Question

A patient underwent right side above knee femoro-popliteal graft using ePTFE graft for acute on chronic limb ischemia as an emergency procedure 6 months ago. He now reports with functioning graft and a discharging groin sinus. Discuss the various options of management.

Hint:

In cases of groin sinus formation after graft surgery, early identification and management of infections, along with regular monitoring of graft patency, are key to preventing severe complications.

Answer 1

Step 1: Introduction
This patient has a history of right side above-knee femoro-popliteal graft using an ePTFE graft for acute on chronic limb ischemia. Six months post-surgery, the patient presents with a functioning graft but also has a discharging groin sinus. A groin sinus may suggest an infection or graft-related complication, requiring a systematic approach to diagnosis and management.
Step 2: Differential Diagnosis
The possible causes for the discharging groin sinus include:
- Infection of the graft: This could be an infection at the anastomotic site or within the graft itself.
- Graft failure or thrombosis: Even though the graft is functioning, the groin sinus may indicate a developing issue such as thrombosis or poor blood flow.
- Groin sinus due to foreign body response: The synthetic ePTFE graft material may induce a chronic inflammatory response leading to sinus formation.
- Non-healing wound or fistula formation: A fistula or non-healing wound may form after surgery, leading to a discharge.

Step 3: Investigation and Diagnosis
To confirm the diagnosis and guide treatment, the following investigations are essential: 1. Ultrasound Doppler: This will assess graft patency and detect signs of thrombosis or stenosis at the anastomotic sites.
2. CT Angiography or MRI Angiography: Imaging can help visualize the graft and surrounding tissues to detect infection or anatomical issues.
3. Blood cultures and wound swab: To identify the pathogen and initiate appropriate antibiotic therapy. 4. Serum inflammatory markers: Such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), to assess for infection.

Step 4: Management Options
The management of this patient will depend on the findings from the investigations. The following management strategies are considered: 1. Antibiotic Therapy:
- If an infection is confirmed, broad-spectrum intravenous antibiotics should be started empirically, with adjustments based on culture results.
- Common antibiotics for vascular graft infections include cephalosporins or vancomycin for Gram-positive infections.
2. Surgical Intervention:
- Debridement: If the infection is localized to the graft or surrounding tissue, surgical debridement of the infected tissue may be necessary.
- Graft Replacement or Revision: If the graft is infected or thrombosed, it may need to be removed and replaced with either a new synthetic graft or a biological graft. Autologous vein grafts may also be considered.
3. Wound Care:
- The discharging groin sinus should be properly managed with regular dressing changes to prevent further contamination and promote healing.
- If the sinus is due to non-healing tissue or drainage, compressive dressings or negative pressure wound therapy (NPWT) may be beneficial.
4. Follow-Up:
- Doppler Ultrasound: To monitor graft patency and ensure there is no further infection or occlusion.
- Blood Pressure and Lipid Management: Ensuring that the patient maintains good control of cardiovascular risk factors is essential to prevent graft failure.
5. Lifestyle Modifications:
- Smoking Cessation: Smoking is a major risk factor for vascular complications, so advising the patient to stop smoking is critical.
- Diet and Exercise: To reduce further cardiovascular risk factors and improve overall health.
Step 5: Conclusion
Timely diagnosis and prompt treatment are essential in preventing further complications and ensuring the longevity of the graft. A comprehensive approach that includes antibiotics, surgical intervention if necessary, and long-term monitoring will lead to better outcomes for this patient.