Outcomes of Early and Late Muscle Flap Salvage of Complicated Lower Extremity Vascular Grafts

Abstract

Introduction:

Muscle flaps are commonly used to protect high-risk vascular grafts in the lower extremities. This study aimed to identify differences between early and late salvage procedures.

Methods:

Patients undergoing lower extremity vascular reconstruction with muscle flap coverage at a tertiary medical center from 2017 to 2023 were identified. Data included demographics, procedure details, and complications. The study compared early (placed at index or ≤7 d after vascular surgical procedure) versus delayed (>7 d) flap inset. Primary outcomes included rates of infection, hematoma, seroma, necrosis, wound dehiscence, flap failure, and patency of the vascular repair. Secondary outcomes included culture results from the surgical site.

Results:

Eighty-one patients met inclusion criteria. Early flaps were inset in 53% of cases, and 47% were delayed. Sartorius flaps were most common (53%), followed by gracilis flaps (37%). The indication for flap coverage significantly varied between immediate and delayed flaps (p = 0.004), with immediate more commonly placed for tissue coverage (37%) and delayed inset to address infection (68%). Flap survival (86.1% vs. 76.3%, p = 0.261) and graft patency (74.4% vs. 68.4%, p = 0.55) were similar between groups. Rates of infection, seroma, hematoma, and wound dehiscence did not differ significantly. Regression analysis did not find associated factors with complication incidence. Enterobacter infections were more common in the delayed group (15.8% vs. 2.3%, p = 0.031).

Conclusion:

This study showed no difference in outcomes between immediate and delayed muscle flaps placed over vascular grafts. Delayed procedures show a greater prevalence of certain bacteria in delayed flaps.

Lower extremity revascularization surgeries, including endarterectomies and bypasses, are vital to restore vascularization and arterial patency in patients with critical limb ischemia. Complications associated with these surgical procedures include hematomas (22%), infections (52%), thrombosis (7.5%), lymphatic leaks (8%), and wound breakdown (36%).^1–4 Notably, a history of hypertension (HTN), diabetes mellitus, smoking, and renal insufficiency predisposes individuals to greater complication rates.⁵ In an effort to mitigate risks, muscle flaps provide coverage for vascular grafts. By reducing dead space, enhancing oxygenation, and lowering microbial counts at the wound site, muscle flaps substantially decrease the incidence of complications.^4,6 Studies have demonstrated that compared with layered closures, muscle flap utilization substantially reduces the need for operative interventions following wound breakdown, consequently improving patient outcomes.⁷

Integrating muscle flaps into surgical protocols has demonstrated substantial benefits, including reduced amputation and mortality rates.^8,9 Notably, muscle flaps have become indispensable in managing oncologic or traumatic defects because of their capacity to cover large soft tissue defects, exposed bone, and critical structures.^8,9 In the context of lower limb revascularization, muscle flaps are commonly inserted in the groin area, where the selection of the appropriate flap depends on factors such as size, flexibility, and rotational ability of the flaps.¹⁰ The most frequently used muscles for covering the wound bed include the sartorius, rectus femoris, rectus abdominis, and gracilis muscles.¹¹

Despite the well-documented efficacy of muscle flap usage following vascular reconstruction, the significance of timing for graft coverage of vascular grafts remains to be explored. This study aims to investigate the trends of muscle flap utilization following vascular reconstruction, compare the incidence of complications associated with immediate versus delayed flap insertion, and elucidate the microbiologic differences between each timing tactic.

Patients and Methods

Study approval was obtained from the Institutional Review Board at Vanderbilt University Medical Center. The study consists of a retrospective cohort analysis of patients undergoing lower extremity revascularizations, including bypasses and endarterectomies of lower extremity arteries. Patients were included in the study if they had a muscle flap covering the reconstructed vasculature. Procedures performed between 2017 and 2023 were included. A waiver of patient consent was obtained as the study posed a limited risk to patient confidentiality, and patient care would be unaffected by the study results.

Data collected from the medical record included patient demographics, procedure details, graft and flap specifics, and post-flap complications. This study compared with the outcomes of flap insertion timing, defined as early if placed at the index procedure or within 7 days of vascular surgery, versus delayed flap procedures, defined as beyond 7 days from flap vascular surgery. The primary outcome is the occurrence of a complication, which includes infection, hematoma, seroma, necrosis, wound dehiscence, and flap failure, defined as an unsuccessful flap that required replacement. Secondary outcomes include the results of microbial culture in the surgical site at the time of flap coverage. The data were extracted from operative notes, daily progress notes, history, physical examination during admission, and discharge summaries.

Statistical analysis

Categoric variables were reported as frequencies and percentages, and data analysis was conducted using a Chi-squared test. Continuous variables were reported as the median and interquartile range (IQR), and their analysis was conducted using a Mann–Whitney U test. A multi-variable logistic regression model was used to identify the factors associated with the occurrence of complications. Statistical analysis was performed using Stata version 16.0 (StataCorp, College Station, TX), with significance defined as a two-tailed p value <0.05.

Results

Demographics

A total of 81 patients were included in the study, with 43 patients in the early flap group and 38 patients in the delayed flap group. The median age of the entire cohort was 66 years (IQR 55–71), with a median age of 62 years (IQR 55–71) in the early flap group and 66.5 years (IQR 55–71) in the delayed flap group (p = 0.7582). The gender distribution was 45.7% female and 54.3% male overall, with 48.8% female in the early flap group and 42.1% in the delayed flap group (p = 0.544). The median Body Mass Index (BMI) was 27.5 (IQR 23–33.4) with no significant difference between the groups (early flap: 28.4, IQR 23.6–34.8; delayed flap: 26.4, IQR 21–32) (Table 1).

Table 1.

Demographics and Comorbidities

	Total flap (N = 81)	Early flap (N = 43)	Delayed flap (N = 38)	p
Median age (IQR)	66 (55–71)	62 (55–71)	66.5 (55–71)	0.7582
Gender				0.544
Female	37 (45.7%)	21 (48.8%)	16 (42.1%)
Male	44 (54.3%)	22 (51.2%)	22 (57.9%)
Median BMI (IQR)	27.5 (23–33.4)	28.4 (23.6–34.8)	26.4 (21–32)
Diabetes mellitus	36 (44.4%)	17 (39.5%)	19 (50%)	0.344
Dyslipidemia	51 (63.0%)	26 (60.5%)	25 (65.8%)	0.62
Coronary artery disease	43 (53.1%)	21 (48.8%)	22 (57.9%)	0.415
HTN	64 (79.0%)	31 (73.1%)	33 (86.8%)	0.104
VTE	35 (43.2%)	19 (44.1%)	16 (42.0%)	0.246
Patient in a hypercoagulable state taking antiplatelet or anticoagulation	39 (48.2%)	16 (42.1%)	23 (53.5%)	0.306
Smoking status				0.189
Never	19 (23.4%)	13 (30.2%)	6 (15.8%)
Former	27 (33.3%)	15 (34.9%)	12 (31.6%)
Current	35 (43.2%)	15 (34.9%)	20 (52.6%)
Radiation to area of vascular procedure	13 (16.1%)	11 (25.6%)	2 (5.3%)	0.013
Any lymph node dissection to the area	9 (11.1%)	8 (18.6%)	1 (2.6%)	0.022

Bolded p value if <0.05.

IQR = interquartile range; HTN = hypertension; VTE = venous thromboembolism.

Comorbidities

The prevalence of diabetes mellitus was 44.4% overall, dyslipidemia was present in 63.0% of the cohort, and coronary artery disease was observed in 53.1% of patients. Hypertension was noted in 79.0% of the cohort, and venous thromboembolism was reported in 43.2% (early flap: 44.1%, delayed flap: 42.0%, p = 0.246). Patients taking antiplatelet or anticoagulant medication comprised 48.2% of the cohort. There was no significant difference in the prevalence of these comorbidities between the two groups (all p < 0.05). Smoking status did not differ significantly between the groups (never smokers: 23.4%, former smokers: 33.3%, current smokers: 43.2%; p = 0.189). Radiation to the area of the vascular procedure was significantly more common in the early flap group (25.6% vs. 5.3%, p = 0.013), as was any lymph node dissection to the area (18.6% vs. 2.6%, p = 0.022) (Table 1).

Operation specifics

The most common vascular procedures performed in the entire cohort were femoral-popliteal bypass (32.1%), aortofemoral bypass (14.8%), femoral–femoral bypass (13.6%), and femoral endarterectomy (11.1%). The distribution of vascular procedures between the early flap and delayed flap groups was significantly different (p = 0.037). In the early flap group, the most common procedures were the femoral–popliteal bypass (34.9%), the femoral–femoral bypass (11.6%), the femoral patch angioplasty (11.6%), the aortofemoral bypass (7.0%), and the external iliac-superficial femoral artery bypass (7.0%). In contrast, in the delayed flap group, the most common procedures were femoral–popliteal bypass (28.9%), aortofemoral (26.3%), femoral endarterectomy (18.4%), and femoral–femoral bypass (18.4%). (Table 2)

Table 2.

Surgical Reconstruction Type and Indication

Type of vascular reconstruction	Total Flap (N = 81)	Early Flap (N = 43)	Delayed Flap (N = 38)	0.037
Femoral–popliteal bypass	26 (32.1%)	15 (34.9%)	11 (28.9%)
Aortofemoral bypass	12 (14.8%)	2 (46.0%)	10 (26.3%)
Femoral endarterectomy	9 (11.1%)	2 (4.7%)	7 (18.4%)
Femoral–femoral bypass	11 (13.6%)	5 (11.6%)	7 (18.4%)
Ilio-profunda bypass	1 (1.2%)	0 (0.0%)	1 (2.6%)
Femoral patch angioplasty	6 (7.4%)	5 (11.6%)	1 (2.6%)
Femoral-anterior tibial bypass	2 (2.5%)	2 (4.7%)	0 (0.0%)
Femoral-profunda bypass	1 (1.2%)	1 (2.3%)	0 (0.0%)
Femoral-posterior tibial bypass	2 (2.5%)	2 (4.7%)	0 (0.0%)
External iliac—superficial femoral artery bypass	3 (3.7%)	3 (7.0%)	0 (0.0%)
Axillary-femoral artery bypass	3 (3.7%)	2 (4.7%)	1 (2.6%)
Ilio-femoral artery bypass	3 (3.7%)	1 (2.3%)	0 (0.0%)
Aorto-bifemoral bypass	1 (1.2%)	2 (2.3%)	1 (2.6%)
Iliac-popliteal bypass	1 (1.2%)	3 (2.3%)	2 (5.3%)
Type of vascular graft				0.486
Prosthetic	38 (46.9%)	18 (41.9%)	20 (52.6%)
Autologous	39 (48.2%)	22 (51.2%)	17 (44.7%)
Human donor	4 (4.9%)	3 (7.0%)	1 (2.6%)
Reconstruction laterality				0.599
Unilateral	79 (97.5%)	41 (95.4%)	38 (100%)
Bilateral	20 (2.5%)	2 (4.7%)	0 (0.0%)
Flap type				0.607
Gracilis	30 (37.0%)	16 (37.2%)	14 (36.8%)
Sartorius	43 (53.1%)	23 (53.5%)	20 (52.6%)
Gluteal myocutaneous	4 (9.30%)	2 (5.3%)	6 (7.4%)
Rectus abdominis	0 (0.0%)	1 (2.6%)	1 (1.3%)
Rectus femoris	0 (0.0%)	1 (2.6%)	1 (1.3%)
Timing of the wound closure after the flap surgery				0.035
Immediate	43 (53.1%)	29 (67.4%)	14 (36.8%)
Delayed using wound vacuum-assited closure (VAC)	38 (46.9%)	14 (32.6%)	24 (63.2%)
Reason for flap				0.004
Infection	42 (51.8%)	16 (37.2%)	26 (68.4%)
Prophylactic tissue coverage	31 (38.3%)	24 (55.8%)	7 (18.4%)
Hematoma or graft leak	6 (6.2%)	1 (2.3%)	4 (10.5%)
Seroma	3 (3.7%)	2 (4.7%)	1 (2.6%)

Bolded p value if <0.05.

Prosthetic vascular grafts (including bovine pericardial patches) were used in 46.9% of cases, autologous grafts in 48.2%, and human donor grafts in 4.9% (p = 0.486). Muscle flap insertions were unilateral in 97.5% of cases and bilateral in 2.5% of cases (p = 0.599). The most common muscle flaps used were sartorius (53.1%) and gracilis (37.0%), with no significant difference between groups (p = 0.607). Wound closure timing was immediate primary closure in 53.1% of cases and delayed with the usage of a wound VAC in 46.9% of cases, with significant differences between groups (early flap: 67.4% immediate, delayed flap: 36.8% immediate; p = 0.035) (Table 2).

The primary reasons for flap insertion across the entire cohort included infection (51.8%), prophylactic tissue coverage (38.3%), hematoma or graft leak (6.2%), and seroma (3.7%). All flaps placed for infection were inset over well-incorporated grafts and did not require removal and vein autografting. The distribution of reasons for flap insertion between the early flap and delayed flap groups was significantly different (p = 0.004). In the early flap group, the most common reasons for flap insertion were prophylactic tissue coverage (55.8%), followed by infection (37.2%), seroma (4.7%), and hematoma or graft leak (2.3%). Conversely, in the delayed flap group, the most common reasons were infection (68.4%), followed by prophylactic tissue coverage (18.4%), hematoma or graft leak (10.5%), and seroma (2.6%) (Table 2).

Microbial cultures

Microbial cultures taken at the time of flap insertion revealed varying rates of microbial detection between the two groups. Patients who received delayed flaps were diagnosed on the basis of clinical symptomatology and brought to the operating suite for washout and collection of definitive cultures. Staphylococcus aureus was present in 11.1% of cases overall, with 7.0% in the early flap group and 15.8% in the delayed flap group (p = 0.208). Methicillin-resistant S. aureus was found in 6.2% of cases overall, with 7.0% in the early flap group and 5.3% in the delayed flap group (p = 0.749). Any Streptococcus species were found in 7.4% of cases overall, with 9.3% in the early flap group and 5.3% in the delayed flap group (p = 0.488). Enterococcus species were present in 11.1% of cases overall, with 4.7% in the early flap group and 18.4% in the delayed flap group (p = 0.049). Pseudomonas aeruginosa was detected in 9.9% of cases overall, with 14.0% in the early flap group and 5.3% in the delayed flap group (p = 0.191). Escherichia coli was detected in 3.7% of cases overall, with 4.7% in the early flap group and 2.6% in the delayed flap group (p = 0.631). Enterobacter was found in 8.6% of cases overall, with 2.3% in the early flap group and 15.8% in the delayed flap group (p = 0.031). Candida was detected in 9.9% of cases overall, with 9.3% in the early flap group and 10.5% in the delayed flap group (p = 0.854). Other organisms were detected in 14.8% of cases overall, with 14.0% in the early flap group and 15.8% in the delayed flap group (p = 0.816). Overall, there was no significant difference in microbial detection rates between the early and delayed flap groups, except for Enterobacter and Enterococcus species, with greater rates in the delayed flap group (Table 3).

Table 3.

Microbial Cultures

Culture growth	Total (N = 81)	Early flap (N = 43)	Delayed flap (N = 38)	p
Candida	8 (9.9%)	4 (9.3%)	4 (10.5%)	0.854
Enterobacter	7 (8.6%)	1 (2.3%)	6 (15.8%)	0.031
Pseudomonas	8 (9.9%)	6 (14.0%)	2 (5.3%)	0.191
Enterococcus	9 (11.1%)	2 (4.7%)	7 (18.4%)	0.049
Any Streptococcus	6 (7.4%)	4 (9.3%)	2 (5.3%)	0.488
Escherichia coli	3 (3.7%)	4 (4.7%)	1 (2.6%)	0.631
Methicillin-resistant Staphylococcus aureus (MRSA)	5 (6.2%)	3 (7.0%)	2 (5.3%)	0.749
Staphylococcus aureus	9 (11.1%)	3 (7.0%)	6 (15.8%)	0.208
Other	12 (14.8%)	6 (14.0%)	6 (15.8%)	0.816

Bolded p value if <0.05.

Outcomes

Overall, 28.4% of patients with a muscle flap placed required an additional revision revascularizing procedure in the same location as the index procedure (early flap: 25.6%, delayed flap: 31.6%, p = 0.55). The amputation rate following flap placement was 18.5% overall (early flap: 14.0%, delayed flap: 23.7%, p = 0.261). A total of 58 vascular grafts were salvaged with no significant difference between groups (74.4% vs. 68.4%, p = 0.55). Flap survival was greater in early flaps, but this difference did not reach significance (86.1% vs. 76.3%, p = 0.261) (Table 4). Four patients whose flap failed required revascularization revision of their index procedure compared with 11 patients with failed flaps who did not require revascularization revision.

Table 4.

Revascularization Outcomes

	Total (N = 81)	Early flap (N = 43)	Delayed flap (N = 38)	p
Revascularization after flap	23 (28.4%)	11 (25.6%)	12 (31.6%)	0.55
Vascular grafts salvaged	58 (71.6%)	32 (74.4%)	26 (68.4%)	0.55
Flap survival	66 (81.5%)	37 (86.1%)	29 (76.3%)	0.261
Amputation after flap	15 (18.5%)	6 (14.0%)	9 (23.7%)	0.261

Bolded p value if <0.05.

Complications

The overall complication rate was 44.4% (early flap: 48.8%, delayed flap: 39.5%, p = 0.292). Infection occurred in 27.2% of cases (early flap: 27.9%, delayed flap: 26.3%, p = 0.872). Flap failure was rare, occurring in 1.2% of cases (early flap: 2.3%, delayed flap: 0%, p = 0.344). Hematoma was noted in 4.9% of cases (early flap: 4.7%, delayed flap: 5.3%, p = 0.899), necrosis in 2.5% (early flap: 0%, delayed flap: 5.3%, p = 0.128), and wound dehiscence in 8.6% (early flap: 14.0%, delayed flap: 2.6%, p = 0.07) (Table 5).

Table 5.

Complications

COMPLICATIONS	Total (N = 81)	Early flap (N = 43)	Delayed flap (N = 38)	p
Any complication	36 (44.4%)	21 (48.8%)	15 (39.5%)	0.292
Infection	22 (27.2%)	12 (27.9%)	10 (26.3%)	0.872
Flap failure	1 (1.2%)	1 (2.3%)	0 (0.0%)	0.344
Hematoma	4 (4.9%)	2 (4.7%)	2 (5.3%)	0.899
Necrosis	2 (2.5%)	0 (0.0%)	2 (5.3%)	0.128
Wound dehiscence	7 (8.6%)	6 (14.0%)	1 (2.6%)	0.07

Bolded p value if <0.05.

Regression analysis was performed to evaluate the impact of various factors on the occurrence of complications. The odds ratio for the delayed flap compared with the early flap was 1.0 (95% CI: 0.28–3.59, p = 0.996). Other parameters included in the model were age, BMI, diabetes mellitus, flap type, gender, HTN, history of radiation to the area, smoking status, type of vascular procedure, type of vascular graft, immediate wound closure, and indication for flap.

Discussion

Muscle flaps for coverage of compromised vascular grafts in the groin address the three most important underlying issues related to the wound bed in which they are placed, namely: tissue deficits, poor vascularization, and high localized microbial count.^6,12,13 The use of pedicled flaps and free tissue transfer for these purposes are well-documented in the literature. Reconstructive options have been described as a means to cover compromised tissue from acute and chronic infections.¹⁴ However, the present study sought to specifically examine the characteristics of muscle flaps used to cover vascular grafts and compare the complications and causative microbial agents associated with early flap inset compared with delayed coverage.

In our cohort, complication rates were consistent regardless of flap timing. In fact, complications, including infection, flap failure, hematoma, necrosis, and wound dehiscence, did not differ significantly when the flap was inset within seven days of vascular graft placement compared with later intervention. Earlier flaps were more likely to be placed for infection prophylaxis, whereas later flaps were more likely to be placed to address an infected graft site by providing micro-circulatory support and oxygenation.¹⁵ These results suggest that early flap placement does not necessarily reduce complication rates, but infection in the immediate post-operative period is a serious concern. Patients who received early flaps in the present study were also more likely to have undergone radiation therapy and lymph node dissection, which generally predispose patients to greater rates of local infection.¹⁶ Our results suggest that preemptive placement of a flap may benefit patients who have undergone this type of therapy. Patients undergoing lower extremity revascularization are often poor operative candidates and are unable to tolerate additional operative time and donor site morbidity from local pedicled flap procedures.¹⁷ Operative candidacy must be balanced against reported risk reduction of vascular graft infection, subsequent amputation, and mortality when flaps can be safely placed earlier.^8,9 Surgeons should tailor their approach on the basis of individual patient characteristics with a preference to perform pedicled flap coverage earlier in patients who can safely tolerate the procedure and may be at increased risk of infection.

Radiation creates fibrosis and tissue distortion and impairs immune function and wound healing in affected sites.^18,19 Radiated wounds tend to exhibit greater rates of necrosis and infection than healthy tissues.²⁰ However, patients in the present study who underwent local radiation did not have an increased incidence of complications. In addition, lymph node dissection is often associated with greater rates of complications, especially seromas, but did not significantly affect our cohort.²¹ Tissue quality is a central concern and may directly affect flap choice in the region; however, our findings suggest that flap viability in patients who underwent radiation or lymph node dissection is independent of those interventions.

Flap choice did not differ significantly between early and late coverage groups, with sartorius being the most used local flap in both. Pedicled flap design is guided by recipient site size, availability of tissue, viability and reach of the pedicle, and donor site morbidity, all of which can be effectively tailored with a sartorius flap making it an attractive option.²² Its proximity, mild alteration of lower extremity function, and segmental blood supply make this flap a good candidate for patients with exposed or infected vascular grafts. Gracilis flaps, gluteal myocutaneous flaps, rectus abdominis, and rectus femoris flaps were also used in the present cohort. Gracilis flaps have been shown to have excellent outcomes when used to cover infected soft tissue in proximity to vascular grafts, especially in patients with smaller sartorius muscles that might not offer optimal coverage. These flaps require a more extensive harvest, which should be considered in pre-operative planning.²³ Gluteal myocutaneous flaps offer larger skin paddles and are workhorses in sacral ulcer reconstruction.²⁴ However, they create a greater tension donor site in patients with vascular insufficiency who may have worse wound healing capability and require a long pedicle to reach the defects created from vascular graft intervention in the groin. Pedicled rectus abdominis flaps on the basis of the inferior epigastric circulation can be reliably turned to cover vascular grafts, but create a morbid donor site and greatly increase the risk of hernia and abdominal insufficiency.²⁵ The rectus femoris can also be used for reliable pedicled flap coverage but causes substantial donor site morbidity in patients who are already at risk of having ambulatory limitations secondary to peripheral artery disease.²⁶ Flap choice is guided by the size of the defect, availability of viable tissue, feasibility, and donor site morbidity, which are unique to each patient. The senior author prefers to mobilize the sartorius when available and use the gracilis as a second-line reconstruction when appropriate. When neither flap is a viable option, the alternatives described above should be considered.

Graft material composition did not significantly impact flap complications when comparing prosthetic, autologous, and allografted repairs. Saphenous vein autografts are preferred for lower extremity revascularization.²⁷ The present study includes a wide variety of reconstructions that range from axillary-to-femoral bypass to focal endarterectomies. Our analysis suggests that although vascular outcomes between grafts may differ, flap complications may be independent of the material of the graft being placed. In addition, the need for additional revascularization and amputation had similar rates between early and late flap placement. Although positive outcomes have been demonstrated from covering threatened grafts with muscle flaps, our findings suggest that earlier flap placement may not improve patency, but does not negatively affect the graft.²⁸

Staphylococcal species are the most common infectious etiology of threatened vascular grafts, with less common gram-negative infections being feared for their tendency to destroy vessel walls.^29–31 Causative infectious microbes and the presence of polymicrobial infection did not differ significantly between groups receiving early or late flap coverage for infection. Given that revascularization and limb salvage were similar between these groups, bacterial virulence likely did not play a role in graft or flap outcomes in the present cohort.

The present study is limited by its relatively small sample size, the inclusion of operations performed by multiple providers across plastic and vascular surgery, and the heterogeneity of the vascular and flap reconstructions analyzed. Although the sample size in our study is small, it was still sufficient to detect noticeable differences in outcomes. A larger sample size, specifically including 98 participants, would be required to identify additional differences, per our power analysis. Nonetheless, this study represents the first investigation to specifically examine differences in muscle flap outcomes and associated infectious organisms in this unique patient population. Detailed operative reports and patient histories facilitated accurate data collection, offering valuable insights that are often challenging to obtain from large, publicly available databases.³² Although these limitations decrease the direct applicability of our results, our findings provide a strong foundation for further research and future meta-analyses and provide valuable insight into the proper management of this complex patient population.

Conclusion

This single-center investigation highlights the trends and outcomes of muscle flaps used to protect compromised vascular grafts. Our analysis compares the incidence of complications associated with immediate versus delayed muscle flap inset following lower extremity vascular reconstruction. These findings suggest that both immediate and delayed flap strategies have comparable complication rates and similar outcomes. Notably, delayed procedures are associated with a greater prevalence of certain bacterial species. Further studies are needed to explore this observation in greater depth and tailor antibiotic agent selection to a broader or more targeted approach to reduce the risk of surgical site infection in this patient population.

Footnotes

Authors’ Contributions

M.S., A.J., Z.A., and W.C.L.: Study conception and design; M.S., A.J., M.W., and H.I.: Acquisition of data; M.S., A.J., and W.C.L.: Analysis and interpretation of data; M.S., A.J., M.W., W.C.L., and Z.A.: Drafting of manuscript; M.S., A.J., W.C.L., Z.A., and H.I.: Critical revision.

Author Disclosure Statement

No interests to disclose.

Funding Information

No funding was received for conducting this study.

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