Eur l Vasc Surg 7, 753-755 (1993)

CASE REPORT

Successful Salvage of an Exposed Axillopopliteal Prosthetic Graft Using Three Muscle Flaps in Sequence

J. B, Reed 1, N, R. McLean 1 and N. A. G. Jones 2

1 Department of Plastic Surgery, Newcastle General Hospital, and 2Freeman Hospital, Newcastle upon Tyne, U.K.

A 45cm length of exposed axillopopliteal Dacron graft in the thigh has been successfully salvaged using three muscle flaps in sequence, covered by meshed split skin grafts.

Key Words: Muscle jqaps; Infection; Vascular prostheses.

In t roduct ion

Exposure of vascular prosthetic grafts may result from graft infection and can have catastrophic results for the patient frequently resulting in loss of the affec- ted limb. 1 The commonest site of infection is in the groin, where the graft lies superficially in a skin crease near to the perineum and is usually caused by Staphylococcus aureus. 1 Traditionally these infections have been treated by removal of the infected pros- thesis and remote bypass surgery, 1"2 but recently, more prominence has been given to the techniques of local debridement and disinfectants before biologic coverage with omental or muscle flaps. 3-5

We present a case in which remote bypass sur- gery had been carried out but infection again super- vened. This resulted in a 45cm length of exposed vascular prosthesis down the lateral aspect of the patient's left thigh. This could have resulted in ampu- tation of the affected limb, but the graft was success- fully salvaged by local debridement and regular dilute betadine irrigation before covering it with three different muscle flaps in series. We believe that sal- vage of a graft of this length and in this position has not previously been reported.

Case Report

A 63-year-old arteriopath, who had smoked heavily

Please address all correspondence to: N. R. McLean, Department of Plastic Surgery, Newcastle General Hospital, Newcastle Upon Tyne, NE4 6BE, U.K.

all his life, underwent an aortobifemoral bypass graft in 1984, followed 12 months later by a left femoro- popliteal graft. In 1987 he proceeded to a right femoropopliteal graft together with unblocking of the right limb of the aortobifemoral graft.

After this he remained well until presenting sud- dently in November 1990 with a false aneurysm in the left groin, associated with frank pus pointing in the wound. The left femoropopliteal graft and the left limb of the aortobifemoral graft were excised first, and after retowelling and changing all instruments a left axillopopliteal bypass was performed. Two weeks after this procedure pus was noticed to be draining from his lateral thigh wound, and this was treated successfully with antibiotics. He was readmitted 3 months later with reinfection and this was treated by daily irrigation of the wound with betadine solution for 3 weeks.

Unfortunately a month later the infection flared again, this time with skin breakdown exposing the graft in two sites in the thigh. Surprisingly the graft continued to function. The graft was laid open for a length of 45 cm (Fig. 1) and he was treated with anti- biotics and betadine dressings for the next 3 weeks until the site was clean and swabs were negative.

To obtain cover for the 45cm of exposed pros- thesis three muscle flaps were required. A vastus lateralis flap was elevated posteriorly from its inser- tion on the femur and transposed over the lower third of the vascular conduit. The gluteus medius was detached from its insertion and transposed to cover the upper third. Finally the tensor fasiae latae muscle was raised on its vascular pedicle and rotated to cover

0950-821X/93/060753+03 $08.00/0 © 1993 Grune & Stratton Ltd.

754 J.B. Reed et aL

Fig. 1. Exposed axillopopliteal prosthetic graft. Fig. 2. Salvaged axillopopliteal prosthetic graft after 6 months.

the middle third of the prosthesis. Good flow was noted in the lateral circumflex femoral vessel which supplied both the tensor fasciae latae and vastus lateralis muscle flaps. The muscles were sutured to the fascial and skin layers, and were covered with unexpanded meshed split skin.

The patient made an excellent and uncompli- cated recovery, mobilised well, and on review at 6 months shows no signs of recurrent vascular graft infection (Fig. 2).

Discuss ion

Despite the many advances in vascular surgery, graft infection continues to pose serious problems, fre- quent ly threatening the affected limb, and indeed sometimes the life of the patient. 1 These infections most commonly occur in the groin, and there are many different techniques available for their treat- ment.

The s tandard t reatment is ligation and removal of the infected graft together wi th remote bypass sur-

gery, 1'2 as was initially performed in this patient. Other methods of t reatment include debr idement and t reatment with systemic and topical anti- biotics,6, 7 disinfectants including povidone-iodine ir- rigation, 8 autologous tissue reconstruction replacing the infected graft with arterial or venous autografts, 9 and coverage of the graft with omen tum 3 or muscle flaps. 3-5 The wide choice available reflects the diffi- culty of eradicating graft sepsis.

The technique of graft coverage using a sartor- ious muscle flap was first described by Mendez in 1980, 4 and subsequent studies have confirmed that this is a reliable technique for treating infected pros- theses in the groin, s Other methods of covering the groin include the inferior rectus abdominis muscle flap,3 o m e n t u m 3,10,11 and tensor fasciae latae 12 flaps. Covering a graft with tissue expansion of neighbour- ing skin has also been described. 13

The use of the lattissimus dorsi muScle to cover an exposed axillobifemoral graft over the chest has recently been described, 14 but as far as we are aware our case is the first successful t reatment of a distal exposure of such length. In this case the affected graft was the distal portion of an axillopopliteal graft, and

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Salvage of Prosthetic Graft Using Three Muscle Flaps 755

of the thigh than is often the case. Due to the length of the exposed graft three different muscle flaps were raised in continuity in order to produce enough coverage for the exposed graft. Vastus lateralis 15 and tensor fasciae latae 12 have long been recognised as useful flaps for reconstruction of defects around the groin, but there has been no previous literature reporting their use with vascular prostheses.

At 6 month review it would appear that this tech- nique has successfully eradicated the infection and maintained the patency of the graft, resulting in pres- ervation of a functional limb for the patient who has been able to lead a normal life.

References

1 BUNT TJ. Synthetic vascular graft infections. Surgery 1983; 93: 733-746.

2 SHAW RS, BAUE AE. Management of sepsis complicating arterial reconstructive surgery. Surgery 1963; 53: 75-86.

3 KRETSCHMER G, NIEDERLE B, HUK I, et al. Groin infections follow- ing vascular surgery: obturator bypass versus "biologic cover- age" - -a comparative analysis. Eur J Vasc Surg 1989; 3: 25-29.

4 MENDEZ FMA, QUAST DC, GEIS RC, HENLY WS. Distally based sartorius muscle flap in the treatment of infected femoral ar- terial prosthesis. J Cardiovasc Surg 1980; 21: 631.

5 LAUSTSEN J, BILLE S, CHRISTENSEN J. Transposition of the sartor- ius muscle in the treatment of infected grafts in the groin. Eur J Vasc Surg 1988; 2: 111-113.

6 ALMCREN B, ERIKSSON I. Local treatment of infected arterial grafts. Acta Chir Scand 1985; 529: 91-94.

7 POPOVSKY J, SINGER S. Infected prosthetic grafts: local therapy with graft preservation. Arch Surg 1980; 115: 203-205.

8 KWAAN JHM, CONNELLY JE. Successful management of pros- thetic graft infection with continuous povidone-iodine irriga- tion. Arch Surg 1981; 116: 716-720.

9 EHRENFELD WK, WILBUR BG, OLCOTT CN, STONEY RJ. Autogen- ous tissue reconstruction in the management of infected pros- thetic grafts. Surgery 1979; 85: 82-92.

10 GOLDSMITH HS, BEATTIE EJ. Protection of vascular prosthesis following radical inguinal excision. Surg Clin N Am 1969; 49: 413-419.

11 WATKINS RM, THOMAS JM. The role of greater omentum in reconstructing the skin and soft tissue defects of the groin and axilla. Br J Surg 1985; 72: 925-926.

12 O'HARE PM, LEONARD AG. Reconstruction of major abdominal wall defects using the tensor fasciae latae myocutaneous flap. Br J Plas Surg 1982; 35: 361-366.

13 Foo ITH, WARD CM. Salvage of an exposed arterial prosthesis by tissue expansion. Br ] Surg 1989; 76: 1320-1321.

14 BROOKS SG, LEVESON SH, SHARPE DT. The use of a latissimus dorsi myocutaneous flap to cover an axillobifemoral vascular prosthetic graft. Eur J Vasc Surg 1989; 3: 367-368.

15 WATERHOUSE N, HEALY C. Vastus lateralis myocutaneous flap for reconstruction of defects around the groin and pelvis. Br J Surg 1990; 77: 1275-1277.

Accepted 13 April 1992

Eur J Vasc Surg Vol 7, November 1993