Management of prosthetic graft infection after lower limb arterial bypasses

目的 总结下肢动脉旁路移植术后人工血管感染的治疗经验,探讨人工血管感染的防治方法.方法 对2004年1月至2009年12月15例下肢动脉旁路移植术后人工血管感染患者的临床资料进行回顾性分析.男性14例,女性1例,平均64.8岁.感染发生在人工血管末次重建术后5 d～59个月,平均6.4个月.临床表现包括伤口不愈合人工血管外露8例,窦道脓液渗出5例,与人工血管相通的窦道不愈合1例,切口积液并人工血管游离1例.均予以广谱抗生素治疗.外科治疗包括局部清创引流4例,清创并转移皮瓣1例,单纯去除感染闭塞的人工血管5例(其中1例初次旁路移植时同期截肢),去除感染闭塞的人工血管后截肢3例,1例仅行部分去除感染通畅的人工血管(原闭塞支架再通),1例去除通畅感染的人工血管并一期解剖外镀银涤纶人工血管旁路移植术.结果 保肢9例,截肢4例,1例死于术后心肌梗死,1例清创并转移皮瓣术后伤口未愈出院后失访.随访13例,2例随访中分别因结肠癌和脑出血死亡.生存11例随访1～70个月,平均22.3个月,保肢8例未出现严重缺血或感染症状,截肢3例无特殊.本组累积病死率20%(3/15),截肢率26.7%(4/15),人工血管闭塞率53.3%(8/15).结论 下肢动脉旁路移植术后人工血管感染,多数感染的人工血管需取出,如出现严重缺血症状需再次旁路移植,对通畅人工血管的局限性感染也可以考虑保留人工血管.Objective To summarize the experience in management of prosthetic graft infection ( PGI ) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment. Methods Records of 15 cases of PGI between January 2004 and December 2009 were retrospectively analyzed, including 14 male and 1 female with the average age of 64. 8 years (ranged from 40 to 84 years). PGI occurred from 5 d to 59 months (average 6. 4 months) after the last reconstructive procedures with symptoms as follow; nonhealing wound with vascular graft exposure in 8 cases, persistent sinus related to vascular graft with purulent secretion in 5 cases and without secretion in 1 case, and ill-incorporated graft with peri-graft fluid in 1 case. Broad-spectrum antibiotics were administrated in all PGI cases. Surgical treatments included local debridement and drainage in 4 cases ( one death from postoperative acute myocardial infarction) , local debridement and skin flap rotation in one case, complete removal of the occluded infected grafts in 8 cases including major amputation in 3 cases, removal of patent infected graft and extra-anatomic bypass with silver-bonded Dacron vascular graft in 1 case, and partial removal of patent infected graft without reconstruction in 1 case with a re-canalized stent-graft. Results Limb salvage was achieved in 9 cases, and 4 cases received major amputation. One case was failed to follow-up and one died of postoperative acute myocardial infarction. Initially 13 patients were followed and 2 died during follow-up ( because of colon carcinoma and intracranial hemorrhage respectively). Eleven patients were followed for 1 to 70 months (average 22. 3 months) including 8 cases with limb salvage and 3 with major amputation. Accumulative mortality rate, amputation rate, and graft occlusion rate were 20% (3/15) , 26. 7% (4/15), and 53. 3% (8/15 ) respectively. Conclusions PGI after lower limb arterial bypasses is a devastating complication with high risk of graft occlusion and amputation. Removal of the infected grafts may be mandatory for most cases, but local management for patent infected grafts may be recommendable for selected cases.中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)013981-9844