Surgical Treatment of Infected Prosthetic Dialysis Arteriovenous Graft

Lee, Jihyoun; Song, Dan; Moon, Chul

Abstract

PURPOSE
Hemoaccess using a polytetraflouroethylene (PTFE) graft is widely performed when primary arteriovenous access is unavailable. An infection of a PTFE graft is a common complication and a major cause of hemoaccess failure. This study reviewed the infected case of PTFE grafts in our hospital, and evaluated the incidence, surgical treatment, progress and outcome.
METHODS
From March 2000 to February 2005, among 1,067 patients who received PTFE graft surgery in Soonchunhyang University Hospital, 58 patients were treated graft infection. These patients were managed by a total graft excision (TGE), a subtotal graft excision (SEG), and a partial graft excision (PEG) with a bypass graft. Usually, SGE is defined as the removal of all of the graft except for 2~3 mm from the arterial anastomosis. However, in our cases, SGE was performed with 1~1.5 cm of the arterial remnants, according to the operative risk, and either the surgical technique or the patient's medical condition. All the records were reviewed retrospectively.
RESULTS
The mean age of the patients was 55 years, and 36 patients had a history of diabetes. The PTFE graft placed in the brachiobrachial position of the upper arm was encountered most frequently (72%). 23 graft infections located within the body of the graft, 20 of these were documented to be at a recent puncture site for hemodialysis access. The most common presentation (29%) was purulent discharge. Among the 58 patients treated for a graft infection, 40 patients received SGE, PGE was replaced by a new graft in 15 patients, TGE was performed in 2 patients, and incision and drainage was performed in 1 patient. After surgery, all the patients were treated with antibiotics. The bacterial cultures were positive in 38 cases. Of the 38 culture positive wounds, the most common organism was Staphylococcus aureus (33 cases). 15 cases developed infectious complications: pneumonia, systemic sepsis, duodenal ulcer with or without bleeding, and septic arthritis. The overall mortality was 8% (5 patients). Among the SGE patients, 11 patients evolved an infection of the remnant prosthesis, and a surgical procedure was required.
CONCLUSION
Infections are one of a serious complications of PTFE graft that can progress more graft failure or death. There are many treatment options. These include 1) Incision and drainage, 2) TGE, 3) SGE and 4) PGE. TGE should be performed if the graft is not well incorporated or the entire graft was infected. In our experience with infected peripheral bypass grafts, a subtotal graft excision was used if the arterial anastomosis was intact and encased in scar tissue. A risky dissection of an artery encased in scar tissue was avoided by oversewing 1~1.5 cm rather than a 2~3 mm cuff of the remainder of the graft.