New measures to prevent inguinal infections in vascular surgery

Surgical site infections (SSIs) are a continuing problem in surgical procedures. Despite all measures being taken with regard to sterility, SSIs remain a healthcare burden. Wounds created during peripheral vascular procedures are particularly prone to becoming infected.Studies have been conducted to evaluate the influence of new developments on the prevention of SSI. One innovative technique suggested gluing down bacteria onto the skin. However, a cohort study of 50 clinical patients indicated for a groin incision did not show a reduction of SSI using this glue.A second innovation suggested fewer SSIs when using absorbable subcutaneous staples. Six patients with an indication for peripheral bypass surgery were tested and compared to normal closure with absorbable sutures, and no advantages were found.Fewer SSIs were expected with a smaller incision size. In a multicenter randomized trial 137 patients undergoing endovascular aneurysm repair were compared with regard to the access approach in both groins. Percutaneous vascular access was less painful and caused less inflammation when compared to an open vascular access groin incision. Preoperative groin skin biopsies were used to compare infected wounds to uninfected wounds. Microscopical skin findings were identical. Next Generation Sequencing 16S-23S rRNA solely identified bacteria of the apathogenic species in the skin biopsies.In this thesis it is concluded that skin gluing and absorbable staples are ineffective to prevent SSI, that causative bacteria of SSI are not identified in skin tissue, and that the burden of SSI deserves continued research, particularly in the light of increasing bacterial resistance

Covering of an exposed vascular graft in the groin with an external oblique muscle rotational flap

Abdominal muscles, such as the oblique-and transverse muscles, find their blood supply from multiple segmental pedicles from the iliac artery. Besides its superior vascularization, its release is simple, leaving two abdominal muscles for securing abdominal wall strength. The release of the muscle and coverage of the graft requires partial muscle mobilization and is a minor reconstruction, but extension of the mobilization cranially enables coverage of larger defects. We present a case of an infected vascular graft in the groin successfully preserved through coverage with an external oblique muscle flap

Tracking Down the Cause of Necrotizing Fasciitis in a Patient with Negative Cultures

In a patient suspected of lower abdominal necrotizing fasciitis cultures remained negative, possibly because broad spectrum antibiotics had already been given before tissue for culture was obtained. 16S-23S rDNANext Generation Sequencing showed that 99.7% of bacterial DNA was of Streptococcus pyogenes. 16S-23S rDNA can replace culture for identification of bacteria, also in polymicrobial infection

Randomized multicenter trial on percutaneous versus open access in endovascular aneurysm repair (PiERO).

BACKGROUND: In endovascular valve and aortic repair, vascular access through a percutaneous approach has become the competing technique to an open surgical approach. The effect on postoperative complications and surgical site infections (SSIs) has been investigated, but randomized evidence is lacking. The objective was to investigate whether percutaneous access of the common femoral artery (CFA) with a percutaneous closure device would decrease the number of SSIs compared with open surgical access of the CFA in endovascular aneurysm repair (EVAR). METHODS: Patients with an abdominal aortic aneurysm suitable for EVAR were randomized to open or percutaneous access of the main device (MD) through the CFA. Through the contralateral side, access was obtained with the other technique than the one for which the MD was randomized. The primary outcome was number of SSIs. Secondary outcomes were wound complications, visual analog scale for pain scores, and standardized wound assessment scores during follow-up. Preoperative screening culture and groin biopsy specimens were obtained from all patients. RESULTS: Both groups contained 137 groins. SSI rate was 1.5% in the open group vs 0% in the percutaneous group. For MDs only, SSI rate was 3.1% (odds ratio, 3.3; 95% confidence interval, 0.31-347; P = .34). Wound complications were comparable in both groups. Neither nasal nor groin Staphylococcus aureus carriage had a significant effect on SSIs, Southampton Wound Assessment score, or visual analog scale score. Adjusted pain score was 0.69 lower, in favor of percutaneous access. Wound assessment was better after 2 weeks (odds ratio, 3.57; 95% confidence interval, 1.02-12.44; P = .046), also in favor of percutaneous access. CONCLUSIONS: Percutaneous access of the CFA does not reduce the number of SSIs. It does, however, reduce pain and improve wound healing with less inflammation 1 day and 2 weeks after EVAR, respectively

A comparison of Percutaneous femoral access in Endovascular Repair versus Open femoral access (PiERO):study protocol for a randomized controlled trial

Background: Access for endovascular repair of abdominal aortic aneurysms (EVAR) is obtained through surgical cutdown or percutaneously. The only devices suitable for percutaneous closure of the 20 French arteriotomies of the common femoral artery (CFA) are the Prostar (TM) and Proglide (TM) devices (Abbott Vascular). Positive effects of these devices seem to consist of a lower infection rate, and shorter operation time and hospital stay. This conclusion was published in previous reports comparing techniques in patients in two different groups (cohort or randomized). Access techniques were never compared in one and the same patient; this research simplifies comparison because patient characteristics will be similar in both groups. Methods/Design: Percutaneous access of the CFA is compared to surgical cutdown in a single patient; in EVAR surgery, access is necessary in both groins in each patient. Randomization is performed on the introduction site of the larger main device of the endoprosthesis. The contralateral device of the endoprosthesis is smaller. When we use this type of randomization, both groups will contain a similar number of main and contralateral devices. Preoperative nose cultures and perineal cultures are obtained, to compare colonization with postoperative wound cultures (in case of a surgical site infection). Furthermore, patient comfort will be considered, using VAS-scores (Visual analog scale). Punch biopsies of the groin will be harvested to retrospectively compare skin of patients who suffered a surgical site infection (SSI) to patients who did not have an SSI. Discussion: The PiERO trial is a multicenter randomized controlled clinical trial designed to show the consequences of using percutaneous access in EVAR surgery and focuses on the occurrence of surgical site infections