Pedicled Muscle Flaps in the Management of Infected Aortofemoral Grafts

Graft infection, although uncommon, is a serious complication of reconstructive vascular surgery, associated with a high mortality and limb loss in a large percentage of the survivors. Although débridement and drainage, specific systemic antibiotics, removal of the entire infected graft and revascularization by extra-anatomic bypass are the general principles of management, this technique has its limitations and in certain circumstances is not feasible. The use of well-vascularized autogenous tissue as coverage of infected grafts has been successful in the lower extremities, with graft and limb salvage, but not when the infection extends above the inguinal ligament. Instances where the infection at the inguinal area extends retrograde along the limb of the aortofemoral graft represent a greater therapeutic challenge. In two instances, a dual muscle flap was used successfully to cover the exposed prosthesis after complete débridement of the perigraft granulation tissue. Sartorius and rectus femoris muscles, with their blood supply, were mobilized and rotated to cover the distal anastomosis and the retroperitoneally exposed graft respectively, with primary wound closure. All flaps survived and the patent grafts were salvaged. There was no long-term functional deficit from the transposition of these muscles. Pedicled muscle flaps appear to be a well-tolerated method of achieving autogenous tissue coverage of an infected graft in the groin, and retroperitoneal portions and should be considered a satisfactory alternative when the traditional methods of management cannot be applied.