Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin

From the Society for Clinical Vascular Surgery

Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin

Ahsan T. Ali, MD,^a Mario Rueda, MD,^b Sarasijhaa Desikan, MD,^a Mohammed M. Moursi, MD,^a Ruosu An, MD,^a Horace Spencer, MS,^a Steven Rueda, MD,^c and John F. Eidt, MD,^d Little Rock, Ark; Baltimore, Md; Cleveland, Ohio; and Dallas, Tex

Objective: Multiple catheterizations and procedures on the femoral arteries can increase the risk of infection and eventual destruction of the overlying skin and subcutaneous tissue. Without adequate tissue coverage, vascular structures are exposed and, thus, vulnerable to disruption. This can lead to loss of limb and/or life and carries a significant mortality. We hypothesized that gracilis muscle flap (GMF) was a reliable adjunct in providing healthy tissue coverage for a complex surgical problem.

Methods: Retrospective review of charts was performed on all patients who had undergone GMF for groin infections at a tertiary care medical center.

Results: From 1997 to 2012, GMF was performed in 68 limbs (64 patients) by vascular surgeons for infectious etiology to cover the common femoral artery. At the time the GMF was placed, the femoral artery had synthetic graft/patch in 14 limbs, whereas 54 limbs had procedures with autologous conduit. Complete healing was achieved in 58 (85%) limbs. Treatment was deemed not successful in 10 limbs where patients continued to have persistent infection. Six out of 10 limbs had anastomosis disruption requiring emergent ligation of the common femoral artery. Nine patients died during the perioperative period (30-day). There were a total of 13 amputations in 12 patients. Limb salvage was achieved in 55 limbs (81%). Univariate analysis suggested that patients that had revascularization procedures with synthetic graft had a higher complication rate compared with autologous/vein reconstruction (24% vs 5%; P [ .021). This group also has a higher rate of persistent infection compared with the autologous group (24% vs 2%; P [ .006). Patients older than 75 years at the time of GMF had a higher incidence of GMF-related complications (57% vs 5%; P [ .04). Multivariate analysis confirmed that presence of prosthesis led to higher incidence treatment failures and muscle flap complications at the surgical site (odds ratio, 6.6; P [ .04; and odds ratio, 13.3; P [ .03, respectively).

Conclusions: GMF is technically simple to perform and provides durable soft tissue coverage with a high rate of healing for complex groin wounds even in the presence of synthetic conduit. (J Vasc Surg 2016;64:452-7.)

Dealing with a vascular infection in the groin can be very challenging, especially if there is destruction of overlying skin and soft tissue.^1-4 The most frequent site for catheter-based interventions is the femoral artery.^1-5 The femoral area is also the most common site of revascularization procedures for open bypasses. Up to 7% of the patients may develop infections when having procedures in the femoral vessels, as opposed to 0.5% at more proximal

From the Division of Vascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rocka ; the Department of Surgery, Johns Hopkins University School of Medicine, Baltimoreb ; the Department of Plastic Surgery, Cleveland Clinic Foundation, Clevelandc; and the Department of Surgery, Baylor Heart and Vascular Hospital, Dallas.^d
Author conflict of interest: none.
Presented at the Fortieth Annual Meeting of the Society for Clinical Vascular Surgery, Las Vegas, Nev, March 12-14, 2012.
Correspondence: Ahsan T. Ali, MD, Division of Vascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham St, Ste 520-2, Little Rock, AR 72205 (e-mail: sibiahsan@ yahoo.com).
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214
Copyright 2016 by the Society for Vascular Surgery. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jvs.2016.03.010

sites.^1-4 Factors that can increase risk are reoperative surgery, poor hygiene, postoperative bleeding, poor nutrition, and systemic infections from central line or urinary tract.^3-6 Other comorbidities such as obesity and end-stage renal disease are strong predictors for graft infections and/or surgical site infection.^3-7 The presentation can vary from deep soft tissue infection with necrosis of the overlying skin to limb or life-threatening sepsis with hemorrhage.^4-6 The ideal treatment would be to excise all involved prosthetic while maintaining vascular continuity using an autologous conduit.^6,7 However, the overlying skin and soft tissue has to be healthy and substantive enough to be able to provide adequate coverage for the underlying vascular structures. Muscle flaps have traditionally been used as an adjunct to provide coverage and assist in treating local infections.^8-10 We reviewed our experience in the usage of gracilis muscle flap (GMF) as an adjunct in the treatment of graft infection with associated groin breakdown.

METHODS

This study was undertaken at The University of Arkansas for Medical Sciences hospital and the Central Arkansas Veterans Hospital. The institutional review boards approved this study. According to the policy and procedures required by the institutional review boards, informed consent was not required. This was a retrospective chart

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review. Patients who underwent vascular procedures and subsequently had GMF between 1997 and 2012 were identified.

Basic demographics, initial vascular procedure as well as type of graft (autologous vein vs synthetic) were recorded. A successful treatment was defined as resolution of infection per limb treated, with healing of overlying skin and soft tissue and no requirements for long-term antibiotics. Treatment failure was defined as persistent infection leading to disruption of the vascular anastomosis or failure to heal. Patients undergoing GMF for indications other than infection were excluded. Primary outcome assessed was freedom from infection with complete healing. Secondary outcomes were limb salvage, GMF-related complications, and long-term survival. Comparison between synthetic and autologous material (vein) was also performed using univariate and multivariate analysis for predictors of poor outcome.

Surgical technique. All GMF procedures were performed by vascular surgeons. A longitudinal medial thigh incision was made avoiding injury to the great saphenous vein (GSV). If the GSV had been recently harvested, then the same incision was used. The gracilis muscle was identified and its insertion tendon isolated. In order to identify the gracilis the following points were considered.

The muscle is tendinous in the distal third, and there are no perforating branches in the distal one-half of the gracilis muscle body. It also tapers down to a tendon, whereas the sartorius muscle maintains its rectangular shape. This helps differentiate the gracilis from the sartorius, which has a segmental blood supply from the superficial femoral artery (SFA).¹⁰ The surgeon’s index finger is easily passed circumferentially around the muscle. This is an essential step required for mobilization. The tendon is then retracted proximally and disconnected as distally as possible. It is important to mobilize and dissect the adductor longus muscle on both sides. No nerve structure should be found anterior to the gracilis muscle.¹¹ The muscle is then retroflexed back proximally to cover the femoral vessels. We do not pass it through the adductor longus muscle or detach it from its proximal attachment to the pubis. Furthermore, we do not intentionally takedown the medial circumflex artery branch. The GMF is then secured with 2-3 absorbable sutures to the inguinal ligament and surrounding structures.

This technique is a variation from Morasch et al⁸ in which they had mobilized the gracilis muscle from the pubic bone and passed through the adductor longus muscle. The technique video is available on YouTube: https://www.youtube.com/watch?v¼FngQbkHtrrE.

Statistics. Statistical analysis was performed using Stata 11.0 (Stata Corp LP, College Station, Tex). The c2 or Fisher exact tests were used for categoric variables and for variables in which frequency was limited to 5 or less occurrences per subgroup. P value required for inclusion in the multivariate analysis was <.05. Data were reported as mean 6 standard deviation. Multivariate analysis using logistic regression was used to assess predictors of primary and secondary end points. Odds ratios were obtained.

RESULTS

During a 15-year period (1997-2012), 68 limbs (64 patients) had GMF for coverage of the ipsilateral femoral artery for an infectious etiology. The mean age was 64.2 +/- 8.1 years. Majority were men (n ¼ 48). The most common presentation was a nonhealing groin wound or a sinus tract in 32/68 limbs (47%). Clinical presentations are mentioned in detail in Table I.

There were 10 patients who were taken to the surgery emergently for ruptured femoral artery aneurysm/pseudoaneurysm or hemorrhage from the femoral artery (Table I). The original vascular procedures are also listed in Table I. The mean follow-up was 34 +/- 28 months (mean 6 standard deviation). The mean number of procedures on each patient was 2.5 +/- 1.2.

Outcomes are described in Table II. Repair of the common femoral artery was undertaken with autologous

Table I.Initial presentation, original procedures

Demographics
Number of patients	64
Number of limbs treated	68
Mean age, years	64.2 6 8.2
Men:women	48:16
Original procedures
Aortofemoral bypass graft	15
Femoral popliteal bypass	17
PTFE	11
Vein/Cryovein	6
Common femoral artery endarterectomy	9
Repair femoral artery from catheter injury	5
Femoral-femoral artery bypass/revision	4
Cut down for endovascular aneurysm repair	2
Embolectomy	3
Femoral artery pseudoaneurysm repair	11
Clinical presentation
Nonhealing wound/exposed femoral artery	32
FAP with intact skin	12
Ischemia/occult infection without FAP	8
FAP with sinus tract	4
Ruptured FAP or expanding hematoma	10

FAP, Femoral artery aneurysm/pseudoaneurysm; PTFE, polytetrafluoroethylene

Table II.Outcomes/gracilis muscle flap (GMF)-related complications

Results
Successful treatment (limbs)	58
Persistent infection or treatment failure (limbs)	10
All amputations	13 (5 þ 9)
In-hospital death	9

Complications from muscle transfer
Necrosis of flap	3
Hematoma	3
Seroma	1

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Table III. Treatment failure with persistent infection

Age/sex	Original procedure	Presentation	Procedure with GMF	Conduit	Microbiology	Complications	Graft salvage	Outcomes
79/M	Common femoral endarterectomy	Nonhealing incision	Debridement of wound	Synthetic pericardium	Pseudomonas aeruginosa	Persistent infection	No	Disruption of anastomosis, amputation/death
87/M	AFBG	Infected FAP	Replacement of distal limbs with rifa mpin soaked graft	Dacron	Never cultured	Persistent infection/ sepsis	N/A	MSOF/death
67/M	Direct repair of the CFA after catheterrelated hematoma	Non healing incision	Debridement	Direct repair	Staphylococcus aureus, Enterococcus faecalis	Necrosis of flap, multiple abscesses	N/A	Multiple I&D with VAC dressing
84/M	Fem-distal with vein	Bleeding from anastomosis	Repair bovine pericardium	Bovine pericardium	Never cultured	Sepsis	Yes	Death
49/M	Fem-pop with vein	Hematoma requiring evac	Debridement	Vein	Never cultured	Local abscess	Yes	Multiple I&D, evacuation of hematoma
84/M	Infected AFBG limb	Infected AFBG limb	Replace limb with Dacron	Synth	Never cultured	Persistent infection	No	Death while undergoing
58/M	Fem-fem graft revision	FAP	Removal of fem-fem,	Auto	Streptococcus viridans	Anastomosis disruption	No	BKA
70/M	Fem-pop with vein	Bleeding from anastomosis	Primary repair with	Auto	No cultures	Anastomosis disruption	No	AKA
54/F	Fem-pop with PTFE previous AFBG	FAP/bleeding	Ligation of fem-pop/ AFBG	Bovine pericardium	Pseudomonas	Disruption with bleeding	No	Ligation of limb > hip disarticulation
60/M	AFBG	Infected FAP, bilateral	NAIS	Deep vein	MRSA	Anastomotic disruption	No	AKA, MSOF death

AFBG, Aortofemoral bypass graft; AKA, above knee amputation; BKA, below knee amputation; F, female; FAP, femoral artery aneurysm/pseudoaneurysm; fem-fem, femoral-femoral; fem-pop, femoral popliteal; GMF, gracilis muscle flap; I&D, incision and drainage; M, male; MRSA, methicillin-resistant Staphylococcus aureus; MSOF, multisystem organ failure; N/A, not applicable; NAIS, neo-aortic iliac system; VAC, vacuum-assisted device.

material at the time of GMF coverage in 54 limbs, whereas 14 limbs had synthetic graft material. Primary outcome was complete healing of the overlying skin and soft tissue. This was achieved in 58 of the 68 limbs. However, in 10 patients, there was evidence of persistent infection and thus were considered treatment failures. These patients are described in detail in Table III. In six of the 10, there was acute hemorrhage, and the common femoral artery had to be ligated, resulting in a major amputation in five patients. There were an additional eight major amputations in eight patients bringing the total number of amputations to 13. These are described in Table IV. These patients either had no revascularization options (lack of conduit or target) or had nonviable limb on initial presentation. Our primary objective in these patients was to save life over limb by eradicating the infected prosthesis and covering the exposed femoral vessels.

The number of in-hospital or 30-day deaths occurred in nine out of 64 patients. Five out of the nine patients died in the treatment failure group with persistent infection (Table III). As mentioned earlier, five of these patients had the femoral artery ligated with a major amputation.

An additional four patients died in the postoperative period and have been described in Table V. They had apparent successful eradication of infection and vascular reconstruction, yet died from other causes (Table V). The overall survival for the entire group was typical of vascular patients (Fig).

From surgical specimen with positive yield, 46% had a single organism while 25% had polymicrobial growth. There were no results available in 14/68 limbs (20%) and no organisms identified in 9%.

Univariate analysis. Comparing autologous vs synthetic graft, the autologous graft was associated with a lower rate of persistent infection or treatment failure. The rate of failure was almost 12 times higher in the synthetic group (24% vs 2%) in the autologous reconstructions, which was highly significant (P ¼ .006). There were no significant differences in flap specific complications across the synthetic and autologous tissue reconstruction groups (P ¼ .16). Complications related to GMF transfer are described in Table II. Univariate analysis for age demonstrated that flap complications rate was 57% in the older group (age >75 years) vs 5% in the younger cohort (P ¼ .04).

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Table IV. Additional amputations (distal ischemia-related)

Age/sex	Original surgery	Presentation	Procedure with GMF	Conduit	Microbiology	Reason for amputation	Level
52/M	Fem-pop with PTFE	Acute occlusion, had thrombectomy but got infected with open groin	Removal of fem-pop, deep vein femoralprofunda bypass	Deep vein	MRSA, Porevotella	Ischemia, no conduit for distal bypass	BKA
64/F	Fem-pop	Graft thrombosis, nonviable limb	Removal of fem-pop w repair of CFA w	Vein	Peptostreptococus, Bacteriods	Non-viable limb	AKA
54/M	Fem-pop w PTFE	Sepsis	Removal of fem-pop, repair CFA	Vein	Staphylococcus aureus	Sepsis, hypotensive	AKA
56/M	Thrombosis of fem-pop	Infected fem-pop/acute ischemia	EIA to profunda bypass w vein GMF	Vein	No growth	No vein, poor run-off	BKA
50/M	Fem-fem	FAP, infected	Removal of fem-fem, patch repair with pericardium,	Bovine	Never cultured	Irreversible ischemia, no vein	BKA
58/M	AFBG/bilat fem-pop	Occult infection, occluded AFBG, fempop	Replace AFBG with NAIS, removal of fem-pop	Deep vein	Candida albicans	No conduits, no signal in foot	BKA
63/M	CFA end with bovine	Non healing wound	Repair with vein	Deep vein	VRE	Tissue loss with no conduit	AKA
63/M	Aortobiliac	Medial thigh abscess	Iliofemoral with vein	GSV	MSSA	Distal tissue loss, nonviable foot	BKA

AFBG, Aortofemoral bypass graft; AKA, above knee amputation; BKA, below knee amputation; CFA, common femoral artery; EIA, external iliac artery; F, female; FAP, femoral artery aneurysm/pseudoaneurysm; fem-fem, femoral-femoral; fem-pop, femoral popliteal; GMF, gracilis muscle flap; GSV, great saphenous vein; M, male; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, Methicillin sensitive Staphylococcus aureus; NAIS, neo-aortic iliac system; PTFE, polytetrafluoroethylene; VRE, vancomycin-resistant Enterococcus.

Table IV. Additional amputations (distal ischemia-related)

Age/sex	Original surgery	Presentation	Treatment	Conduit	Microbiology	Wound closure	Cause of death
54/M	AFGB/Ax-fem bypass	Acute ischemia, groin sinus	NAIS, bilateral SFA remote end	Deep vein	Enterococcus faecalis, Lactobacilus	VAC	Presumed MI 3 weeks after discharge
68/F	Fem-distal vein bypass 3 weeks before presentation	Acute hemorrhage from anastomosis	Repair with pericardial patch, GMF	Pericardial patch	Candida, klebsiella, Escherichia coli	VAC	Sepsis
99/F	Embolectomy 4 weeks before presentation	Infected FAP	Repair with vein patch, GMF	Vein	Pseudomonas aeruginosa	Primary closure	MSOF in hospital
71/F	Femoral endarterectomy	Infected FAP	Repair with deep vein	Vein	VRE, MRSA	VAC	MSOF in hospital

AFBG, Aortofemoral bypass graft; AX-fem, axillary-femoral; F, female; FAP, femoral artery aneurysm/pseudoaneurysm; fem, femoral; GMF, gracilis muscle flap; M, male; MI, myocardial infarction; MRSA, methicillin-resistant Staphylococcus aureus; MSOF, multisystem organ failure; NAIS, neo-aortic iliac system; SFA, superficial femoral artery; VAC, vacuum-assisted device; VRE, vancomycin-resistant Enterococcus.

Multivariate analysis. A multivariable analysis revealed the gracilis-related flap complications had a 6.6 times higher odds of developing a flap complication when a synthetic graft was used compared to the group with vein reconstruction (P ¼ .04). Likewise the frequency of persistent infection was 13.3 times higher when a synthetic vascular conduit/graft was used compared with autogenous (P ¼ .03).

DISCUSSION

Reoperative surgery and/or hematoma in the groin area after catheterizations could lead to an increased risk of infection.^1-7 A nonhealing incision with exposed femoral

artery and active infection can be a nightmare for the vascular surgeon. The presence of a complex wound is not the only issue as these patients are often nutritionally depleted with significant other comorbidities.^1,2,6 Even with an in-line bypass using autologous conduits, lack of adequate soft tissue coverage could render the femoral vessels exposed and prone to disruption. Restoring vascular continuity is the primary goal. However, covering the area with healthy soft tissue is an equally important adjunct for a successful outcome.^12-14

An extra anatomical bypass may not be an option if the SFA is occluded with no outflow above the knee joint.

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Fig. 1 Survival Kaplan-Meyer curve after discharge.

Muscle flaps have been used as an adjunct to treat groin infections.^8-13 Well-perfused muscle tissue provides coverage to vascular structures and allows successful treatment of infection with soft tissue healing. The profunda femoris artery is usually patent and spared from catheterbased interventions. The gracilis muscle derives its blood supply from the branches of the deep profunda artery as a pedicle. It also has a greater arc of rotation and minimal restrictions in postoperative ambulation.¹¹ This makes the GMF an appealing option for groin wound coverage. The use of sartorius muscle has been well described; however, we have found it often to be ischemic or inflamed from an invasive infection with an occluded SFA.^10-12 The use of sartorius muscle is quite infrequent at our institute and, thus, was not included.

In the current study, the majority of limbs (58 out of 68) were successfully treated with complete resolution of the infection. These patients were able to be discharged without any additional surgical interventions and did not require long-term antibiotics. The maximum duration of antimicrobial treatment was 6 weeks for patients who survived and were discharged.

The type of graft used for revascularization prior to performing a GMF also affected the outcome. Synthetic grafts were more prone to developing infections. Univariate as well as multivariate analysis in our study suggested that there were acceptable cure rates for patients who underwent femoral artery reconstruction with a synthetic material. However, the rate of flap complications was significantly increased when compared to autologous conduit (24% vs 5%). Amputations in the group as a whole represent a cohort of patients with usually failed bypasses

and end-stage vascular disease. The primary goal was always “life over limb.” The authors believed that the groin with active infection without adequate tissue coverage could result in life-threatening hemorrhage even with an autologous repair. It is important to point out that a significant number of autologous vein reconstructions had been performed for infected synthetic bypasses/patches. The occurrence of treatment failures was significantly higher in patients with synthetic grafts compared with autologous graft or patch (P ¼ .03). The autologous graft material was ipsilateral GSV, femoral vein, translocated endarterectomized SFA, and cryo vein (two cases). Using a vein graft or patch rendered a favorable outcome with a decreased complication rate and a significantly higher freedom from infection.

Early studies have described the use of a GMF with favorable short-term results.⁸ However, to date this is the largest report of a GMF by vascular surgeons for complex groin wounds after vascular procedures.

We also observed that the highest frequency of treatment failure was in patients with a gracilis flap over synthetic graft with primary skin closure. The authors recommend using femoral vein, or when a suitable vein is not available, a translocated endarterectomized SFA can be used. With the use of GMF, we strongly recommend leaving overlying skin open and using local wound care and/or vacuum assisted devices (VACs). VACs have been used and recommended in reports for Szilagyi III wounds with acceptable results.¹⁵ Although VACs have shown promise, we recommend adjunctive usage of a GMF, especially when the vessels are exposed. Trying to primarily close the skin/soft tissue can place the wound under

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significant tension. We do not recommend placing the sponge in VAC therapy directly in contact with the vascular structures. This study was limited as it was a retrospective review. Additional risk factors such as diabetes, smoking, body mass index/obesity, hypertension, and coronary artery disease were not factored in the final analysis. Also, we did not assess the previous sartorius muscle flap failures that eventually ended up with a GMF and synthetic graft material replaced with autogenous conduit. Finally, no other specialist was involved as vascular surgeons performed all GMF procedures. The procedure did not take longer than 15-20 minutes of additional time. Currently at our institution, we use the gracilis muscle retroflexed flap as the first line treatment when a muscle flap is planned to treat a complex groin wound.

CONCLUSIONS

Creation of the GMF can serve as an important adjunct for treating femoral artery infections while providing healthy soft tissue coverage. The cure rate after gracilis muscle rotational flap was significantly higher when vein graft or patch was used compared with synthetic grafts. Future research could focus on identifying patients that are at high risk and perform a gracilis flap prophylactically to prevent an infection.

AUTHOR CONTRIBUTIONS

Conception and design: AA, MR, MM, JE
Analysis and interpretation: AA, MR, SR, HS, JE
Data collection: AA, MR, SD, RA
Writing the article: AA, MR, JE
Critical revision of the article: AA, MR, JE
Final approval of the article: AA, MR, SD, MM, SR, HS, RA, JE
Statistical analysis: MR, SR, HS
Obtained funding: AA
Overall responsibility: AA
AA and MR contributed equally to this article and share
co-first authorship.

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Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin

Summary