Use of autologous spiral vein grafts for vascular reconstructions in contaminated fields

Use of autologous spiral vein grafts for vascular reconstructions in contaminated fields Richard J. Fowl, MD, Kevin D. Martin, MD, Harry C. Sax, MD, and Richard F. Kempczinski, MD, Cincinnati, Ohio Vascular reconstructions in heavily contaminated fields can be particularly challenging. Prosthetic grafts are rarely suitable because of the risk of infection, but the saphenous vein is usually too small for isodiametric replacement of large arteries and veins. Although surgeons rarely consider the use of spiral vein grafts, they may occasionally be the ideal autogenous vascular replacement because they can be tailored to fit a vessel of any size. We report the use of spiral vein grafts in three patients requiring vascular reconstructions in the presence of heavy bacterial contamination. (J VAsc SuRG 1988;8:442-6.) The need for vascular reconstruction in the presence of overt infection or extensive bacterial contamination is a challenging surgical problem. Ideally, an autogenous conduit, such as saphenous vein, should be used. However, if large arteries or veins must be replaced, the saphenous vein is usually too small and prosthetic grafts are contraindicated because of risk of graft infection. In such situations, autogenous spiral vein grafts, although rarely considered for this purpose, may be the ideal vascular conduit. We have recently used this technique to treat three patients who required arterial and venous reconstructions in heavily contaminated fields. CASE REPORTS Case 1. On Aug. 2, 1985, a 20-year-old black man was admitted to the University of Cincinnati Hospital after sustaining multiple gunshot wounds to the left flank and thigh, resulting in a compound, comminuted fracture of the femur with extensive soft tissue destruction and wound contamination. He was initially hypotensive, but after administration of large volumes of fluid, the blood pressure increased to 154/80 mm Hg with a pulse rate of 120 beats/min. He had a palpable left femoral pulse, but no popliteal or pedal pulses were felt. He was then transported rapidly to the operating room and the common, superficial, and profimda femoris arteries were exposed and controlled From the Division of Vascular Surgery, Universig of Cincinnati Medical Center. Presented at the Twelfth Annual Meeting of the Southern Assodation for Vascular Surgery, St, Thomas, Virgin Islands, Jan. 27-30, 1988. Reprint requests: Richard J. Fowl, MD, Dept. of Surgery, Universitx! of Cincinnati Medical Center, 231 Bethesda Ave., Cincinnati, OH 48267-0558. through a left groin incision. Simultaneously a traction pin was placed through the proximal tibia. An intraoperative arteriogram (Fig. 1) revealed occlusion of the superficial femoral artery. (SFA) with thrombus extending into the popliteal artery. The SFA was exposed through a medial incision in the thigh and was found to be disrupted in three separate areas over a 12 cm length. The superficial femoral vein was transected in two places over a 3 cm distance. After proximal and distal control of the injured vessels was obtained, the saphenous vein was harvested from the right leg. A reversed saphenous vein interposition graft was used to reconstruct the SFA. Because there was such extensive soft tissue destruction of the thigh, it was feared that the venous collateral outflow of the leg would be inadequate unless the superficial femoral vein was reconstructed. Because the saphenous vein was small (3 ram), a 4 cm long spiral vein graft (10 mm diameter) was constructed and used as an interposition graft to restore superficial femoral vein integrity. Once this was completed, lower leg fasciotomies were performed and pedal pulses were palpable. Postoperatively the patient was placed in traction and over the next three weeks had skin grafting of the left thigh wounds and dosed reduction of the femur fracture with a Grosse-Kempf nail. No wound or vascular graft infections developed and he was discharged from the hospital on Aug. 31, 1985. One month after operation, the anlde-brachial pressure index (ABI) was greater than 1.0 with palpable pedal pulses. During the next two years, the patient complained only of minimal swelling of the left leg when walking. A venous duplex scan performed 2 },ears after injury revealed patency of the reconstructed superficial femoral vein. The left ABI remained greater than 1.0 and he was able to walk without discomfort. Case 2. On July 19, 1987, a 40-year-old black man with longstanding intravenous drug abuse presented with fever and pain in the neck and right leg. One year before 442

Volume 8 Number 4 October 1988 Spiral vein grafts in contaminated fields 443 Fig. 1. Intraoperative arteriogram from case 1 shows occluded superficial femoral artery (top arrow) and thrombus in the popliteal artery (bottom arrow) with extensive femur destruction from bullets. Fig. 2. Arteriogram from case 2 shows patent external iliac (EIA) to superficial femoral artery (SFA) PTFE graft (arrow) routed through a subcutaneous plane. admission, he suffered a ruptured mycotic aneurysm of the right common femoral artery. At that time, he went to another hospital and a reversed saphenous vein graft was used in an attempt to replace the femoral aneurysm. However, this graft became thrombosed during surgery. To save the extremity, an 8 mm polytetrafluoroethylene (PTFE) interposition graft was placed from the right external iliac artery to the right superficial femoral artery. Postoperatively, the patient did well and was discharged from the hospital. He received no further medical follow-up until he came to the emergency department of the University of Cincinnati with his current complaints. Physical examination showed that the body temperature was 101 F, pulse rate was 115 beats/min, and blood pressure was 120/80 mm Hg. There was obvious inflammation in the right groin with purulent fluid draining from an opening in the old incision. The right knee was swollen and tender to palpation and tender petechiae were present on the toes of the right foot. The femoral, popliteal, dorsalis pedis, and posterior tibial pulses were all palpable. The patient was admitted to the Vascular Service and intravenous cephalothin was started. The fever subsided promptly and CT scanning of the abdomen and pelvis revealed fluid around the PTFE graft but no evidence of a pseudoaneurysm. An arteriograrn_demonstrated a patent iliofemoral graft (Fig. 2) with normal distal nmoff to the foot. All 10 blood cultures were positive for Staphylococcusaureus. Forty-eight hours after admission purulent fluid was drained from the knee joint. The next day, the patient was taken to the operating room where the infected PTFE graft was completely removed. Because the presence of local and systemic infection precluded the use of prosthetic graft, an 8 mm spiral vein graft 12 cm in length was constructed with the left greater saphenous vein. This graft was anastomosed between the right external iliac artery and the SFA (Fig. 3). Two layers of subcutaneous tissue were closed over the graft and the skin was left open and packed with gauze. Postoperatively, the ABI was 0.91 with a palpable pedal pulse. Intravenous nafcillin as given for 6 weeks postoperatively. During this time, osteomyelitis of the cervical

444 Fowl et al. Journal of VASCULAR SURGERY / E I A-J~; ".:.."..'... :,C SVG---~:,, ~ ~;... -.?... /2' t [---.~)r.,~ ""-..~ ""'-.. ".,... arterial flow was restored, the lower limb became very tense and swollen. Fasciotomies were performed, but the leg remained extremely swollen. A superficial femoral vein reconstruction was initially attempted with reversed saphenous vein, but this did not adequately decompress the leg because of its inadequate diameter. A 5 cm long spiral vein graft was then constructed over a 20F catheter. This graft was implanted as an interposition graft in the proximal superficial femoral vein (Fig. 4). Once this venous reconstruction was completed, the edema in the leg and subcutaneous tissue markedly decreased. At the end of the procedure, a pulse was palpable in the popliteal artery. However, on the third postoperative day, the right leg became septic and required a right above-knee amputation, despite the presence of patent arterial and vein grafts. Thirty days later, after multiple debridements, the patient was transferred to a rehabilitation facility in another state and has not returned for follow-up at our institution. S FA--~: (::.~,,,:~ Fig. 3. Artist's drawing from case 2 of iliofemoral interposition graft with spiral vein graft (SVG). EIA, external iliac artery; SFA, superficial femoral artery. vertebrae was diagnosed, which required a cervical spine fusion on Aug. 24, 1987. At the time of discharge, on Sept. 9, all surgical wounds were healed and a pedal pulse waspalpable. The patient has failed to return for scheduled follow-up. Case 3. On June 30, 1985, a 14-year-old white boy fell beneath a mechanized farm plow, which resulted in extensive soft tissue destruction of the right thigh. On admission, there was no motor function of the right leg and the superficial femoral vein and the SFA had been completely transected. Because the patient was young, an attempt was made to save the limb despite this extensive injury. During operative exploration of the wounds, it was discovered that the SFA had been transected 4 cm distal to the inguinal ligament and again near the adductor hiatus. The superficial femoral vein had been divided near the inguinal figamenc Both the femoral and sciatic nerves had also been transected. After the injured vessels were exposed and controlled, the saphenous vein was removed from the left leg. Two separate interposition grafts of reversed saphenous vein were used to reconstruct the SFA. Once / DISCUSSION In 1974, Chiu et al. 1 first described the technique for constructing a spiral vein graft to replace the superior vena cava (SVC) in a canine model. In 1976, the first clinical use of a spiral vein graft to relieve a benign obstruction of the SVC was reported. 2 In this case, a graft from the irmominate vein to the right atrium resulted in immediate relief of the patient's symptoms. Since this initial case, there have been 14 additional instances of spiral vein grafts used to relieve SVC obstruction. 3-8 The largest single series was reported by Dory 3 in 1982; he described 10 patients who had spiral vein grafting to treat SVC obstruction (four because of benign disease and six because of bronchogenic carcinoma). All patients obtained immediate relief of their symptoms and all grafts were confirmed patent from 7 dab,s to 18 months postoperatively. The longest follow-up was 6 years and this patient remained asymptomatic. Spiral vein grafts have also been used successfully for replacement of the internal jugular vein after bilateral radical neck dissections, 9 for a mesoeaval shunt in a 12-year-old with portal vein obstruction, 1 for replacement of the common femoral vein after a traumatic injury, n and for replacement of an axillary artery aneurysm in one patient and a subclavian artery aneurysm in another) 2 Although spiral vein grafts have been used in various locations, the venous reconstructions we report represent only the second and third examples of its use in the femoral venous system and our femoral arterial reconstruction is only the third such reported use of a spiral vein graft. Vascular injuries in heavily contaminated wounds are among the most difficult challenges facing vas-

Volume 8 Number 4 October 1988 Spiral vein grafts in contaminated fieids 445 Fig. 4. A, Intraoperative photograph from case 3 shows proximal superficial femoral artery reconstruction with reversed saphenous vein (RSV) and superficial femoral vein reconstruction with a spiral vein graft (SVG). B, Artist's drawing of A. Fig. 5. Construction of spiral vein graft shows vein initially wrapped loosely around a stent (top), then construction completed (bottom). cular surgeons. If infection develops in the vascular repair, it could result in anastomotic disruption and potential exsanguination. Reversed autogenous saphenous veins are frequently too small in diameter to serve as interposition grafts for large vessels such as the iliac, femoral, or subclavian arteries. Therefore, an isodiametric autogenous conduit is frequently difficult to find. Although PTFE grafts have been used successfully in such situations for arterial reconstructions, their use remains controversial. In a report by Feliciano et al., 13 206 patients had 236 PTFE vascular grafts inserted in contaminated fields over a 5-year period. Although there were few early graft infections, only 18% of the original patients were followed up over the long term. Because prosthetic vascular graft infections may not appear until months or years after implantation, we believe that this report does not justify the indiscriminate use of PTFE vascular grafts in the presence of extensive bacterial contamination. Furthermore, venous reconstructions with PTFE have had poor patency. 13 The main advantages of autogenous spiral vein

446 Fowl et al. Journal of VASCULAR SURGERY grafts are their resistance to infection and their ability to mold to vessels of any size. Their main disadvantage is the time and effort required to construct them. Depending on the length of graft needed, it may take up to an hour to fashion such a graft. In a trauma patient who is hemodynamically unstable, a PTFE graft may be preferred, despite the risk of infection, to reduce the operating time. The following formula can be used to calculate the length of donor vein required to construct a spiral vein graft~: 1 = R/r L where 1 is length of donor vein, R is radius of recipient vessel, r is radius of donor vessel, and L is length to be substituted at recipient site. The requisite length ofsaphenous vein is excised from the opposite leg and gently distended with heparinized saline solution. All side branches are ligated. An Argyle chest tube of appropriate diameter is then selected to form a stent for constructing the spiral vein graft. The saphenous vein is split longitudinally and wrapped around the stent in a spiral fashion with its luminal surface facing the stent (Fig. 5). The vein graft edges are sutured together with a continuous 6-0 or 7-0 polypropylene suture. Once the graft is constructed, it is gently slid off the stent and anastomosed to the recipient vessel in either an end-to-end or end-to-side manner. Before the last anastomisis is started, the spiral vein graft should be distended with blood to ensure there are no major leaks. Care should be tal<en to approximate the diameter of the recipient vessel when constructing the spiral vein grafts because their ends cannot be spatulated at the anastomosis to aid in correcting for size mismatch. Most contaminated vascular injuries can usually be managed with conventional techniques such as primary repair, vein patch angioplasty, or reversed saphenous vein interposition grafts. Spiral vein grafts should be considered in situations where extensive bacterial contamination is present and a large vessel must be replaced. Although experience is limited, spiral vein grafts appear to have durable patency rates when used to replace large veins (femoral and SVC). Their long-term patency when used for arterial reconstructions is unknown. However, even if they do not remain patent for the long term, they may be useful as a temporary conduit to maintain limb viability until sepsis has resolved and a more durable reconstructive procedure can be performed. REFERENCES 1. Chin CI, Terzis 1~ MacRae ML. Replacement of superior vena cava with spiral composite vein graft: a versatile technique. Ann Thorac Surg 1974;17:555-60. 2. Dory DB, Baker WH. Bypass of superior vena cava with spiral vein graft. Ann Thorac Surg 1976;22:490-3. 3. Dory DB. Bypass of superior vena cava: six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. I Thorac Cardiovasc Surg 1982;83:326-38. 4. Brandt B III, Hiratzka LF, Marvin WJ. Spiral vein graft: an alternative method for relief of superior vena caval obstruction following the Mustard repair. J Thorac Cardiovasc Surg 1985;89:943-5. 5. Smith ER, Brantgan CO. Bypass of superior vena cava obstruction using spiral vein graft. I Cardiovasc Surg 1983; 24:259-61. 6. Utley JR. Relief of superior vena caval syndrome with spiral vein bypass grafting. J SC Med Assoc 1985;81:489-90. 7. Miller JD, Kinley CE. Spiralvein graft for obstruction of the superior vena cava. Can I Surg 1983;26:537-8. 8. Anderson RP, Wei-i L. Segmental replacement of superior vena cava with spiral vein graft. Ann Thorac Surg 1983; 36:85-8. 9. Leafstedt SW, Rubenstein RB, Pallanch JF, Wilder WH. Spiral saphenous vein graft for replacement of internal jugular vein: a series of case reports. Angiology 1985;36:82741. 10. Kaufman BH, Puga FJ, Perrault J, Gilchrist GS~ Johnson CM. Drapanas shunt using a spiral saphenous vein graft. J Pediatr Surg 1987;22:3-7. 11. Hobson RW II, Yeager RA, Lynch TG, et al. Femoral venous trauma: techniques for surgical management and early results. 12. Am J Surg 1983;146:220-4. Koga Y, Tomita M~ Shibata K, Onitsuka T. An experience using spiral vein graft as arterial substitute. Jpn J Surg 1981;11:305-9. 13. Feliciano DV, Mattox KL, Graham JM, Bitondo CG. Fiveyear experience with PTFE grafts in vascular wounds. I Trauma 1985;25:71-82.