Surgical Management of Infected PTFE Hemodialysis Grafts: Analysis of a 15-Year Experience

Tabbara, Marwan R.; O׳Hara, Patrick J.; Hertzer, Norman; Krajewski, Leonard P.; Beven, Edwin G.

doi:10.1007/bf02139410

Cited by 31 publications

(16 citation statements)

References 13 publications

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“…Other previous studies have reported reinfection rates ranging from 15% to 47% for partially excised grafts and 0% for completely excised grafts (Table V). 8,[11][12][13][14] In the present study, partial excision was also observed to result in a significantly increased incidence of reinfection compared with complete excision; in the latter group, only 1 patient subsequently developed a clinically significant reinfection.…”

Section: Discussionsupporting

confidence: 57%

Complete versus partial excision of infected arteriovenous grafts: Does remnant graft material impact outcomes?

Liu

Fraser

Zhou

et al. 2020

Journal of Vascular Surgery

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Objective: Infected arteriovenous grafts necessitate intervention to obtain source control. However, excising the graft material can be challenging and can lead to complications. Leaving a cuff of graft at the sites of anastomosis allows for the avoidance of potential risks. However, it is unclear whether doing so places patients at risk of recurrent graft infection. The purpose of the present study was to investigate the effect of complete vs partial excision of infected arteriovenous prosthetic dialysis access grafts. Methods:The data from all patients who had undergone surgical intervention for infected arteriovenous grafts at a single institution were retrospectively reviewed. The patients were grouped according to intervention type: complete excision and partial excision of arteriovenous prosthetic grafts. Partial excisions were further substratified based on whether flow had been restored through the arteriovenous access. The primary outcome was freedom from subsequent intervention for infection, defined as the number of days from excision to subsequent reoperation for reinfection. Freedom from infection was analyzed using the Kaplan-Meier method.Results: A total of 117 patients had undergone surgical intervention for 122 infected arteriovenous grafts from 2003 to 2016. Of these 117 patients, 79 (64.8%) had undergone partial excision of infected arteriovenous grafts, and 43 (35.2%) had undergone complete excision with vascular repair. Within the partial excision cohort, 71 infected arteriovenous grafts (58.2%) were not flow restored and 8 (6.6%) were flow restored using either prosthetic or autogenous interpositions. The median follow-up time was 2.4 years (interquartile range, 0.6-4.5 years). The most common causative organisms included methicillin-resistant Staphylococcus aureus (n ¼ 34; 27.9%), methicillin-sensitive S. aureus (n ¼ 17; 13.9%), and S. epidermidis (n ¼ 15; 12.3%). The recurrent infection rate in the partial excision group was 16.5% (n ¼ 13) compared with 2.3% (n ¼ 1) in the complete excision group. In the flow-restored subcohorts, those with restoration using prosthetic interposition grafts had the greatest reinfection rate at 57.1% (n ¼ 4), and those with restoration using autogenous conduits did not experience reinfection (P ¼ .033).Conclusions: Incomplete excision of infected arteriovenous prosthetic grafts was associated with a higher rate of reinfection compared with complete graft excision. Complete excision presents technical challenges but could provide superior source control in managing infected dialysis access. Complete excision with vascular reconstruction should be performed when possible to avoid leaving remnant prosthetic material. (J Vasc Surg 2020;71:174-9.)

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Section: Discussionsupporting

confidence: 57%

Complete versus partial excision of infected arteriovenous grafts: Does remnant graft material impact outcomes?

Liu

Fraser

Zhou

et al. 2020

Journal of Vascular Surgery

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“…First, among patients with AV grafts, complications and costs that are associated with an AV graft revision/resection can be significant (37,38,41). In contrast, patients with catheters required a large number of procedures (e.g., catheter removal and replacement, prosthetic device removal, surgery for infective endocarditis), which likely escalated the mortality rate and cost in this cohort.…”

Section: Discussionmentioning

confidence: 99%

Relationship between Clinical Outcomes and Vascular Access Type among Hemodialysis Patients with Staphylococcus aureus Bacteremia

Inrig

Reed

Szczech

et al. 2006

Clinical Journal of the American Society of Nephrology

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The association between hemodialysis vascular access type, costs, and outcome of Staphylococcus aureus bacteremia (SAB) among patients with ESRD remains incompletely characterized. This study was undertaken to compare resource utilization, costs, and clinical outcomes among SAB-infected patients with ESRD by hemodialysis access type. Adjusted comparisons of costs and outcomes were based on multivariable linear regression and multivariable logistic regression models, respectively. A total of 143 hospitalized hemodialysis-dependent patients had SAB at Duke University Medical Center between July 1996 and August 2001. A total of 111 (77.6%) patients were hospitalized as a result of suspected bacteremia; 32 (22.4%) were hospitalized for other reasons. Of the 111 patients, 59.5% (n ‫؍‬ 66) had catheters as their primary access type, 36% (n ‫؍‬ 40) had arteriovenous (AV) grafts, and 4.5% (n ‫؍‬ 5) had AV fistulas. Patients with fistulas were excluded from analyses because of small numbers. Patients with catheters were more likely to be white, had shorter dialysis vintage, and had higher Acute Physiology and Chronic Health Evaluation II scores compared with patients with grafts. Unadjusted 12-wk mortality did not significantly differ between patients with catheters compared with patients with grafts (22.7 versus 10.0%; P ‫؍‬ 0.098); neither did 12-wk costs differ by access type ($22,944 ؎ 18,278 versus $23,969 ؎ 13,731, catheter versus graft; P > 0.05). In adjusted analyses, there was no difference in 12-wk mortality (odds ratio 1.63; 95% confidence interval 0.29 to 9.02; catheter versus graft) or 12-wk costs (means ratio 0.84; 95% confidence interval 0.60 to 1.17; catheter versus graft) among SAB-infected patients with ESRD on the basis of hemodialysis access type. Twelve-week mortality and costs that are associated with an episode of SAB are high in hemodialysis patients, regardless of vascular access type. Efforts should focus on the prevention of SAB in this high-risk group.

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“…181 In case series, the percentage of grafts that become infected has been reported to range between 2% and 35%, with most studies reporting rates between 5% and 15% over the duration of the observation. 182,185 Less commonly encountered organisms include Staphylococcus epidermidis, Streptococcal species, gram-negative bacteria, and occasionally, candida or other fungal species. 93 The majority of infections are due to Staphylococcus aureus.…”

Section: Infectionmentioning

confidence: 99%

“…* One report found that the infection rate was higher in the first year after access placement compared to the second year. 185 Infection or abscess around the graft may present with localized erythema and tenderness over the graft site, but graft infection can also present with fever and systemic symptoms without localized evidence of infection. 182,185 Less commonly encountered organisms include Staphylococcus epidermidis, Streptococcal species, gram-negative bacteria, and occasionally, candida or other fungal species.…”

Section: Infectionmentioning

confidence: 99%

“…192 Other factors that predispose to graft infection include frequent access surgeries and procedures, poor personal hygiene, intravenous drug abuse, and skin rash or infection. 182,185,186 Vancomycin with addition of gram-negative coverage, if the patient is septic, is appropriate. The use of preoperative vancomycin prior to access surgery has been recommended to decrease the frequency of subsequent post-operative graft infections.…”

Section: Infectionmentioning

confidence: 99%

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Vascular Access

Himmelfarb¹,

Dember²,

Dixon³

2005

Chronic Kidney Disease, Dialysis, &Amp; Transplantation

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Surgical Management of Infected PTFE Hemodialysis Grafts: Analysis of a 15-Year Experience

Cited by 31 publications

References 13 publications

Complete versus partial excision of infected arteriovenous grafts: Does remnant graft material impact outcomes?

Complete versus partial excision of infected arteriovenous grafts: Does remnant graft material impact outcomes?

Relationship between Clinical Outcomes and Vascular Access Type among Hemodialysis Patients with Staphylococcus aureus Bacteremia

Vascular Access

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