Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана

Aortobifemoral bypass has excellent early patency (85%–92% at 5 years) and late patency (80%–85% at 10 years). Graft thrombosis is the most commonly encountered late complica­tion and is usually due to progression of atherosclerotic disease. Correction of the disease at the origin of the profunda femoris artery is important to maintain long-term patency. If there is stenosis at the origin of the profunda femoris artery, a concomitant profundoplasty should be performed or a graft-femoral anastomosis should be carried down to the profunda femoris artery past the orificial disease. There is no difference in long-term patency between end-to-end versus end-to-side proximal anastomosis. Bilateral limb thrombosis or complete graft occlusion is significantly less common than single-limb thrombosis and may be due to an inflow problem. Early graft thrombosis requires operative thrombectomy and repair of the underlying technical issue or, rarely, an infrainguinal reconstruction to improve the outflow. Unilateral graft limb thrombosis may present as intermittent claudication due to the presence of collateral flow, but up to 20%–25% of patients may present with acute criti­cal limb ischemia. Long-term patency after revision is approximately 68% with an 85% limb salvage rate.

Brewster, D. C. (2014). Aortofemoral by pass for atherosclerotic aor toiliac occlusive disease. In James C.

Aortic graft infection is a rare (0.2%–5%) but devastating complication of aortofemoral recon­struction. It is generally a result of inoculation of bacteria from elsewhere in a patient at the time of surgery, most often from the skin, but the microorganisms can also be seeded in the postop­erative period as a result of skin breakdown. Contact between the graft and the gastrointestinal tract can also result in infection. The average time from the index operation to symptomatic infection ranges from 41 to 62 months and is associated with a high mortality (40%) and limb loss (11%) with a reinfection rate of 18% if not treated adequately. Concomitant or nosocomial infection, particularly bloodstream, septicemia, urinary tract infection, and surgical site infec­tion, are strong predictors of late graft infection. Patients with a graft infection can present with fulminant sepsis, and many indolent infections can be difficult to diagnose. The groin incision may demonstrate erythema or a draining sinus tract. Patients may exhibit abdominal or back pain. There may be leukocytosis with elevated inflammatory markers. Imaging may demon­strate gas or heterogeneous fluid around the graft. The principles of treatment are complete graft excision and debridement of local infected tissue. Reconstructive options include extra­anatomic bypass graft and several methods of in-line bypass such as cryopreserved allograft, rifampin-bonded prosthetic Dacron graft, and autologous vein using a neo-aortoiliac system (NAIS). Each procedure has its advantages and disadvantages. The treatment should be based on virulence of infection, urgency of the operation, and general medical condition of the patient. Graft preservation may be considered in a limited subset of circumstances. Patients who present with focal infection, such as those in whom infection is limited to one limb or in the groin with low-virulence bacteria and no systemic signs of sepsis, have been treated suc­cessfully with antibiotics without total graft excision. Elderly frail patients with a hostile abdo­men may also be considered for graft-preservation therapy with serial surgical debridement, segmental vascular reconstruction ideally with an autologous (vein) conduit, use of antibiotic­impregnated beads, and long-term parental antibiotics. Infections with more virulent organ­isms such as Pseudomonas and MRSA require complete graft excision.

(a) increased BMI, (b) diabetes mellitus, and (c) reoperation in the groin. The most common com­plication is a seroma/lymphocele. A seroma occurs when there is dead space and/or a reaction to a foreign body such as graft. The inflammatory response within the surrounding tissue leads to transudate of serous fluid with a straw-colored appearance with a consistency similar to that of pleural fluid. A lymphocele occurs when the lymphatic channels are not appropriately ligated or cauterized during dissection of the groin, resulting in lymph collection. Clinically, both are simi­lar as a soft, compressible, bulging mass in the groin without any overlying changes in the skin. In contrast, hematoma appears more heterogenous on duplex imaging, with seroma and lympho­cele appearing cystic. Surgical wound dehiscence can be superficial or deep, and management is dictated by concomitant infection and depth of involvement. Type I is limited to skin necrosis, superficial wound dehiscence, or local infection. Type II includes deep wound dehiscence. Type III involves the underlying graft. Treatment involves meticulous dissection, suture ligation of any lymphatic vessel, use of transverse incision in the groin, and use of topical negative pressure wound therapy using a self-contained dressing consisting of a sponge and occlusive dressing placed over a closed incision and connected to a portable vacuum device that maintains a subat­mospheric pressure that decreases the amount of fluid in the wound bed with minimal external contamination. These are applied for 5–7 days and have decreased the rate of wound infection from 20% to 5.11%. Small asymptomatic seromas can be safely observed. Larger seromas within skin breakdown should be drained, preferably in the operating room. For suspected lymphocuta­neous fistula, injection of isosulfan or methylene blue in the foot will help identify the disrupted lymphatic channels. Excisional wound debridement is performed in many patients who may also need sartorius myoplasty to obtain adequate tissue coverage. Antibiotics are not necessary unless there is cellulitis or signs of local infection. Wound complications lengthen the overall recovery from weeks to months and increase the risk for graft infection and thrombosis.