Division of Vascular and Endovascular Surgery University of South Florida School of Medicine Tampa, Florida

Division of Vascular and Endovascular Surgery University of South Florida School of Medicine Tampa, Florida

Appearance: oearly < 3 mo. olate > 3 mo.. Extent: Szilagyi Classification: Grade I: infection involves only the dermis Grade II: extends into SQ tissue, does not expose arterial graft Grade III: arterial graft is involved a. involves the graft body b. Involves anastomosis without bacteremia or bleeding c. Involves anastomosis with bacteremia or bleeding Samson Criteria

oincidence: Endovascular aortic interventions 1-2% Open lower extremity bypass grafting 10-20% o Sequela of infection Anastomotic bleeding Pseudoaneurysm development Graft thrombosis Amputations (8-25%) Perioperative mortality 14-58% o Up to 90% of patients have risk factors for VSSI

Superficial SSI < 30 days of procedure Involves Skin and SQ a. Purulent drainage b. Microbiology from aseptic culture or non-culture microbiologic testing (Nucleic Acid Testing) c. Surgeon opening of incision due to pain, swelling, or erythema d. Surgeon diagnosis of SSI: Deep SSI < 90 days of procedure Involves deep soft tissues (fascial / muscle) a. Purulent drainage b. Wound dehiscence or opening by Surgeon with Microbiology from aseptic culture or non-culture microbiologic testing with at least one s/sx: fever, pain, tenderness c. An abscess or other evidence of infection detected on gross, histopathologic or imaging exam.

1) Comorbid Conditions (DM, BMI > 30, CRF) 2) Emergency procedure 3) Prolonged operative time (> 4 hrs) 4) POTAs (dirty or contaminated case) 5) Groin incision 6) Reoperative surgery 7) Periopeartive hyperglycemia 8) Perioperative Hypothermia 9) Use of prosthetic conduit

o Classic: warm, red, swollen o Fever, malaise, loss of appetite o Leukocytosis o Bacteremia / Sepsis o Sinus tract (3/4 of cases) o Pseudoaneurysm o Graft exposure Herald Bleed

Obvious (Physical Exam) o Cellulitis tracking the graft o Exposed graft o Sinus tract Suspected o o o o o o CT imaging Perigraft fluid Perigraft / soft tissue inflammation Aspiration of fluid collection Laboratory Findings Leukocytosis Inflammatory markers (e.g. CRP) + blood cultures MRI WBC Tagged Scan PET Scanning

Gram + o most common o 30% Staph aureus MSSA 10% MRSA 20% o 10% Staphylococcus epidermis o 5% Streptococcus Gram o 20% Pseudomonas sp Polymicrobial o 1/3

8 x increase risk VSSI o2009 Intranasal bactroban alone does not reduce SS o2010 Intranasal bactroban + Chlorhexidine does reduce SSI o2017 Cochrane Review Two RCT: uncertain benefits vs. risks

oinitiation of Broad Spectrum ABX Coverage for resistant species (MRSA and Pseudomonas) oculture Guided ABX therapy oduration of therapy 4-6 weeks oadverse effects diarrhea / C. diff mylosuprression (16%) nephrotoxicity (8%) altered appetite access complications (10%)

o Chlorhexidine bath o Perioperative control of blood sugar o Preoperative ABX prophylaxis 30-60 min prior to incision o Normothermia ominimally invasive techniques o Intraoperative glove changes o Meticulous wound closure o Postoperative oxygenation

o Szilagyi Grade I Superficial VSSI (skin) Antibiotic therapy x 2 weeks o Szilagyi Grade II Deep VSSI into the SQ but does not expose the graft Broad Spectrum IV ABX Surgical Debridement o Szilagyi Grade III Deep VSSI Arterial Graft is exposed Broad Spectrum IV ABX Staged Surgical Debridement Wound Sterilization

Wound Debridement Deep Tissue Cultures Antibiotic Beads Positive Cultures Wound Debridement Deep Tissue Cultures Antibiotic Beads Positive Cultures Negative Cultures Revascularization Muscle Flap? Antibiotic Beads USF Audit 240 lower limb bypass infections o 30 d mortality was 1% o Wound isolates 70% gram + 20% gram -, 10% mixed o Recurrent infections 40% with graft preservation < 3% with autologous tissue o Amputation rate 2% risk factors: hx of inflow and outflow bypass nonhealing lower extremity wounds hx of one or more surgical procedures prior to referral

Muscle Flaps Sartorius Gracilis Rectus Femoris Antibiotic Beads Polymethylmethacrylate (PMMA) ( thermoplastic) Dissolvable (impregnated calcium sulfate) Negative Pressure Therapy

Wound Debridement Deep Tissue Cultures Antibiotic Beads Positive Cultures Wound Debridement Deep Tissue Cultures Antibiotic Beads Positive Cultures Negative Cultures Revascularization Muscle Flap? Antibiotic Beads Poor Soft tissue coverage Muscle flap failure Large skin defect Wound vacuum failure GI / GU Fistula Aggressive Debridement Alternative Flaps Diversion

Selective Preservation of Infected Prosthetic Arterial Grafts Analysis of a 20-Year Experience with 120 Extracavitary-lnfected Grafts Keith D. Calligaro, M.D.,* Frank J. Veith, M.D.,t Michael L. Schwartz, M.D., Jamie Goldsmith, R.N.,t Ronald P. Savarese, M.D.,* Matthew J. Dougherty, M.D.,* and Dominic A. DeLaurentis, M.D.* ANNALS OF SURGERY, 1994 Vol. 220, No. 4,461-471 20 Yr Multicenter Experience: 120 patients hospital mortality of 12% amputation rate in survivors of 13% long-term complete graft preservation was successful in 71% partial graft preservation successful in 85% Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases).

oautologous Tissue GSV LSV Arm Vein Spliced Vein Femoral Vein (Deep Vein) oalternative options Rifampin Soaked PTFE Cryopreserved Vein

o Vascular graft infection is a devastating complication o Prevention is worth a pound of cure o Conservative therapies are rarely successful o Individual care plans combined with staged surgical sterilization is rational

Division of Vascular and Endovascular Surgery University of South Florida School of Medicine Tampa, Florida

Contemporary Management of Selective Preservation of Infected Prosthetic Arterial Grafts Analysis of a 20-Year Experience with 120 Extracavitary-lnfected Grafts Keith D. Calligaro, M.D.,* Frank J. Veith, M.D.,t Michael L. Schwartz, M.D., Jamie Goldsmith, R.N.,t Ronald P. Savarese, M.D.,* Matthew J. Dougherty, M.D.,* and Dominic A. DeLaurentis, M.D.* ANNALS OF SURGERY, 1994 Vol. 220, No. 4,461-471 20 Yr Multicenter Experience: 120 patients hospital mortality of 12% amputation rate in survivors of 13% long-term complete graft preservation was successful in 71% partial graft preservation successful in 85% Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases).

Extracavitary Vascular Graft Infection Negative pressure wound therapy on exposed prosthetic vascular grafts in the groin Paul Berger, MD, Dennis de Bie, MaNP, Frans L. Moll, MD, PhD, and Gert-Jan de Borst, MD, PhD, Utrecht, The Netherlands Objective: This study assessed the outcome of vacuum-assisted closure (VAC) as primary therapy for exposed prosthetic vascular grafts in the groin (Szilagyi III). Methods: The study included all consecutive patients with Szilagyi III groin infections and exposed prosthetic graft material from 2009 to 2011. After initial wound debridement, VAC was applied using a two-layer combination, consisting of polyvinyl alcohol and polyurethane sponges. Continuous negative pressure was set on a maximum of 50 mm Hg. All patients received complementary antibiotic therapy. The primary end point was defined as complete wound closure. Secondary end points comprised bleeding complications, amputation, and death. Results: The study evaluated 15 patients with 17 Szilagyi III groin infections. Mean total length of VAC therapy was 43 days (range, 14-76 days). Mean time until complete healing was 51 days (range, 24-82 days). Mean length of VAC therapy in the hospital was 21 days (range, 5-61 days). Eleven patients received continued VAC treatment at home for a mean length of 22 days (range, 5-69 days). Complete healing was achieved in 14 groins (82%). Three o Antibiotic Beads o Muscle Flaps o Wound Vacuum