Salvage of an Exposed Axillo-profunda Bypass Graft and Discussion of Reconstructive Options on the Torso.

INTRODUCTION: A case of salvage of an exposed axillo-profunda bypass graft is presented. REPORT: Robust coverage of the graft was achieved with a pedicled latissimus dorsi muscle flap and overlying bi-pedicled cutaneous flap. DISCUSSION: Reconstructive options to salvage an exposed prosthetic graft will depend on the position on the trunk but can be successful if a reconstructive plastic surgery algorithm is followed. The options are discussed within this report. Exposed axillo-profunda graft can be salvaged successfully through a variety of reconstructive techniques. Close cooperation between vascular and plastic surgeons is vital for a successful outcome.

Introduction

A 65 year old man was referred with an exposed axillo-profunda bypass graft (Dacron) at the level of the ribs 8–10 on the right antero-lateral chest wall. The graft had been inserted uneventfully in a subcutaneous tunnel 15 months previously. Replacement of the graft was not an option and the patient was at risk of an above knee amputation. Exposure of the armoured graft was thought to be due to pressure ulceration through the thin subcutaneous layer. The patient was of a low body mass index and suboptimal nutrition; these issues were addressed by dieticians. There was no evidence of microbial infection on culture and the graft remained patent on imaging.

Report

Under general anaesthesia, the wound was debrided and the graft mobilised. A posterior incision created a bi-pedicle flap, which facilitated access to the latissimus dorsi muscle (Fig. 1). The bi-pedicled flap was created by undermining the skin and subcutaneous fat between the two parallel incisions, leaving the tissue attached proximally and distally. This muscle flap was released distally and posteriorly, allowing it to transpose anteriorly based on its insertion and origin of the vascular pedicle in the axilla. This provided robust coverage of the vascular graft, and the bi-pedicled flap ensured tension free primary closure of the wounds (Fig. 2). The donor site was quilted in a standard fashion to minimise the risk of seroma formation.

Figure 1

(A) Incision to harvest latissimus dorsi flap. (B) Bi-pedicled flap. (C) Exposed graft post-debridement.

Figure 2

(A) Donor site closed primarily tension free. (B) Latissimus dorsi flap now in situ covering exposed graft; skin closed primarily tension free.

All wounds were healed within 2 weeks, and the graft remains patent and well covered 6 months post-operatively.

Discussion

While prosthetic vascular graft exposure is well recognised, in the majority of cases this is on the limb, usually as a result of wound breakdown. Muscle flaps such as gracilis, sartorius, rectus femoris, tensor fascia lata, rectus abdominis, external oblique, and gastrocnemius have all been described as reconstructive options for exposed and/or infected lower limb grafts.1, 2, 3, 4, 5, 6 Negative pressure wound therapy has also been shown to be effective in managing an exposed infected vascular prosthesis, and has been used with an artificial dermal matrix (Integra).7, 8

Exposure of an axillo-femoral graft within the truncal region is extremely rare, with only two case reports identified in the literature.9, 10 Reconstructive options to salvage an exposed prosthetic graft will depend on the position on the trunk, but can be successful if a reconstructive plastic surgery algorithm is followed. As has been demonstrated previously, the use of artificial dermal matrices and/or negative pressure dressings may allow sufficient secondary wound healing to support skin grafting, which may be useful in a patient where comorbidities prevent more extensive surgery. Local subcutaneous and fascio-cutaneous flaps may also be successfully elevated to cover exposed grafts. However, in the presence of infection, it is still thought that vascularised muscle flaps are most likely to result in graft salvage.3, 4

In the chest, the options would be a pectoralis major flap, elevated on the thoracoacromial pedicle, latissimus dorsi flap on the thoraco-dorsal pedicle, or the serratus anterior muscle, also on the thoraco-dorsal pedicle. On the lower chest and abdominal wall, the options would include the latissimus dorsi based on either the thoraco-dorsal pedicle or lumbar perforators, proximally or distally based rectus abdominis, external oblique, or tensor fascia lata. An alternative to muscle flaps would be the use of the omentum.

In summary, an exposed axillo-profunda graft can be salvaged successfully through a variety of reconstructive techniques. Close cooperation between vascular and plastic surgeons is vital for a successful outcome.

Conflict of interest

None.

Funding

None.