Case 2
64years old male heavy smoker and Diabetic. Patient had left femoral endarterectomy and iliac angioplasty done in another hospital 4 weeks ago. He presented to your hospital with temperature 38.9 and WCC 19. His groin wound shows area of erythema and fluid discharge.
Q1: How would you approach this case? what are the key factors you need to find out about the previous surgery?
Q2: Please indicate your initial management plan?
Q3: Are you aware of any scoring system for groin infection?
Q4: Could you please describe steps of surgical techniques aiming to preserve the circulation of this limb? what are your options ?
Q(1):
Q(2):
Q(3):
1. CDC Surgical Site Infection (SSI) Criteria:
– Superficial Incisional SSI:
Involves skin/subcutaneous tissue within 30 days, with erythema, pain, or purulence.
– Deep Incisional SSI:
Affects fascia/muscle, often with abscess or dehiscence, within 30 days (or 1 year if a graft is present).
– Organ/Space SSI:
Involves structures deeper than the incision (e.g., vascular graft, artery), presenting with fever, pain, or systemic signs.
2. Szilagyi Classification (Peripheral Arterial Graft Infections):
– Grade I: Superficial infection (skin/subcutaneous tissue), sparing the graft.
– Grade II: Graft involvement without anastomotic disruption.
– Grade III: Anastomotic infection with hemorrhage/pseudoaneurysm.
3. Samson Classification (Aorto-femoral Graft Infections):
– Type I: Graft body infection.
– Type II: Anastomotic infection (e.g., femoral artery).
– Type III: Combined graft body and anastomotic involvement.
4. Timing of Infection:
– Early (<4 weeks): Typically skin flora (Staph-aureus, coagulase-negative staph).
– Late (>4 weeks): Often gram-negative bacteria or polymicrobial.
5. Clinical Severity:
– Mild: Localized cellulitis.
– Moderate: Purulent discharge without systemic signs.
– Severe: Sepsis, graft disruption, or tissue necrosis.
6. Microbiological Classification:
– Mono microbial: Common in early infections.
– Poly microbial: Associated with late or necrotizing infections.
Q(4):
A1 general examination including temp, BP, RR, HR, local wound examination including prescence of wound collection or pulsatile mass ( psuoaneurysm), whether there was serous discharge from the wound , frequency of wound dressing and its isolation from the surrounding skin, onset of redness of wound, antibiotics if taken due to wound infection.
A2 obtaining IV access with saline infusion and baseline labs as cbc, s crt and inr, obtaining a swab from the wound for C and sensitivity. USS on femoral region assessing the presence of flow inside the collection or not.
A 3 ASPESIS score
A4 wound exploration with cross over iliac balloon control if needed.
circulation can be achieved using extra anatomical bypass whether lateral or transobturator
or using fem fem bypass.
Q1- I would like to know about smoking cessation , control of diabetes , whether the patch is synthetic or autogenous , the patient was on good antibiotic coverage pre & post op & wound care post op
Q2- labs : CBC – ESR -CRP-HBA1C
Culture & sensitivity test
Ct angiography
Fluid aspiration from the wound
Q3-Asepsis scoring system
Q4-Exploration of the wound
Irrigation with saline & antibiotic
Debridement of necrotic tissue
Removal of synthetic patch & replacing it by venous patch if not severely infected
If the patch is severely infected , ligate the left femoral and undergo bypass extra anatomical to preserve the limb
I would approqch the case by taking full history from the patient and local examantion of the femoral wound for signs of infection ( erythema,swelling,purlunt discharge ) and assment of its depth and wheter it affectes the graft itself or just perigraft infection, I would ask about hx of bleeding from the graft, systemic examantion for fever >38 or chills and rigors ,
The key factor about the previous surgery is wheter the graft was autogenous or synthetic and if the surgery was pure surgery or hybrid apporach including stenting , and pre + post operative antibiotic prophylaxis
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Q2 the initial managment plan includes getting a microbiological proof of infection by obtaining culture and senstivtiy from the wound
May be US guided aspiration of the fluid if present for bacteriological examantion
CTA would be the 1st imagaing modality to asses the graft and the extention of infection and presence of deep infection (absecess)
Of course I will not forget CBC (looking for TLC), ESR,CRP ,LFT,KFT ,HBA1C (uncontrolled diabetes is an important factor to look for)
I will asses the depth of infection to postulate the plan for treatment whether it needs only debridment or the need for graft removal or negative pressure dressing methods (eg.VAC)
And if it is gaped wound It will need a flap or graft
____________
Q3 yes, I am aware by reading the ESVS guidelines for VGEI
SziÂlagyi, SamÂson classifications
ASEPSIS score
_________________________________
Exploration of the wound , irriagtion of the wound with saline and antibiotic
Extensive debridemtn and removal of necrotic tissue
If the graft itself is infected we will ligate the artery and if the leg become ischemic
We will proceed to iliofemoral or transobturator bypass
Q1: How would you approach this case?
groin examination
taking sample for culture and sentivity
ct angio to assess the patency of iliac artery and to exclude infected pseudoaneurysm
assess the extent of infection ( superficial or extended infected hematoma to the artery )
what are the key factors you need to find out about the previous surgery?
type of patch venous or synthetic
Q2: Please indicate your initial management plan?
hospitalization
culture and sensitivity from the wound
wide spectrum of antibiotics
ct angio
preparation for surgery
Q3: Are you aware of any scoring system for groin infection?
asepsis scoring system
Q4: Could you please describe steps of surgical techniques aiming to preserve the circulation of this limb? what are your options ?
groin exploration , evacuation and debridement of all necrotic tissue
1- removal of synthetic patch and closure of arteriotomy with venous gsv patch
protecting the anastomosis with sartorius flap
2- reconstruction of the trifurcation with cadaveric sfa or gsv
3- extra anatomical transobturator bypass
4-covered stent insertion through contralateral side and debridement and evacuation of infected groin ( but high risk of bleeding and reinfection and sacrifice with the profunda femoris )
A1
I would approach this pt by bundle 6 for sepsis
O2 mask
Insert 2 wide pore cannula
Cbc
Take blood group and culture
Mesure lactate
Give iv AB according to hospital protocol
And monitoring
And resuscitation of pt by fluids
Then
key factors;
History taking and risk factors of patient
-operative details including the type of patch used to close the longitudinal artery incision either autologous or syntheitic or cadaveric.
-Iliac angioplasty, type of balloon used, stent placed and its position.
-Arterial duplex U/S or CTA pre-operative.
-Pattency of CFA and tibial vessels.
……
A2
First I will resuscitation pt and control sebsis
By investigate discharge from wound do superficial US and swab
May aspirated collection by us guided
Or surgically drainage
…….
A3
ASEPSIS score
…….
A4
explanation over patch and do another patch either vein or cadaveric
with sartorial graft coverage
we may need to ligate the artery if it severely infected and do extra anatomical bypass either lateral or transobturator bypass
Q1:
Approach to the Case:
> Full History about the course of the presenting symptoms, and risk factors as diabetes control and current medications
> Examination including vitals of the patient and local wound assessment, also I will check the vascularity of the limb
> Investigations:
Lab: CBC, CRP, blood cultures, renal function, coagulation profile and ABG
also I will obtain wound culture.
Imaging:
Duplex ultrasound to assess vascularity if there is pseudoaneurysm i will order CTA
>> Key factors about the previous surgery:
type of the patch used for closure is it venous or synthetic?
the iliac angioplasty was it only balloon dilatation or stent placement.
Q2:
Resuscitation with IV fluids and monitoring as tge patient maybe in a spetic shock
broad-spectrum antibiotics then according to the culture results, and the investigations i mentioned above
Q3:
actually No, i don’t know
Q4:
If Infection is Superficial I will do wound debridement and irrigation with Vacuum-assisted closure (VAC) later
but if the infection is deep I will do sofg tissue debridement with artery preservation if no signs of catching infection with muscle flap to cover the area of the patch
if the artery is involved I will do ligation and bypass ( if i find the limb is threatened) either trans obturator bypass or Axillary femoral or fem fem if the other femoral is patent with good distal flow
A1 I will manage this patient according to ccrisp protocol
give patient O2 mask
iv fluids
withdraw blood cultures and lactate level and start broad iv antibiotics
take a good history about patient risk factors and the type of angioplasty and patch used
why he had this operation
type of dressing used
since when this discharge started and is it pus or not
is he compliment to his medication and his hygiene level
I will do us assessment for collection
and do duplex and CTA to assess vascularity
A2 according to us assessment
if it is superficial collection no related to the vessels
we may do aspiration to this collection
if it is deep or loculated or related to the vessels then it needs exploration and evacuation
A3 penn groin assessment score
A4 explanation over patch and do another patch either vein or cadaveric
with sartorial graft coverage
we may need to ligate the artery if it severely infected and do extra anatomical bypass either lateral or tranobturator bypass
A1:
Approach the case by admitting the ptn iv antibiotics fluids labs c/s from the discharge may use US to get information about the infected groin and the extent of infection xray for FB CTA for anatomical consideration and planning venous mapping for conduit
taking detailed history about the prev op the indications the procedure type of patch and the post op care dressing antibiotics and the risk factors modification regarding DM control and smoking cessation
A2:
Ptn is in sepsis so admission fluids resuscitation antibiotics cultures and preparation for reintervention
Options could be vein patch redo interposition vein bypass with sartorial flap or extraanatomical transobturator bypass if the anastmosis was disrupted and the froin severly infected
A3: Southampton scoring system foe grading of wound infection
ASEPSIS scoring sys but it is used for cardiac surgery SSI
A4:
vein patch redo interposition vein bypass with sartorial flap or extraanatomical transobturator bypass if the anastmosis was disrupted and the froin severly infected
Q1: Admit patient and resuscitate, and give IV antibiotics
I will need to ask about the operative details, its indications, and the type of patch used in the endarterectomy.
Q2: Admit the patient and monitor him while providing resuscitation, fluids, and cardiac assessment. Ultrasound should be done to assess if there is any collection of fluids, and drainage if applicable. Duplex and possibly CTA should be done to assess leg perfusion.
Q3: ASEPSIS scoring system
Q4: Open surgery and debridement of any infected tissue and assessing the quality of the patch done. If the anastomosis line is fine and patch doesn’t look infected I will leave as is. If anastomotic line looks infected; I will attempt to re-patch with LSV patch if present, and will apply local intra-wound antibiotic before closure. Followed by careful monitoring while giving broad-spectrum antibiotics.
Q(1):
Urgent admission of patient and fluid rescusitiation is done.
key factors;
Pre-operative sepsis control
-use of antibiotics
-operative details including the type of patch used to close the longitudinal skin incision either autologous or syntheitic or cadaveric.
-Iliac angioplasty;;; type of balloon used, stent placed and its position.
-Arterial duplex U/S or CTA pre-operative.
-Pattency of CFA and tibial vessels.
History taking and risk factors of patient.
Q(2):
This patient maybe in septic shock so sepsis six control should be applied:
-urine output
-Adequate oxygenation
-Antibiotics
-Blood and wound culture
-ABG and measurement of Lactate
-Fluids
Blood group and cross matching
Ultrasound to detect the collection and drainage of collection
and to exclude pseudoaneurysm, thromboses or hematoma.
Explration of the wound.
Q(3):
ASEPSIS score
Q(4):
Extra-anatomical bypass as transobturatior approach or muscular flaps may be considered.
Q1:
admit the patient and iv antibiotics started and examination of the surgical site if there is discharge culture was taken
ultrasound to the groin to see the extant of the infection and its relation to the artery if possible
what was the indication of the previous operation the presentation at that time
what was done in the iliac angioplasty ballooning only or stenting also
what has been used to control the arteriotomy venous patch or prosthetic PTFE patch
Q2:
after resuscitation of the patient proceed for controlling the surgical site and drainage
Q3:
Szilagy’s classification Samson’s classification
Q4
good debridment of the infected tissue and if it involve the anastmotic line an In situ GSV used as interposition graft
another option can be ligation and extra anatomical bypass
A1
My approach in this case:
1 resuscitate the patient if needed
2 control sepsis and drainage of abscess if present
3 limb salvage through preserve circulation to the limb and assess tissue loss if present or foot infection
4 control modifiable risk for CLTI and modifiable risk for groin infection
The key factors from previous surgery:
1 indication of revascularization and presence of distal disease or not
2 what type of iliac angioplast done and if there is iliac stent or not with its position in common or external iliac
3 femoral endarterctomy with vein patch or synthetic and if there is profundoplasty done or not
4 the preexisting risk factors for groin infection like uncontrolled blood sugar, hospital stay, operation time, had prophylactic antibiotic prior surgery, sepsis, operation done as emergency, icu admission
5 available perioperative arterial duplex or CTA
A2
1 assess the patient if the patient in septic shock and go for abc resuscitation and initiate icu admission . Collect labs for cbc (Hb, platelets ), kidney function test LFTs, coagulation profile, ABG. Swap culture and sensitivity from discharged fluid and send fluid sample to assess wbcs and bacteria, septic work up like blood culture.
2 assess general condition of the patient like cardiac assessment, book blood derviatives if needed
3 assess the vascularity of the affected limb and if there is rest pain or tissue loss, go for CTA if needed
4 assess the groin using superficial ultrasound if there is a collection (deep or superficial and its extent) and exclude pseudoaneurysm, then prepare for exploration of the wound and intervention
A3
Penn groin assessment score (0 to 7) was devised: obesity, for a value of 1; smoking, 2; reoperation for open groin surgery, 2; and prosthetic graft material, 2. Patients with higher scores had significantly more complications, infections, and more frequently required secondary salvage flap procedures. John P Fischer, Jonas A Nelson, Jeff I Rohrbach, Liza C Wu, Edward Y Woo, Stephen J Kovach, David W Low, Joseph M Serletti, Suhail Kanchwala.
Prophylactic muscle flaps in vascular surgery: the Penn Groin Assessment. Plast Reconstr Surg. 2012 Jun;129(6):940e-949e. doi: 10.1097/PRS.0b013e31824ecb17
A4
Strategy to preserve peripheral circulation by extranatomical bypass , or endoluminal graft by covered stent
Q1 / Full history, wound progression, systemic symptoms.
Examine wound for erythema, discharge, fluctuance, necrosis.
Check graft type (vein or prosthetic), any perioperative contamination, antibiotics used, and iliac angioplasty details.
Q2 / Admit, monitor vitals, blood cultures, CRP, wound swab.
Start broad-spectrum antibiotics.
Duplex ultrasound, consider CTA if needed.
Wound debridement if indicated
Q3 / not familial to me any scoring system about groin infection.
Q4 / Debridement and irrigation.
Graft salvage for early infection if feasible.
Hi Ahmed
very good answer.
They used vein Patch and it was only angioplasty with no stent
What do you expect US could show you? When would you need CTA?
could you do some search to find a scoring system.
A1..
Depending on the history of femoral end endarterectomy 4 weeks ago, there is now a fever and local signs of inflammation in the operative wound. full lab is required for this patient CBC, ESR, CRP, LFT, KFT, RBS,
superficial probe US to detect any collection
I want to know what type of batch was used saphenous or bovine
is there any stent used during angioplasty or not
A2..
patient admission
starting an immediate course of empirical broad-spectrum antibiotic therapy and IV fluids
culture and sensitivity from the secretions of the wound
preparing the patient for wound exploration and the possibility of debriding any necrotic tissues
and of course, getting tissue culture from infected tissues
A3..
GIVE SSI risk prediction model and the GIVE deep/organ space SSI risk prediction models are used for Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction
A4..
in the setting of infection, extra anatomical trans obturator bypass is a good option to restore limb revascularization
Hi Mahomud,
very good answer,
they used vein patch no stent.
Could you discuss what muscle flaps options for coverage of infected femoral patch?
Sartorial muscle flap is commonly used for coverage
Also rectus muscle flap is an option
Issues in management
1. Delayed Smoking Cessation Intervention
Despite a history of NSTEMI, heavy smoking (cigarettes and cannabis) was not addressed before or after initial intervention By Comprehensive smoking cessation support
2. Suboptimal Preoperative Optimization
Polycythemia (likely secondary to smoking) and other systemic factors were not adequately addressed before surgery Elevated hematocrit increases thrombosis and graft failure risk
And patient is high risk for infection
3. Use of PTFE Graft in a High-Risk Smoker Synthetic grafts (PTFE) have a higher risk of infection, particularly in smokers or those with poor wound healing potential
This increases the likelihood of graft-related complications.
Autologous grafts arm veins should be explored first
If not enough combined PTA+ short native graft
4. Inadequate Postoperative Monitoring:
Early signs of infection missed
5. Cadaveric Graft Use
Cadaveric grafts are not first-line choices Autologous vein grafts should be used firest with beter outcome
Thank you so much Abdulrhamn for your answers. I have updated the case. Please have a go answering the new questions.
After detailed Full lab assessment+ superficial US to assessment infection and it’s relation to artery and if there is any anastomotic or patches ruptured
Duplex us for saphenous viens assessment
Start empirical ab+ culture and sensitivity for further ab regime
Surgical exploration+debridement of infected tissues debridement of infected patches and arterial wall till clean area+ interposition veins graft By long saphenous after good irrigation of the Wound+ Wound closure by sartorial muscles falb
Superficial
Deep
Infection involving Graft Graft
Thank You Abdelraheem,
Can you expand on limitation of US in the case of groin infection assessment.
.