Management of infected prosthetic dialysis arteriovenous grafts
Management of infected prosthetic dialysis arteriovenous grafts
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DOI：
10.1016/j.jvs.2003.07.002
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发表时间：
2004-01-01
影响因子：
4.3
通讯作者：
Dougherty, MJ
中科院分区：
文献类型：
--
作者：
Ryan, SV;Calligaro, KD;Dougherty, MJ
背景：血液透析通路是血管外科和普通外科医生最常见的血管手术之一。假体动静脉移植物（AVG）感染可能造成危及生命的脓毒症和出血并发症，以及透析途径的丧失。采用的策略，以保留一些移植物，防止发病率在那些重大感染，并保持访问提出。方法：1995年7月1日至2002年8月1日，在同一医院进行了1441例AVG手术。45例患者中有51例（3.5%）假体AVG感染。27例移植物感染发生在移植物放置或修复的先前切口。其他24例感染位于移植物体内，其中14例被记录为发生在最近的血液透析穿刺部位。最常见的表现（47%[24/51]）是暴露的移植物或引流窦道。当患者出现脓毒症或整个移植物浸泡在脓液中时，治疗包括全移植物切除（TGE）；次全移植物切除（SGE），当所有移植物被移除时，除了在下方未闭动脉上覆盖一小块假体材料；部分移植物切除（PGE），仅切除移植物的有限感染部分，并将新移植物重新穿过邻近的无菌组织，以保持原移植物的通畅。结果：45例患者无死亡或发生手部缺血。所有接受TGE（13/13: 8个静脉贴片，4个初步闭合，1个动脉结扎）或SGE（15/15）治疗的患者均取得了一致的成功结果。然而，这些治疗需要放置中心静脉导管进行临时透析，并在之后进行新的AVG。所有28例伤口均通过二次创面愈合，包括所有15例保留了缝合的假体材料袖带。74%（17/23）的PGE感染患者获得了移植物通畅和伤口愈合，并且避免了放置临时透析通路导管和新的AVG。6例PGE失败患者因伤口未愈合最终需要TGE，但无急性出血或脓毒性事件。结论：假体AVG感染引起的全身性败血症需要TGE。SGE和PGE可以安全地应用于感染假体AVGs的患者。SGE维持了基底动脉的通畅，避免了困难和耗时的剥离。PGE的优点是最大限度地减少了对整合良好的未感染移植物节段的广泛剥离，并允许在移植的整合部分进行持续的透析。
Background: Hemodialysis access is one of the most common vascular procedures that is performed by vascular and general surgeons. Prosthetic arteriovenous graft (AVG) infections pose potentially life-threatening septic and bleeding complications, as well as loss of dialysis access. Strategies employed to preserve some grafts, prevent morbidity in those with major infections, and maintain access are presented.Methods: Between July 1, 1995 and August 1, 2002, 1441 AVG procedures were performed at a single institution. Fifty-one (3.5%) prosthetic AVG infections in 45 patients were identified. Twenty-seven graft infections occurred at a prior incision for placement or revision of a graft. The other 24 infections were located within the body of the graft, and 14 of these were documented to be at a recent puncture site for hemodialysis access. The most common presentation (47% [24/51]) was an exposed graft or a draining sinus tract. Management included total graft excision (TGE) when patients presented with sepsis or the entire graft was bathed in pus; subtotal graft excision (SGE), when all of the graft was removed except an oversewn small cuff of prosthetic material on an underlying patent artery; and partial graft excision (PGE), when only a limited infected portion of the graft was removed and a new graft was rerouted through adjacent sterile tissue to maintain patency of the original graft.Results: None of the 45 patients died or developed hand ischemia. A uniformly successful outcome was achieved in all patients who were treated with TGE (13/13: 8 vein patches, 4 primary closure, 1 arterial ligation) or SGE (15/15). However, these treatments necessitated placement of a central venous catheter for temporary dialysis access and a new AVG later. All of these 28 wounds healed by secondary intention, including all 15 cases in which an oversewn cuff of prosthetic material remained. Graft patency and wound healing were achieved in 74% (17/23) of infections treated with PGE, and placement of a temporary dialysis access catheter and new AVG were avoided. The 6 failures of PGE ultimately required TGE because of nonhealing wounds, but there were no acute hemorrhagic or septic events.Conclusions: Systemic sepsis caused by prosthetic AVG infections mandates TGE. SGE and PGE can be safely employed in selected patients with infected prosthetic AVGs. SGE maintains patency of the underlying artery and avoids a difficult and time-consuming dissection. PGE offers the advantage of minimizing extensive dissection of well-incorporated uninfected graft segments and allows continued dialysis access at the incorporated portion of the graft.