During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the
wound, 15 with
wound separation and
cellulitis, 18 with
soft tissue infection extending to the graft, 4 with an
abscess and
cellulitis, and 4 with
bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty
infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients.
Wound cultures were positive for bacteria in 52 patients, and most
infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven
infections. Twelve patients had
polymicrobial infections. The interval from operation to
infection ranged from 7 to 180 days. All patients were treated with oral
antibiotics, 48 after intravenous
antibiotics. Forty-five patients had operative
debridement, including 18 who had muscle flap coverage. Four patients presented with
hemorrhage, and three had immediate graft
ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee
amputation, and one had a nonhealed
wound but intact limb. Overall, 61
wounds (91%) healed, 4 patients required below-knee
amputations, and 3
wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control
hemorrhage. Of the 61
wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with
bleeding died because of the acute episode. No patient had delayed
hemorrhage. All 18 patients treated with a muscle flap healed.
Bleeding (P <.001), elevated white blood cell count (P <.029),
fever (P <.001), and
renal insufficiency (
creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and
limb salvage was 97%, 92%, and 92% at the same intervals, respectively.
CONCLUSIONS: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to
infection, or
Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with
fever,
leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft
ligation or excision should be reserved for patients presenting with
bleeding or
sepsis.