December 12, 2008

Graft Preservation in Early Groin Infections Using Vacuum-Assisted Closure Without Muscle Flap Coverage: A Consecutive Patient Series.

Hasan H. Dosluoglu, MD¹, Cyrus Logmanee, MD², Purandath Lall, MBBS¹, Gregory S. Cherr, MD², Linda M. Harris, MD², Maciej L. Dryjski, MD².
¹SUNY at Buffalo, VA Western NY Healthcare System, Buffalo, NY, USA, ²SUNY at Buffalo, Buffalo, NY, USA.

Objective: Stand-alone Vacuum-assisted closure (VAC) therapy is our primary approach in early, deep groin infections with and without exposed grafts, however concerns remain regarding safety.
Methods: All patients with early (<3 months), deep (Szilagyi 2/3) vascular groin infections between 09/2003-12/2007 were reviewed.
Results: Twenty-two patients (26 groins,mean age 69±10) presented with deep groin infections 19±12 days after procedure (bypass-PTFE (12), GSV (2), endarterectomy/patch (6), extraanatomic bypass (5), percutaneous with closure device(1). Grafts were exposed (Szilagyi 3, 10 with suture lines) in 13 patients. VAC was started 1-7 days (median 3) after operative debridement. All had positive cultures (MSSA (4), MRSA (4), Gram (-) (8), polymicrobial (10)), and were treated with culture-directed antibiotic therapy for 51±48 (range 14-180) days. LOS was significantly more in Szilagyi 3, whereas mean VAC use, time-to-healing was similar (Table). Mean follow-up was 22±16 (2-48) months. All wounds healed (49±21 days). Two treatment failures occurred in Szilagyi 3 group (15%). One patient had bleeding from the anastomotic heel 8 days after debridement, had graft removal/in situ replacement; One presented with reinfection on day 117, had partial graft removal/extraanatomic bypass. There was no perioperative mortality, limb loss and 3 late unrelated mortalities.
Conclusions: Management of early, deep groin wound infections with radical debridement, antibiotics and VAC treatment as a stand-alone modality is safe, and enables graft preservation in the majority of patients with minimal morbidity (reinfection, bleeding), no limb loss or mortality. This may be a safe alternative in medically ill patients in whom muscle flap is considered.

Characteristics and clinical outcomes in Szilagy 2 and 3 early groin infections
	Szilagyi 2 (n=13)	Szilagyi 3 (n=13)	P value
Indication CLI	85%	77%	1.0
WBC (%>10K)	12.3±6.7(46%)	13.0±7.0(62%)	0.826 (0.695)
Time to VAC (days)	3.0±1.8	2.3±1.0	0.231
VAC use (days)	28±13	25±15	0.553
Primary wound healing (VAC/final)	100%	85%/100%	0.480
Wound healing (days)	50±20	48±23	0.829
Graft preservation	100%	85%	0.480
Limb loss	0	0
LOS (days)	9.9±13.4	20.5±12.6	0.048

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