#15 ISOLATED AV DIALYSIS ACCESS GRAFT SEGMENT
INFECTION: THE RESULTS OF SEGMENTAL BYPASS AND PARTIAL GRAFT
EXCISION.
Donald P. Schwab, MD, Spence M. Taylor, MD, David L. Cull, MD, Eugene
M. Langan, III, MD, Bruce A. Snyder, MD, and Timothy M. Sullivan,
MD
Greenville Hospital System, Greenville, SC
Arteriovenous access graft infection results in disruption of
dialysis and usually necessitates graft removal when the entire graft
is involved. The management of an isolated infected segment of an
otherwise non-infected AV access graft, however, remains
controversial.
Methods: To evaluate the utility of segmental bypass and
partial graft excision (SB/PE) for the treatment of an isolated
infected AV access graft segment, 17 consecutive cases in 12 patients
(7 females; 14 arm grafts/3 leg grafts; median age = 69 yr) were
analyzed on a vascular teaching service that performed 1244 total
access procedures from January 1995 through February 1999.
Infections presented as a draining sinus or a sinus with hemorrhage
emanating from an area over the graft.
At operation, the infected sinus was covered by a transparent
occlusive dressing and the graft was dissected through clean
incisions proximal and distal to the infected segment. If the graft
was incorporated and free of infection, a piece of PTFE was
anastomosed proximally end-to-end and tunneled through non-infected
tissues around the infected sinus. After the distal anastomosis was
performed, the skin incisions were closed and covered with occlusive
dressings. The infected graft segment was then removed through the
infected sinus wound.
Results: There were no operative deaths or major morbidities.
Two unrelated late deaths have occurred. During the follow-up
interval (mean = 6.3 months; range = 1-22 months), 16 (94%) SB/PE
procedures successfully eradicated infection and allowed for
maintenance of continuous dialysis, in each case through a portion of
non-infected graft. All wounds healed. One graft (6%) became
infected 22 days after SB/PE, necessitating entire graft removal.
Infection free interval for each graft ranged from 1-20 months (mean
= 7.1 months). Three patients had at least one additional remote
graft infection presenting 3-20 months after SB/PE. Each was
successfully treated by additional SB/PE. Only one of these patients
required eventual total graft removal 4 months after the second SB/PE
for an unrelated total graft infection. Of the 10 surviving
patients, 7 (70%) have healed extremities with no evidence of
infection and a functioning AV access graft.
Conclusion: The technique of SB/PE results in predictable
eradication of infection, graft salvage, and maintenance of
interrupted dialysis in patients presenting with an isolated AV
dialysis access infection.
