Table 1: Demographic and clinical variables
Surgical technique
Under general anesthesia, the cardiovascular team
performed vascular interventions with debridement
around the femoral vessels. Vascular graft infections
were confirmed based on excised alloplast cultures from specimens obtained during the operations. An
“ipsilateral” (cases 2, 3, and 5) or “contralateral”
(cases 1 and 4) VRAM flap was performed depending
on the choice of a suitable flap pedicle. The flap
was created through a longitudinal, mid-abdominal
incision, preserving the umbilicus. The fascia closure
(without mesh) was performed with a 2-4 cm opening
which allowed the muscle cuff to pass through. Care
was taken to protect the small muscle cuff at the
pubic bone to prevent the pedicle from stretching. The
VRAM flap was wrapped and sutured circularly only
around the superficial femoral artery or vascular graft
(Figure 1a, b). All anastomosis sites were completely
covered by muscle. A split thickness skin graft was
applied to the muscle surface (Case 1: Figure 1d, e;
Case 2: Figure 1f, g; Case 3: Figure 1h, ı; Case 5:
Figure 1j, k).
All vascular grafts were replaced during surgery. Tissue and excised graft cultures indicated the presence of Acinetobacter baumannii and Pseudomonas and the patients were treated accordingly. No hemorrhage was noted at the surgical wrapped site. All muscle flaps survived completely. No vessels or prosthetic grafts were exposed as documented with MRI imaging (Figure 1c). The postoperative graft (3/5 cases) patency was 66.6% by MRI (Case 5 - died). The follow-up period ranged from 1 to 36 months (mean: 14.4 months). The patients with peripheral artery disease (PAD) suffered from two major complications. One patient (Case 5) died (postoperative day 30) from diabetic complications-related sepsis. The other patient (Case 4) experienced hip disarticulation after four months of follow-up.
Furthermore, the mortality rates are high in patients with prosthetic graft infections in the groin region which are related to PAD.[4] In PAD group, one patient died due to sepsis. Profunda femoris artery revascularization is a critical aspect of controlling thigh infections to prevent hip disarticulation, as described by Poi.[5] The long-term limb amputation and mortality rates in patients with PAD are still high (40%) and these rates are closely related to comorbidities. In our study, we observed no graft complications with normal PFAs in the patients with gunshot wounds.
However, this study has some limitations. Firstly, the sample size was small. Secondly, the follow-up period was less than five years. Further large-scale studies with long-term follow-up are required to confirm these results.
In conclusion, our study results suggest that the wrap-around technique can decrease the risk of complications during the reconstruction of complex groin defects in patients with high-energy gunshot wounds. For patients with PAD, this technique should be applied more cautiously.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
1) Skoll PJ, Kowalczyk J. Superiorly based rectus abdominis
wraparound flap for axillofemoral graft sepsis. Ann Plast
Surg 2001;47:191-3.
2) De Santis F, Chaves Brait CM, Caravelli G, Pompei
S, Di Cintio V. Salvage of infected vascular graft via
‘perivascular venous banding’ technique coupled with rectus abdominis myocutaneous muscle flap transposition.
Vascular 2013;21:17-22.
3) LoGiudice JA, Haberman K, Sanger JR. The anterolateral
thigh flap for groin and lower abdominal defects: a better
alternative to the rectus abdominis flap. Plast Reconstr Surg
2014;133:162-8.