Salvage: A different approach to graft infections in the groin

The principles of salvage are in rescuing valuable undamaged goods in the setting of catastrophe. This guided me when a patient was flown in from an outside institution to our ICU with a saline soaked OR towel in his right groin -he had had an aorto-bifemoral bypass for aorto-iliac occlusive disease a year prior, but had never properly healed his right groin wound which continued to drain despite VAC therapy and wound care. On revealing his groin, this is what I saw:

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A CT scan was sent with the patient but has been lost to time, and it showed a patent aorto-bifemoral bypass send flow around an occluded distal aorta and iliac arteries. The graft did not have a telltale haze around it nor a dark halo of fluid which signaled to me that it was likely well incorporated and only sick in the exposed part. The patient was not septic, but had grown MRSA from the wound which was granulating from the extensive wound care that had been delivered.

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I felt that it would be possible to move his anastomosis point more proximally on the external iliac in a sterile field (figure above), and then close, then endarterectomize the occluded external iliac artery after removing the distal graft, then after vein patching, cover the repair with a sartorius muscle flap. It would salvage the remaining graft and avoid a much larger, more intense operation which was plan B. To prepare for that, I had his deep femoral veins mapped.

The patient was prepped and draped, the groin was excluded by placing a lap pad soaked in peroxide/betadine/saline solution (recipe for “brown bubbly” liter saline, a bottle of peroxide, a bottle of betadine), and covering with an adesive drape. The rest of the abdomen was then draped with a second large adhesive drape. A retroperitoneal (transplant-type) right lower quadrant incision was made (below) and the external iliac artery and graft were exposed. As predicted on CT, the graft was well incorporated.

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The external iliac artery was opened and focally endarterectomized of occlusive plaque (image below). The adventitia had good quality despite the longstanding occlusion.

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The graft was mobilized and transected and anastomosed end to side to this segment of artery (below). Dissecting was made difficult by how well incorporated it was.

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The wound was irrigated (with brown bubbly) and closed, dressed, and sealed over with the adhesive drape. The groin wound was then revealed and the graft pulled out (below).

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Remote endarterectomy using a Vollmer ring was used -in this case I didn’t use fluoroscopy given the short distance to the terminus of the plaque which i had mobilized in the pelvis.

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The plaque came out easily and was not infected appearing. It is shown below ex vivo.

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A segment of saphenous vein was harvested from the patient medially and the arteriotomy was patched. The sartorius muscle was mobilized and applied as a flap over this. The wound was irrigated with brown bubbly and packed open with the intention of VAC application.

The patient healed very rapidly and remains infection free. I had used this approach on several occasions in the past and twice more recently. It truly is salvage as it preserves the uninfected graft while never exposing it to the infection in the process of operating. It avoids having to remove the whole graft which then damages the left side -I have seen other surgeons take this approach elsewhere taking a all-or-nothing approach to graft infection to considerable morbidity to the patient. It avoids having to harvest deep femoral vein -another large operation to which the body responds truculently. The patient recently came by for his 4 year followup, still smoking, but legs preserved.

 

 

Reversing paralysis with a bypass

Dissection CTA

The patient is middle aged and had a type B thoracic aortic dissection (TBAD) as a consequence of recreational substances that acutely raised his blood pressure. At the outside hospital, he had a CTA showing the dissection extending from his left subclavian artery and causing occlusion of his superior mesenteric artery (SMA). He developed abdominal pain and was swiftly transported to our acute aortic syndrome unit. He was taken to the operating room and underwent a TEVAR of the dissection and stenting of his SMA -this is similar to other cases I have discussed in prior posts so I am omitting the technical details. The stent covered the left subclavian artery origin to exclude the origin of the dissection. The stent was extended to the distal thoracic aorta but did not go to the celiac origin. 

TBAD post stent

Post procedure, his lactate never rose and he was maintained on the usual post procedure protocol of keeping MAP’s (mean arterial pressure) above 80mmHg. His left subclavian artery was covered but I do not routinely bypass, especially when the left vertebral artery is at least equal in size to the contralateral one. I don’t often place spinal drains for urgent/emergent cases particularly in patients who have never had infrarenal aortic surgery and patent hypogastric arteries. He was kept sedated overnight and awoke in the morning unable to move his legs to command. He had no pain sensation up to his umbilicus.

A spinal drain was emergently placed and his blood pressure was raised to MAPs of 90+, but these failed to reverse his paralysis. After discussion among my world class partners, I chose to take the patient back for a carotid subclavian bypass which was done through a single incision with a dacron bypass graft.

Carotid subclavian bypass CTA

His paralysis resolved. He was discharged home, ambulating without assistance. Spinal cord complications are reported to occur between 1-5 percent of patients undergoing TEVAR for complicated TBAD. They were seen in 2 of 72 patients in the TEVAR arm of the INSTEAD trial (Circulation, 2009 vol. 120(25) pp. 2519-28), and was permanent in 1. While there are some who routinely place prophylactic drains, it is unclear to me that they have a significant effect if placed unselectively. I will place a Preop drain in the instance of infra renal graft, hypogastric arterial occlusive disease. In the instance of a dominant left vertebral, I will perform concomitant bypass, but just as often not. This is a gratifying and rare outcome of paralysis reversed with a carotid subclavian bypass when spinal drain and permissive hypertension did not.