VCU DEATH AND COMPLICATIONS CONFERENCE. Introduction Complication Graft infection Procedure ...

VCUDEATH AND COMPLICATIONS CONFERENCE

Introduction

Complication Graft infection

Procedure Femoral-femoral bypass

Primary Diagnosis Left leg rest pain

60 yo male presenting 2/24 to ER with left leg pain at rest

Sudden worsening that am from prior 2 block claudication

No foot wounds

PMH: DM2, CAD, COPD, GERD, PVD, bipolar d/o,

arthritis, ED, hypothyroidism, chronic back pain

PSH: CABG, Penile implant

Soc Hx: Heavy smoker

PE Cool left leg with decreased motor function, no

palpable pulses left side, palpable right femoral, dopplerable PT/DP, no tissue loss

Placed on heparin gtt WBC 10.5, CRE 1.15, other labs WNL Arterial dopplers:

right leg triphasic CFA, right femoral disease, ABI= 0.67

Left leg monophasic CFA, occlusion of SFA and PT, ABI = 0.27

Underwent angiography on 2/27

OR on 3/2 for fem-fem bypass Aortobifem not done due to subacute

presentation and medical comorbidities 8mm PTFE used Preop antibiotics given Did well post-op and was discharged on

3/5

Returned to clinic on 3/13 with drainage from right incision

No fevers, good flow in bypass, improved symptoms

WBC 12, wound opened, MRSA cultured, blood cx negative

Deep layer remained closed with no graft exposure

On Vanc x7 days in hospital with resolution of leukocytosis, no fevers

d/c home on bactrim

Returned on 3/23 with fever to 105, WBC 25.5, positive blood cx x2 for MRSA

Taken to OR where purulence found in right groin around graft

graft excision, redo of fem-fem with vein, sartorious flap of right groin

Did well with resolution of sepsis, d/c 5 days later

Analysis of Complication

• Was the complication potentially avoidable?– No- patient had appropriate operation, known

infection rate

• Would avoiding the complication change the outcome for the patient?– Yes- graft excision, readmission x2

• What factors contributed the complication?– Poor hygiene, indwelling foreign body, diabetes

Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl

5:S35-41 Most common organism in vascular

infections = S. aureus >80% from endogenous source

Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl

5:S35-41 Vascular Surgery Site infections 5-10% Gram positives most common organism MRSA has mortality of 20.7% with SSI Extra 5 days in hospital and $40K

additional cost compared with MSSA Nasal carriage 2-9X risk of SSI

Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl

5:S35-41 Vascular prosthetic graft infection (VPGI) 1-5% MRSA VPGI mortality 25-88%, amputation rate

80% PTFE 10-100x more resistant to infection than

Dacron Conservative management (Abx only) is highest

risk factor for mortality Surgical principles:

Graft removal Wide debridement Extraanatomic bypass (or in situ abx

inpregnated graft or vein)

Teaching points

MRSA graft infection carries high mortality and complication rates

requires early graft excision and extraanatomic bypass