title: Avoiding infrainguinal bypass wound complications in patients with chronic renal insufficiency: the role of the anatomic plane.
abstract: OBJECTIVE
  To study the factors leading to wound problems in patients with chronic renal insufficiency (CRI) with emphasis on subcutaneous vs. deep placement of grafts.
  
  
  METHODS
  The outcomes of patients undergoing an infrainguinal bypass with preoperative CRI (serum creatinine > or = 2.0 mg/dl) were reviewed. Surgical site infection (SSI) was classified as superficial or deep according to the Centres for Disease Control standards.
  
  
  RESULTS
  Forty-two patients underwent a total of 47 infrainguinal bypasses for ischaemic rest pain or tissue loss. The graft location was partially or predominantly subcutaneous in 21 limbs (Group I) and 26 grafts were positioned in the anatomic or subfascial planes (Group II). In Group I, seven early (< 30 days postoperative), one intermediate (4-6 weeks postoperative), and one late (> 6 weeks postoperative) SSI's were found (9/21, 43%). In three of these patients the graft was exposed and two required removal. In contrast, only two early and one intermediate SSI's (3/26, 12%) were noted in Group II (p = 0.02). A logistic regression analysis, with twelve possible covariables wound healing, confirmed the subcutaneous location to be the only controllable factor significantly predicting SSI (relative risk = 11.6, p = 0.01).
  
  
  CONCLUSIONS
  The infrainguinal bypass in patients with CRI is associated with a high incidence of wound complications. In our retrospective series, the presence of a vascular conduit in the subcutaneous plane was connected with a higher rate of SSI. Despite the growing trend toward the use of the in situ bypass, CRI may represent a circumstance where deeply placed grafts should be used preferentially.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Blankensteijn
authors.forename: J P
authors.initials: JP
authors.lastname: Gertler
authors.forename: M J
authors.initials: MJ
authors.lastname: Petersen
authors.forename: D C
authors.initials: DC
authors.lastname: Brewster
authors.forename: R P
authors.initials: RP
authors.lastname: Cambria
authors.forename: G M
authors.initials: GM
authors.lastname: La Muraglia
authors.forename: W M
authors.initials: WM
authors.lastname: Abbott
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001807:Blood Vessel Prosthesis; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection; D014656:Vascular Surgical Procedures / Q000379:methods*; D014680:Veins / Q000637:transplantation