Ann Thorac Surg 2000;69:960-961
© 2000 The Society of Thoracic Surgeons
How To Do It
Management of closed space infections associated with endoscopic vein harvest
Keith B. Allen, MDa,
Edward B. Fitzgerald, MDa,
David A. Heimansohn, MDa,
Carl J. Shaar, PhDa
a St. Vincent Hospital and Health Care Center, Indianapolis, Indiana, USA
Address reprint requests to Dr Allen, 8333 Naab Rd, Suite 300, Indianapolis, IN 46260
e-mail: cvsurgeon{at}iquest.net
 |
Abstract
|
|---|
Wound complications are uncommon following endoscopic saphenous vein harvest. However, closed space infections within the endoscopic tunnel may occur and are difficult to manage. We describe the management of closed space infection in 3 patients and a method that allows drainage without unroofing the endoscopic tunnel.
|
Introduction
|
|---|
Wound complications are uncommon following endoscopic saphenous vein (SV) harvest when compared to traditional harvest methods. In a prospective randomized trial, endoscopic vein harvest (EVH) was associated with a 4% wound complication rate compared to 19% when SV was harvested using the traditional longitudinal method [1]. Most endoscopic wound complications are minor. However, when they are associated with an infected tunnel hematoma, the closed space abscess presents difficult management options, which usually leads to unroofing the endoscopic tunnel to drain the infected space. We describe the management of 3 patients who developed postoperative infected hematomas and a method that allows drainage of the closed space without unroofing the endoscopic tunnel.
|
Patients and methods
|
|---|
Between September 1996 and April 1999, 4,084 patients underwent coronary artery bypass grafting, at St. Vincent Hospital and Healthcare Center, utilizing greater saphenous vein. While 2,825 of these patients had traditional longitudinal harvest, 1,259 (31%) had veins harvested endoscopically. Three patients undergoing EVH developed a closed space infection (0.2%). Two of the 3 patients had tunnel infections involving the lower leg, whereas 1 patient had a tunnel infection in the thigh. All 3 patients who developed closed space infections had early postoperative tunnel hematomas. Patients were readmitted an average of 12 days postoperatively with evidence of closed space infection, as demonstrated by tenderness and fluctuation over the endoscopic tunnel and drainage from the endoscopic access incision. Staphylococcus aureus was the infecting organism in all 3 patients. Treatment of all patients involved abscess drainage and IV antibiotics.
The first patient was managed by surgically unroofing the entire tunnel with a longitudinal incision to provide adequate drainage. This patient was neither obese nor a diabetic. The wound was allowed to granulate and heal by secondary intention (Fig 1A). In the second and third patients the closed space infection was treated successfully by providing drainage without unroofing the endoscopic tunnel. In these 2 patients, the endoscopic access incision was opened at the bedside following intravenous sedation. One of the patients was a diabetic and 1 patient was obese. The tunnel was compressed to remove the purulence and a Blake drain (Ethicon, Inc, Somerville, NJ) was positioned along the length of the endoscopic tunnel. The Blake drain was irrigated every 8 hours with normal saline and was gradually withdrawn from the tunnel over a 10 day period. When the drain was completely removed, the access incision was treated with dressing changes and allowed to granulate until closure (Fig 1B). Following open drainage, the first patient had complete wound healing in 6 weeks, whereas the other 2 patients treated with closed irrigation achieved complete healing in 15 days.
View larger version (68K):
[in this window]
[in a new window]
|
Fig 1. Closed space infections following endoscopic saphenous vein harvesting managed by unroofing the endoscopic tunnel to provide (A) adequate drainage versus using a (B) closed space irrigation system.
|
|
|
Comment
|
|---|
Wound complications are uncommon following endoscopic saphenectomy. Major complications related to closed space infections in the endoscopic tunnel can occur and are associated with postoperative hematomas. The use of closed space irrigation can successfully manage this complication with equal success and less morbidity than open drainage. [2]
|
References
|
|---|
-
Allen K.B., Griffith G.L., Heimansohn D.A., et al. Endoscopic versus traditional saphenous vein harvesting. Ann Thorac Surg 1998;66:26-32.[Abstract/Free Full Text]
-
Allen K.B., Shaar C.J. Endoscopic saphenous vein harvesting. Ann Thorac Surg 1997;64:265-266.[Abstract/Free Full Text]
Accepted for publication November 24, 1999.
Top
Abstract
Introduction
