N. Zamani1, S. E. Sharath1, P. Kougias1 1Baylor College of Medicine / Michael E. DeBakey VA Medical Center,Division Of Vascular Surgery And Endovascular Therapy, Michael E. DeBakey Department Of Surgery,Houston, TX, USA
Introduction: Lower extremity prosthetic graft infections continue to be serious postoperative complications. Though complete graft excision with extra-anatomic bypass has traditionally been required, graft preservation techniques have been proposed for select patients in order to avoid the physiologic demand of such a reconstruction. We aimed to assess the attitudes of practicing surgeons regarding their preferred management strategy and their perceptions about which operative technique results in the most favorable long-term outcomes.
Methods: A voluntary, anonymous, cross-sectional survey was administered to actively practicing members of the Society for Clinical Vascular Surgery (SCVS) in the United States. Surgeons were asked to: (1) rank the factors that influence their management strategy, (2) choose between graft excision or preservation in a standard clinical scenario, and (3) identify the most effective strategy for promoting long-term limb preservation.
Results: Ninety (19%) licensed surgeons participated in the survey. The three factors that were most influential in determining the management of lower extremity prosthetic graft infections were: the presence of sepsis, involvement of an anastomosis, and the presence of Pseudomonas. Conversely, the three least influential factors were: operating room availability, projected length of stay, and prosthetic graft material (Figure 1). In a stable, non-septic patient, 67% (n = 60) of respondents most frequently excise the graft. A form of preservation, however, was the preferred management strategy in 31% (28) of instances, with 20% (18) of all surgeons using antibiotic beads as their preferred method of graft preservation. In assessing the operative strategy associated with the greatest long-term limb preservation rates, 52% (47) of surgeons believed that excision provides the best limb outcomes, while 29% (26) identified preservation as the preferred overall strategy. The remainder (19%) felt that there was probably no difference in the outcomes of these two approaches. Interestingly, of those that prefer to excise the graft, 15% (9/60) actually believed that preservation with antibiotic beads may be the more beneficial therapeutic option.
Conclusion: Substantial discrepancy exists among providers regarding their personal management of lower extremity graft infections and their perception of which operative strategy is ultimately associated with higher rates of limb salvage. Given the range of personal, clinical, and institutional factors that influence a surgeon’s preferred operative approach, a well-designed study is required to definitively address this issue and inform clinical practice.
