Limb-threatening ischemia complicated by perigenicular infection

When graft infection or infection of the medial leg or popliteal fossa precludes a standard approach to revascularization of the ischemic leg, the literature suggests amputation may be the most prudent course because of excessive perioperative mortality and morbidity of attempts to reestablish axial flow. The purpose of this study is to define the outcome of revascularization when limb-threatening ischemia is complicated by perigenicular infection. Of 1020 infrainguinal reconstructions performed since 1984, nine (0.9%) presented with limb-threatening ischemia and graft or wound infections involving the popliteal fossa (6) or medial thigh or calf wounds (3) which precluded standard revascularization in the five women and four men. Risk factors for infection included diabetes mellitus (5/9), wound hematoma at initial operation (2/9), and intravenous drug abuse (1/9); Staphylococcus aureus was the predominant organism in all infected wounds and two popliteal fossa infections. The other deep infections grew group D streptococci, Enterococcus, and Salmonella. Extraanatomic reconstruction was performed from the femoral (7) and iliac vessels (2) extending to the below-knee popliteal (2), the anterior tibial (4) and the peroneal (3) arteries using vein (5), and PTFE (4) in a lateral tunnel which avoiding the plane of the infection. Postoperative complications included MI (1), early graft thrombosis (2), and osteomyelitus of the femur (1); there were no deaths. With a mean follow-up of 19 months (3-57 months), primary graft patency was 66% and secondary patency was 78%, resulting in salvage of 66% of extremities at risk. These data demonstrate the safety and efficacy of extraanatomic reconstruction for maintaining axial flow when limb-threatening ischemia is complicated by perigenicular infection. We recommend an aggressive approach to this problem.