shortell CK. Validated prediction model for severe groin wound infection after lower extremity revascularization procedures. J Vasc Surg 2016; 63:414-9. [DOI: 10.1016/j.jvs.2015.08.094] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 08/18/2015] [Indexed: 11/29/2022]
|
39
|
de Blic R, Deux JF, Kobeiter H, Desgranges P, Becquemin JP, Allaire E. Initial Experience with Percutaneous Angioplasty of the Common Femoral Artery in De Novo Stenotic Lesions. Ann Vasc Surg 2015; 29:1493-500. [DOI: 10.1016/j.avsg.2015.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 05/01/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
|
40
|
Wiseman JT, Fernandes-Taylor S, Barnes ML, Saunders RS, Saha S, Havlena J, Rathouz PJ, Kent KC. Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery. J Vasc Surg 2015; 62:1023-1031.e5. [PMID: 26143662 PMCID: PMC4586313 DOI: 10.1016/j.jvs.2015.04.453] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is one of the most common postoperative complications after vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients who develop SSI after discharge. In this study, we explore the factors that lead to postdischarge SSI, investigate the differences between risk factors for in-hospital vs postdischarge SSI, and develop a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds. METHODS Patients who underwent major vascular surgery from 2005 to 2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of postdischarge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low, low/moderate, moderate/high, and high risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI. RESULTS Of the 49,817 patients who underwent major vascular surgery, 4449 (8.9%) were diagnosed with SSI (2.1% in-hospital SSI; 6.9% postdischarge SSI). By multivariable analysis, factors significantly associated with increased odds of postdischarge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurologic disease, prolonged operative time >4 hours, American Society of Anesthesiology class 4 or 5, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected C statistic, 0.691) and excellent internal calibration. The postdischarge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high-risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI. CONCLUSIONS The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high risk for SSI after discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.
Collapse
Affiliation(s)
- Jason T Wiseman
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Maggie L Barnes
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - R Scott Saunders
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Sandeep Saha
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Jeffrey Havlena
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - K Craig Kent
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
| |
Collapse
|
41
|
Salvage of Exposed Groin Vascular Grafts with Early Intervention Using Local Muscle Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e514. [PMID: 26495227 PMCID: PMC4596439 DOI: 10.1097/gox.0000000000000480] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 07/13/2015] [Indexed: 11/25/2022]
Abstract
Background: Peripheral vascular surgery may be complicated by wound infection and potential graft exposure in the groin area. Muscle flap coverage of the graft has been promoted to address these wound complications. The authors present their findings regarding graft salvage rates and patient outcomes using local muscle flaps to address vascular graft complications of the groin. Methods: Data were obtained by retrospective cohort study of patients who underwent a local muscle flap procedure by a single surgeon following vascular graft complication in the groin. Results: Seventeen patients undergoing local muscle flap coverage of a vascular graft were reviewed. Six men and 9 women, 51–80 years old, were included in the study. Wound complications in the groin occurred anywhere from 3 days to 3.5 years following graft placement. Graft exposure was the most common presenting complication (14 of 17 patients). Muscle flap coverage occurred within 15 days of complication presentation in all patients (average, 6.4 days). Seven of the 15 patients experienced postoperative complications within 6 months of the procedure, most commonly wound dehiscence. However, analysis demonstrated that vascular grafts were successfully salvaged in 10 of the 17 patients (59%) over the course of follow-up (range, 104–1748 days). Average time to muscle flap coverage was 4.2 days in patients who retained the graft and 9.6 days in patients who ultimately lost their vascular graft. Conclusion: The authors demonstrate improved vascular graft salvage rate when local muscle flap procedure is performed early after initial wound complication presentation.
Collapse
|
42
|
Jongkind J, Ünlü Ç, Vahl A, Voorwinde T, van Nieuwenhuizen R, Bosma J. Antibiotic Prophylaxis in Autologous Vein Graft Reconstructions of the Lower Extremity. Vasc Endovascular Surg 2015; 49:24-9. [PMID: 25977207 DOI: 10.1177/1538574415585732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Different factors contribute to infection after arterial reconstructive surgery. Prophylactic antibiotic use during surgery is widespread, however, there is insufficient evidence to support the use of prophylactic antibiotics with autologous vein grafting. The aim of our study was to assess the effect of single-dose prophylactic antibiotics in patients undergoing autologous vein grafting. METHODS Patients undergoing arterial bypass reconstruction in the lower extremity between 2004 and 2012 were retrospectively screened for use of vein grafts. Patients receiving single-dose antibiotic prophylaxis (group 1) were compared with those not receiving prophylaxis (group 2). RESULTS Primary outcome was surgical site infection (SSI), and 142 patients were included. The SSI occurred in 22% of patients in group 1 and in 29% of patients in group 2 (P = .39; odds ratio: 1.46 confidence interval 95%: 0.61-3.47). CONCLUSIONS Results showed no significant effect from single-dose antibiotic prophylaxis on lowering the incidence of SSI.
Collapse
Affiliation(s)
- Jeroen Jongkind
- Sint Lucas Andreas Ziekenhuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| | - Çaĝdaş Ünlü
- Sint Lucas Andreas Ziekenhuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| | - Anco Vahl
- Onze Lieve Vrouwe Gasthuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| | - Tony Voorwinde
- Sint Lucas Andreas Ziekenhuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| | - Roos van Nieuwenhuizen
- Sint Lucas Andreas Ziekenhuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| | - Jan Bosma
- Sint Lucas Andreas Ziekenhuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands Onze Lieve Vrouwe Gasthuis, Department of Vascular Surgery, Vascular Centre Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
43
|
Gouaillier-Vulcain F, Marchand E, Martinez R, Picquet J, Enon B. Utility of Electrofusion for the Femoral Approach in Vascular Surgery: A Randomized Prospective Study. Ann Vasc Surg 2015; 29:801-9. [DOI: 10.1016/j.avsg.2014.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/12/2014] [Accepted: 09/09/2014] [Indexed: 12/30/2022]
|
44
|
|
45
|
Abstract
OBJECTIVES The objectives of this study were to describe the rate and predictors of surgical site infection (SSI) after gynecologic cancer surgery and identify any association between SSI and postoperative outcome. MATERIALS AND METHODS Patients with endometrial, cervical, or ovarian cancers from 2005 to 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program. The extent of surgical intervention was categorized into modified surgical complexity scoring (MSCS) system. Univariate and multivariate logistic regression analyses were used. Odds ratios were adjusted for patient demographics, comorbidities, preoperative laboratory values, and operative factors. RESULTS Of 6854 patients, 369 (5.4%) were diagnosed with SSI. Surgical site infection after laparotomy was 3.5 times higher compared with minimally invasive surgery (7% vs 2%; P < 0.001). Among laparotomy group, independent predictors of SSI included endometrial cancer diagnosis, obesity, ascites, preoperative anemia, American Society of Anesthesiologists class greater than or equal to 3, MSCS greater than or equal to 3, and perioperative blood transfusion. Among laparoscopic cases, independent predictors of SSI included only preoperative leukocytosis and overweight. For patients with deep or organ space SSI, significant predictors included hypoalbuminemia, preoperative weight loss, respiratory comorbidities, MSCS greater than 4, and perioperative blood transfusion for laparotomy and only preoperative leukocytosis for minimally invasive surgery. Surgical site infection was associated with longer mean hospital stay and higher rate of reoperation, sepsis, and wound dehiscence. Surgical site infection was not associated with increased risk of acute renal failure or 30-day mortality. These findings were consistent in subset of patients with deep or organ space SSI. CONCLUSIONS Seven percent of patients undergoing laparotomy for gynecologic malignancy developed SSI. Surgical site infection is associated with longer hospital stay and more than 5-fold increased risk of reoperation. In this study, we identified several risk factors for developing SSI among gynecologic cancer patients. These findings may contribute toward identification of patients at risk for SSI and the development of strategies to reduce SSI rate and potentially reduce the cost of care in gynecologic cancer surgery.
Collapse
|
46
|
Factors associated with surgical site infection after lower extremity bypass in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI). J Vasc Surg 2014; 60:1238-1246. [DOI: 10.1016/j.jvs.2014.05.012] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/06/2014] [Indexed: 11/17/2022]
|
47
|
Ozaki CK, Hamdan AD, Barshes NR, Wyers M, Hevelone ND, Belkin M, Nguyen LL. Prospective, randomized, multi-institutional clinical trial of a silver alginate dressing to reduce lower extremity vascular surgery wound complications. J Vasc Surg 2014; 61:419-427.e1. [PMID: 25175629 DOI: 10.1016/j.jvs.2014.07.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 07/22/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Wound complications negatively affect outcomes of lower extremity arterial reconstruction. By way of an investigator initiated clinical trial, we tested the hypothesis that a silver-eluting alginate topical surgical dressing would lower wound complication rates in patients undergoing open arterial procedures in the lower extremity. METHODS The study block-randomized 500 patients at three institutions to standard gauze or silver alginate dressings placed over incisions after leg arterial surgery. This original operating room dressing remained until gross soiling, clinical need to remove, or postoperative day 3, whichever was first. Subsequent care was at the provider's discretion. The primary end point was 30-day wound complication incidence generally based on National Surgical Quality Improvement Program guidelines. Demographic, clinical, quality of life, and economic end points were also collected. Wound closure was at the surgeon's discretion. RESULTS Participants (72% male) were 84% white, 45% were diabetic, 41% had critical limb ischemia, and 32% had claudication (with aneurysm, bypass revision, other). The overall 30-day wound complication incidence was 30%, with superficial surgical site infection as the most common. In intent-to-treat analysis, silver alginate had no effect on wound complications. Multivariable analysis showed that Coumadin (Bristol-Myers Squibb, Princeton, NJ; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.03-2.87; P = .03), higher body mass index (OR, 1.05; 95% CI, 1.01-1.09; P = .01), and the use of no conduit/material (OR, 0.12; 95% CI, 0.82-3.59; P < .001) were independently associated with wound complications. CONCLUSIONS The incidence of wound complications remains high in contemporary open lower extremity arterial surgery. Under the study conditions, a silver-eluting alginate dressing showed no effect on the incidence of wound complications.
Collapse
Affiliation(s)
- C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Mark Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Nathanael D Hevelone
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| |
Collapse
|
48
|
The limited incision harvest of the rectus femoris flap for complex groin wound management. Ann Plast Surg 2014; 73 Suppl 2:S161-4. [PMID: 25046666 DOI: 10.1097/sap.0000000000000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Muscle flaps can be effective in the protocol of complex groin wound management, yet donor-site morbidity remains a continued concern. The purpose of this study was to present a minimally invasive approach to the harvest of the rectus femoris flap (RFF) for groin wound vascularized tissue coverage. PATIENTS AND METHODS A retrospective study examined all patients undergoing RFF coverage and reconstruction of a complex groin wound between July 1, 2010, and December 31, 2011. During the study period, the senior author (S.K.K.) performed all RFF harvests through a minimally invasive approach, whereas all other surgeons performed the RFF harvest through a standard approach. Patients who underwent a minimally invasive RFF approach were compared with those who underwent the standard incision. RESULTS Forty-three patients underwent RFF coverage procedures, 11 of which were carried out using the minimally invasive technique. The patients in the minimally invasive cohort were older (P = 0.03) but had similar rates of medical comorbidities. Minimally invasive RFF harvests were more commonly performed in the planned, salvage setting (P = 0.03). No difference was found in the vascular surgery procedure type (P = 0.13), presence of exposed prosthetic graft material (0.2), or rate of culture-positive wound (P = 0.67). Importantly, no differences in operative time (184.4 [45.5] minutes vs 169.3 [31.7] minutes, P = 0.45) or postoperative complications were observed, with no graft losses or major limb-related morbidity in either group. CONCLUSIONS The RFF continues to be a workhorse flap for complex groin wounds, most often in the salvage setting. This study demonstrates that a minimally invasive approach can be used for flap harvest with equivalent results to that of the standard longitudinal incision.
Collapse
|
49
|
Endoscopic Vein Harvesting in Lower Extremity Arterial Bypass: A Systematic Review. Eur J Vasc Endovasc Surg 2014; 47:621-39. [DOI: 10.1016/j.ejvs.2014.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/11/2014] [Indexed: 11/19/2022]
|
50
|
Abstract
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.
Collapse
Affiliation(s)
- J Turtiainen
- Department of Surgery, North Karelia Central Hospital, Joensuu, Finland
| | - T Hakala
- Department of Surgery, North Karelia Central Hospital, Joensuu, Finland
| |
Collapse
|