The groin wound infection after arterial surgery remains a significant clinical challenge. Multiple factors, including rich lymphatic tissue and fascia tissue, the proximity to the perineum, predispose inguinal femoral arterial reconstruction to complicated with infections8,9. In particular, persistent lymphatic leakage after arterial reconstruction in the groin has subsequently emerged as a common and potentially serious complication. Persistent epithelial breach poses the wound and graft at high risk of secondary infection, these serious complications were presented in all of our cases series. The complex conditions imply that it is notoriously difficult to treat and do not succumb to the remedy for simple vascular reconstruction surgery. The goal of treatment for IWI-AS should be to salvage the limbs and their functions. In our case series, all patients achieved well-vascularized lower limb, elimination of infection and wound healing in 6 weeks after intra-incisional NPWT surgeries.
For complicated femoral arterial injury, ligation is the simplest approach, collateral branches around the hip avoid limb loss in most healthy populations in case of ligation, but it is inevitable to cause critical ischemia and disability in lower limb, especially in patients with pre-existing arterial disease8,10. Therefore, ligation is not firstly recommended. The optimal strategy is supposed to rebuild the trunk of artery to maximize blood supply for limb salvage. In situ arterial reconstruction often failed to restore aortic blood flow in the setting of infected groin, which was attribute to uncontrolled infection and erosion-related bleeding11,12. In this regard, the bypass strategy was proposed. For bypass technique, the graft is tunneled through uninfected tissue, it protects the graft from erosion of infection. LFB and OCB are the frequently-used extra-anatomical techniques and have comparable effect in graft latency and limb salvage8,13-15. Nonetheless, OCB is more technically-challenging than LBP due to the difficult traverse of obturator foramen. It also has a risk of obturator vessel and nerve injury and potentially damages the collateral circulation of affected limb, whereas LBP is close to anatomic site and less invasive to surrounding tissues8. Additionally, given LBP is operatively convenient and time-saving, it is quite suitable for emergent bleeding cases15. Notably, 25% patients suffered acute bleeding6. In our study, all cases suffered sudden bleedings and received emergent LFB operations. All affected lower limbs were succeeded to be well revascularized without graft re-perforation that indicated by the distal pulses of dorsalis pedis arteries and vascular ultrasound at final follow-ups.
As ready-to-use grafts, prosthetic conduits are extensively used in vascular surgeries. Indeed, our cases also received prosthesis reconstructions in previous surgeries. Prosthesis-related bacteria colonization often leads to recurrence of wound infection, thus once infecting, the prosthetic graft would inevitably be completely removed. Although harvest of autograft, such as great saphenous vein, maybe bring donor site damage and the graft needs massive further process, including dilation and branch ligations, autograft was still the first choice in term of its long-lasting durability and resistance to infection, especially in young populations and infected setting16. Cryopreserved human cadaveric allografts present comparable performance with autografts but take relative higher cost and serve as alternative substitute for vascular graft in the absence of autografts8.
Sustaining inguinal lymphatic leakage and secondary infection are another challenge for wound healing. Unsurprisingly, debridement, especially radical debridement, is obligate and primary to infected wound. The debridement may be not enough for wound healing. Vascularized muscle flaps and NPWT therapy were well-documented methods for treating lymphatic leakage and infection, in particular for graft-preserved cases1,9,16-18. However, the use of flaps is often restricted to the already compromised blood supply of muscle and surgeon’s skills. NPWT, as another reliable method for infected wound, was prophylactically and therapeutically applied alone in groin wound following vascular surgery and showed good results18. However, there were 6.4% reinfections and 7.1% bleeding events in previous report19. In addition to debridement, the times and manners of NPWT application also play a role in recurrence of infection. Our previous study indicated that NPWT in intra-incisional manner was much more effective for drainage and compressing lymphatic tubes than that in closed-incisional manner20. Therefore, we enveloped the NPWT device in incision on basis of aggressive debridement and performed periodic replacement of intra-incisional NPWT until the volume of drainage was less than 50ml every day. All cases showed negative wound bacteria result after the first NPWT and achieved wound closure after 1-3 times of NPWTs. Providing reinfection was occurred, muscle flap could serve as a remedy. Nevertheless, bypass graft was away from NPWT, the NPWT caused bleeding was not observed in our study.
Major adverse event was quadriceps femoris weak in case 5. Although we had carefully protected the femoral nerve, quadriceps femoris weak still appeared. We did not know the situation of muscle before the surgery. We also had no electromyographic evidence to affirm the incomplete nerve injury-related muscle weak. In fact, it cannot exclude disuse-atrophy cause. Finally, strength of quadriceps femoris was restored via rehabilitation.
As a fact, there are several limitations in this study. Firstly, CT angiographies were not routinely performed in all patients at last visit, as the patients concerned about the radiation hazard, thus long-term durability were not well evaluated postoperatively. Secondly, this is a retrospective study. Recall bias probably existed. Thirdly, the study had only 5 patients. Thereby, the power of conclusions is limited. In all, the reliable outcomes need to be further validated in well-designed study with larger populations.