Surgical Site Complications After Complex Iliofemoral Reconstruction and the Role of Negative Pressure Wound Therapy

A Retrospective, Single-Center Study

Ahmed A. Sorour, MD; Levester Kirksey, MD, MBA; Vishnu Ambur, MD; James Bena, MS

Disclosures

Wounds. 2022;34(4):e22-e28. 

In This Article

Abstract and Introduction

Abstract

Introduction: Surgical site infection (SSI) of groin incisions after vascular surgery is a significant source of morbidity and is associated with high rates of readmission and reoperation, as well as longer hospital length of stay. The patient-reported health care experiences are diminished for those in whom SSI complications occur. Previous studies have analyzed patients undergoing all types of surgery requiring groin incision. The role of closed incision negative pressure therapy (CiNPT) as an adjunct to the primarily closed femoral incision after vascular surgery is unclear.

Materials and Methods: This retrospective single-center study focuses on complex iliofemoral reconstruction with extensive dissection, including profundoplasty. The role of CiNPT and short-term outcomes are analyzed. Multivariable logistic regression was used to identify factors that place patients at high risk for SSI. A prediction model was performed to predict high-risk patients.

Results: A total of 337 patients who underwent 422 femoral endarterectomies (85 bilateral) were included. The overall SSI rate was 16.1% (9.3% Szilagyi grade II and III), and SSI was associated with a 44% readmission rate, 38% reoperation rate, and longer mean length of stay (8.5 days vs 5.1 days; P =.02). No differences in SSI were evident between the CiNPT (n = 47) and standard dressing cohorts. The final prediction model used 5 variables: obesity (body mass index > 30), insulin use, chronic obstructive pulmonary disease (COPD), immunosuppression, and surgical duration.

Conclusions: Patients with obesity, COPD, and insulin-dependent diabetes mellitus are at increased risk for SSI after femoral incisions for peripheral revascularization. A prediction model may assist in identifying patients at high risk for SSI so that targeted risk reduction strategies can be implemented to decrease morbidity and economic costs. Targeted use of CiNPT may help reduce the severity of SSI in these at-risk patients.

Introduction

Surgical site infection (SSI) of femoral incisions after vascular surgery occurs in up to 44% of patients.[1] These infections are a significant source of morbidity and are associated with increased rates of readmission and reoperation, increased overall cost of care, and longer hospital length of stay.[2] In addition to clinical morbidity, the patient-reported care experience is negatively affected by this seemingly avoidable complication. Currently, limited guidance exists regarding best management practices to consistently mitigate wound complications associated with this common incision site for vascular and cardiovascular procedures.

The femoral incision is used in many different types of vascular intervention, including for thoracic and abdominal aortic aneurysm, aortoiliac occlusive disease, and infrainguinal revascularization. Increasingly, hybrid reconstructions that include common and deep femoral endarterectomy combined with aortoiliac endovascular intervention are supplanting historical approaches to Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) C and D aortoiliac artery occlusive lesions. Durable outcomes with the hybrid approach are predicated on the complete removal of plaque burden, which frequently necessitates extensive vessel exposure and lymphatic disruption over a longer operation. Both are clinical predictors of increased risk of surgical site occurrence and SSI.

The role of closed incision negative pressure therapy (CiNPT) as an adjunct to the primarily closed femoral incision after vascular surgery is unclear, and the data are seemingly inconclusive. Positive results with use of CiNPT have been reported in several randomized controlled trials (RCTs).[3,4] The Inguinal Vascular Surgical Wound Protection by Incisional Negative Pressure Wound Therapy (INVIPS) trial demonstrated a significantly decreased SSI incidence with use of CiNPT.[5] However, a Cochrane review published in 2019 concluded that use of CiNPT may reduce the rate of SSI, noting a "low certainty of evidence" and "high risk of bias."[6] These mixed results achieved with CiNPT, coupled with the additional procedural expense associated with the technology, may affect its adoption for widespread use in the clinical setting, because there are less expensive standard wound dressings available. Currently, no standardized protocol is available to prospectively enhance the identification of high-risk patients who would derive the most benefit from such therapy.

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