Key points

• Infection of prosthetic vascular grafts is associated with a high mortality and morbidity

• Prosthetic grafts should be avoided if the risk of infection is high

• Early diagnosis requires a low index of suspicion

• The greatest chance of long-term success lies in complete removal of the infected prosthesis and revascularisation with autologous material

• A groin abscess in an intravenous drug abuser should be considered to be an infected false aneurysm of the femoral artery until positively excluded

Introduction

Managing the infective complications of arterial surgery represents one of the most complex challenges facing the vascular surgeon. Medical management alone seldom produces a satisfactory outcome but the removal of an infected prosthesis in a debilitated patient, possibly in the face of life-threatening haemorrhage, is rarely straightforward. The problem of then restoring distal perfusion may require innovative approaches whilst minimising the risk to the patient's life and reducing the likelihood of recurrent infection.

Epidemiology

Conventional surgical teaching is that ‘clean’ operative procedures should carry a postoperative wound infection rate of less than 1% (Table 20.1). Data from the Health Protection Agency (HPA) surveillance of surgical site infection rates however suggests that this is rarely achieved and approaches the sort of rates generally seen with clean-contaminated or contaminated procedures.

Causative organisms

Forty-six per cent of organisms seen in early postoperative infections following vascular procedures are staphylococcal, two-thirds of these being methicillin resistant Staphylococcus aureus (MRSA).