An aggressive policy of bilateral saphenous vein harvest for infragenicular revascularisation in the era of multidrug resistant bacteria

Background: The success of infragenicular revascularisation for lower limb ischaemia is limited by the high proportion of patients without ipsilateral long saphenous vein (LSV) of adequate length or quality. The aim of this study was to report the results of an autogenous vein only policy for infrag...

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Bibliographic Details
Published in:Postgraduate medical journal 2002-06, Vol.78 (920), p.339-343
Main Authors: Murphy, G J, Kipgen, D, Dennis, M J S, Sayers, R D
Format: Article
Language:English
Subjects:
Adult
Aged
Aged, 80 and over
Anti-Bacterial Agents - administration & dosage
autogenous vein
Bacterial infections
Biological and medical sciences
critical limb ischaemia
digital subtraction angiography
DSA
Female
femorodistal bypass
Heart attacks
Humans
Infusions, Intravenous
Ischemia
Ischemia - mortality
Ischemia - surgery
Leg - blood supply
long saphenous vein
Long term
LSV
Male
Medical sciences
Methicillin Resistance
methicillin resistant Staphylococcus aureus
Methods
Middle Aged
Morbidity
Mortality
MRSA
Original
polytetrafluoroethylene
Prevention
Prostheses
PTFE
Saphenous vein
Saphenous Vein - transplantation
Staphylococcal Infections - drug therapy
Staphylococcus aureus
Staphylococcus infections
Surgery
Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases
Surgical Wound Infection
Surveillance
Survival Rate
Tissue and Organ Harvesting - methods
Transplantation, Autologous
Ultrasonic imaging
Vancomycin - administration & dosage
Vascular grafts
Vascular surgery
Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
Veins & arteries
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Summary:Background: The success of infragenicular revascularisation for lower limb ischaemia is limited by the high proportion of patients without ipsilateral long saphenous vein (LSV) of adequate length or quality. The aim of this study was to report the results of an autogenous vein only policy for infragenicular revascularisation utilising contralateral LSV when ipsilateral LSV is inadequate. The treatment and outcome of infection of autogenous grafts with methicillin resistant Staphylococcus aureus (MRSA) is also reported. Patients and methods: The vascular audit database and patient case notes were reviewed retrospectively for patients with arterial occlusive disease requiring infragenicular reconstruction. There were 68 critically ischaemic legs in 65 patients of whom 48 were male: median age (range) 74 years (41–94), over a three year period. Results: Thirty six patients (53%) underwent revascularisation (eight infragenicular femoropopliteal bypass, 28 femorodistal), 24 (35%) underwent primary amputation and a further eight (12%) were found to have unsuitable distal vessels for revascularisation after tibial vessel exploration and intraoperative angiography. Thirty three grafts (92%) utilised LSV and three (8%) were polytetrafluoroethylene grafts. Thirteen patients (39%) lacked adequate ipsilateral LSV of whom 12 had the contralateral leg explored providing suitable LSV in 10/12 (83%). Contralateral LSV was used as a single length conduit in two cases and as a venovenous composite graft in eight cases. Primary, primary assisted, and secondary patency rates at two years were 38%, 77%, and 81% respectively. Actuarial limb survival and patient survival rates at two years were 86% and 61% respectively. Eleven patients developed ipsilateral wound complications (30%) including seven (21%) who developed MRSA infection of the ipsilateral leg wound. MRSA wound infection was treated successfully in all cases by antibiotic therapy (intravenous vancomycin). No patient subsequently required saphenous vein harvesting for a secondary reconstruction or coronary artery bypass graft. Conclusion: Excellent long term results can be achieved using autogenous vein for infragenicular revascularisation and the contralateral LSV is an excellent alternative in the absence of suitable ipsilateral LSV. Autogenous vein may confer some protection against severe complications observed with MRSA infection seen in vascular patients and therefore its use is recommended.
ISSN:0032-5473
1469-0756
DOI:10.1136/pmj.78.920.339