Dear Editor:

In this study we present three ASO cases operated with using PTFE grafts. Methicillin-resistant Staphylococcus Aureus(MRSA) grew in all of our 3 cases. Our first case that his left femoropopliteal PTFE graft was infected two months ago after operation because incorrect dressing for wound in an other institution(Figures 1 and 2).

Figure 1

Figure 1

Figure 2

Figure 2

In our first case,the artificial graft was extracted and femoral profundoplasty was carried out for limb salvage.

Our second case underwent aortobifemoral Y-grafting and a right femoropopliteal bypass grafting 2 months ago at another institution. Our second case underwent removal of the infected graft via femoral and supragenual exploration in the first operative session. The first session includes the removal of one third of the right limb of the infected Y-graft. During the second session prior to complete removal of Y-graft, left axillofemoral bypass grafting was carried out.

Our last case underwent aorto-right femoral artery bypass grafting 3 months ago at another institution having a purulent drainage from inguinal incision(Figure 3).

Figure 3

Figure 3

Our third case received proper parenteral antibiotherapy for 6 weeks to control the infection.

All of these cases were discharged with cure and no limb loss.

Comments

Arterial reconstruction is the most important surgical strategy for patients with arteriosclerotic obstruction in the lower limbs. One of the most feared complications of the use of a prosthetic material is the appearance of infection after implant. Wound dehiscence with exposure of the lower anastomosis is a limb- and life-threatening complication of femorodistal bypass(₁).

Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia(₂). Virulent graft infections presenting with sepsis, anastomotic dehiscence, or graft enteric fistula should continue to be treated with total graft excision(₃).

In the study of Young et al., 25 patients with aortic graft infection, treated by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months. Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection(₂).

Complete or partial removal of infected grafts with adjacent or in situ replacement by PTFE or otogen saphenous graft is possible, simplifies management, and permits maintenance of distal circulation with low morbidity and mortality rates(₄). Complete excision of infected graft material results in a significant reduction in the incidence of recurrent sepsis(₅).This procedure is safe, durable, and associated with eradication of clinical signs of infection.

In the study of Giacometti et al., a rat model was used to investigate the efficacy of levofloxacin, cefazolin and teicoplanin in the prevention of vascular prosthetic graft infection. The efficacy of levofloxacin against the methicillin- susceptible strain did not differ from that of cefazolin or teicoplanin. Levofloxacin showed slight less efficacy than teicoplanin against the methicillin-resistant strain. The levofloxacin-rifampin combination proved to be similarly effective to the rifampin-teicoplanin combination and more effective than the rifampin-cefazolin combination against both strains. The rifampin-levofloxacin combination may be useful for the prevention of late-appearing vascular graft infections caused by S. epidermidis because it takes advantage of the good anti-staphylococcal activity of both drugs(₆).

In conclusion; synthetic vascular prostheses have been developed to supply the limited supplement of native graft materials. The combined usage of systemic antibiotic prophylaxis and native saphenous grafts in high risk patient has been shown to be more effective in decreasing the incidence of prosthetic vascular graft infections.

Correspondence to

Doç. Dr. Ufuk YETKIN, 1379 Sok. No: 9,Burç Apt. D: 13 - 35220, Alsancak – IZMIR / TURKEY Tel: +90 505 3124906 , Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr