1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction  Complication  Graft infection  Procedure  Femoral-femoral bypass  Primary Diagnosis  Left leg rest pain

3.  60 yo male presenting 2/24 to ER with left leg pain at rest  Sudden worsening that am from prior 2 block claudication  No foot wounds

4.  PMH:  DM2, CAD, COPD, GERD, PVD, bipolar d/o, arthritis, ED, hypothyroidism, chronic back pain  PSH:  CABG, Penile implant  Soc Hx:  Heavy smoker

5.  PE  Cool left leg with decreased motor function, no palpable pulses left side, palpable right femoral, dopplerable PT/DP, no tissue loss  Placed on heparin gtt  WBC 10.5, CRE 1.15, other labs WNL  Arterial dopplers:  right leg triphasic CFA, right femoral disease, ABI= 0.67  Left leg monophasic CFA, occlusion of SFA and PT, ABI = 0.27

7.  Underwent angiography on 2/27

8.  OR on 3/2 for fem-fem bypass  Aortobifem not done due to subacute presentation and medical comorbidities  8mm PTFE used  Preop antibiotics given  Did well post-op and was discharged on 3/5

9.  Returned to clinic on 3/13 with drainage from right incision  No fevers, good flow in bypass, improved symptoms  WBC 12, wound opened, MRSA cultured, blood cx negative  Deep layer remained closed with no graft exposure  On Vanc x7 days in hospital with resolution of leukocytosis, no fevers  d/c home on bactrim

10.  Returned on 3/23 with fever to 105, WBC 25.5, positive blood cx x2 for MRSA  Taken to OR where purulence found in right groin around graft  graft excision, redo of fem-fem with vein, sartorious flap of right groin  Did well with resolution of sepsis, d/c 5 days later

11. Analysis of Complication Was the complication potentially avoidable? – No- patient had appropriate operation, known infection rate Would avoiding the complication change the outcome for the patient? – Yes- graft excision, readmission x2 What factors contributed the complication? – Poor hygiene, indwelling foreign body, diabetes

12. Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl 5:S35-41  Most common organism in vascular infections = S. aureus  >80% from endogenous source

13. Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl 5:S35-41  Vascular Surgery Site infections 5-10%  Gram positives most common organism  MRSA has mortality of 20.7% with SSI  Extra 5 days in hospital and $40K additional cost compared with MSSA  Nasal carriage 2-9X risk of SSI

14. Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl 5:S35-41  Vascular prosthetic graft infection (VPGI) 1-5%  MRSA VPGI mortality 25-88%, amputation rate 80%  PTFE 10-100x more resistant to infection than Dacron  Conservative management (Abx only) is highest risk factor for mortality  Surgical principles:  Graft removal  Wide debridement  Extraanatomic bypass (or in situ abx inpregnated graft or vein)

15. Teaching points  MRSA graft infection carries high mortality and complication rates  requires early graft excision and extraanatomic bypass