Total resection of infected peripheral hemodialysis grafts has a favorable impact on outcomes

Ying-Sheng Li, Pin-Chao Feng, Po-Jen Ko, Wen-Cheng Wei, Sheng-Yueh Yu, Tsung-Chi Kao, Chun-Hsien Hsin, Ta-Wei Su
Annals of Vascular Surgery 2020 August 5

AIMS: Surgical resection could be an eradication treatment for patients with infected hemodialysis arteriovenous grafts (AVGs). This study aimed to investigate the outcomes of three surgical methods, including total resection, sub-total resection, and revision.

METHODS: The patients who underwent surgical excision of infected AVGs performed at a single center from August 2012 to March 2019 were retrospectively analyzed. The following three surgical methods were used in our study: revision, sub-total resection, and total resection. Patients' demographics, medical history, perioperative details, reconstruction time, and follow-up data were collected. The outcomes including peri-operative complications (within 30 days), mortality, re-infection rate of AVGs, with new access reconstruction or not, and the outcomes between reconstruction and non-reconstruction in the follow-up period were evaluated.

RESULTS: Forty-one patients had infected AVGs in our study. Patients' mean age was 62 years, and 65.9% of the patients were female. The mean duration from the time of diagnosis to the operation was 14.4 days. Signs and symptoms at presentation included fever (51.2 %), swelling (43.9%), pain (58.5%), erythematous change (92.7%), and more severe features, such as altered consciousness (14.6%) and hypotension (12.2%). The pathological changes in the infected grafts included bleeding (29.3%), pus formation (73.2%), pseudo-aneurysm (26.8%), and graft exposure (17.1%). Wound and graft cultures revealed an infectious etiology with fungi (7.3%), Pseudomonas aeruginosa (12.2%), Enterococcus spp. (2.4%), and Staphylococcus spp. (58.5%), with Methicillin-resistant Staphylococcus aureus accounting for only 7.3%. Total resection, subtotal resection, and revision surgery were performed in 17.1%, 63.4%, and 19.5% of patients, respectively. Seven patients with complications required re-operation (17.1%), and adhesion ileus and hospital-acquired pneumonia occurred in only 2.4% and 7.3% of patients, respectively. During follow-up, most patients (82.9%) had reconstruction of the peripheral hemodialysis access with mean time of 64.3 (range: 21-92) days; mean time of use of new access was 90.5 days; mean time of removal of catheter was about 106.3 days. Mortality rates in patients without and with reconstructed AV access during follow-up were 50% and 18%, respectively (P<.004). Eight cases (19.5%) had recurrence of AV access infections during follow-up; of these, two had revision surgery and six had sub-total resection. However, no patient with total resection had recurrent infections.

CONCLUSIONS: The total resection group had no recurrent infection compared to the sub-total and revision groups. In addition, patients with reconstruction of peripheral hemodialysis access had a low mortality rate during the follow-up period.

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