Infected Arterial Grafts GLYN G. JAMIESON, F.R.A.C.S., JAMES A. DEWEESE, M.D., CHARLES G. ROB, M.D. The case notes of 664 patients who underwent surgery and arterial grafting between the years of 1955 and 1973 at the University of Rochester Medical Center have been analyzed. There were 15 cases of infected grafts-a rate of 2.3%. The outcome of the infection was determined in 12 of these cases. Four patients had no surgical treatment and all 4 died. Three patients had simple ligations with excision and one died, one had an above knee amputation and one continues to have a draining sinus. Five patients had axillofemoral bypasses. Two died and three patients are alive and well. The role of prophylactic antibiotics is briefly discussed and the influence of possible etiological factors is also considered.
TNFECTED ARTERIAL GRAFTS are an uncommon and ex1tremely serious complication of aorto-iliac surgery.
From the Department of Surgery, University of Rochester, Rochester, New York.
One way analysis of variance has been used to find an F ratio between groups being compared. Results In the 664 cases there were 15 cases of an infected graft-a rate of 2.3%. In 7 cases the infecting organisms, were Staphylococci and in 5 of these cases it was one limb only of the graft which was involved. In 6 cases the infecting organisms were E. coli and in 4 cases it was the main body of the graft which was involved. There were two cases of Klebsiella infection, one involving the body and one involving a limb of a graft. Pseudomonas and Streptococcus was also cultured once each from the above cases. The outcome of infection was determined in 12 cases and 7 of these patients died.
The incidence of infection has been reported in the range 1% to 6%.4 7-9.16 Opinion still varies regarding the use of prophylactic antibiotics in preventing infection and in the management of the graft once infection has occurred. This report analyzes a retrospective survey of 664 cases of patients who underwent surgery with arterial prosthetic insertion between the years 1955 and 1973 at Factors Affecting the Rate of Infection (Table 2) the University of Rochester Medical Center. Groin incision. There were 315 cases with a groin inciMaterial sion and 10 infected grafts in this group. There were 325 Operations were performed because of occlusive arte- cases without a groin incision and three infected grafts in rial disease in 297 cases. Of these, 153 cases had an this group. It could not be determined whether there was aortofemoral bypass, 43 had an aorto-iliac bypass and a groin incision or not in 24 cases. This difference is not 101 had an iliofemoral bypass. Operations were per- significant at 5% level of probability. formed because of aortic aneurysmal disease in 362 In the groin, if a swelling occurred which subsequently cases. Of these, 61 had an aortofemoral bypass and 301 drained blood or serous fluid this was designated a groin an aorto-iliac bypass (Table 1). 54 of these bypasses were complication. Of the 315 cases with a groin incision 293 performed as emergency procedures and the rest were had no groin complication and there were 6 infected elective bypasses. The operations were performed by grafts in this group. In the 22 cases who did have a groin both the attending and the resident staff and followup complication there were four infected grafts and this is a was done on the patients every 6 months. The great significantly greater number than in the uncomplicated majority of the grafts were woven or knitted Dacron in group at a 1% level of probability. type. Early in the series a few nylon grafts were used. Prophylactic antibiotics: It is a policy at this institution to give all patients prophylactic antibiotics if an aortic prosthesis is to be inserted. Early in the series penicillin Submitted for publication January 23, 1975. Reprint requests: Dr. G. G. Jamieson, Department of Surgery, The and streptomycin was the most popular combination of University of Adelaide, Adelaide 5000 South Australia. drugs but now keflin and kanamycin are nearly always 850
VOl. 181-No. 6
TABLE 1. Classification of Operations Performed
Type of Operation
851 same operation and the other two had staged procedures. They had an axillofemoral bypass on the side of an infected aortic prosthesis and excision of the infected limb at the first operation and then some weeks later they had
INFECTED ARTERIAL GRAFTS
Reason for Operation Occlusive arterial disease Aortic aneurysm
Aorto-iliac bypass Aortofemoral bypass Iliofemoral bypass
43 153 101
301 61
Totals
297
362
used. Antibiotics are started prior to operation and continued for 5-7 days postoperatively. As this policy was not always followed early in the series, 44 patients did not receive prophylactic antibiotics and one prosthesis became infected. There were 510 patients to whom it is known prophylactic antibiotics were given. Eleven of these prostheses became infected. Although the infection rate of the two groups is the same it is not valid to compare them. Emergency or elective case: In 314 cases of elective aneurysm surgery there were 5 infected prostheses. In 53 cases of emergency operation for aneurysm there were 4 infected prostheses. This is a significantly greater number at the 1% level of probability.
an axillofemoral bypass on the opposite side and the remainder of the aortic prosthesis removed.
Discussion Mortality. The extremely serious nature of an infected graft is attested to by the high reported mortality rates of 25% to 75%.4 15,16 The mortality rate in our series is of a similar large order with 7 deaths in 12 cases. Groin incision. In this series a groin incision was associated with a larger number of infected grafts. In those patients with a groin incision there was a 3.2% incidence of infection and in those without a groin incision an 0.9o incidence of infection. Szilyagi et al.16 observed a 1.6% infection rate in patients with a groin incision as opposed to 0.7% infection rate in those without a groin incision in patients undergoing aorto-ilio-femoral surgery. Although these findings suggest that patients who have groin incisions are more apt to have infected grafts, the differences in both series are not significant at the 5% level of probability. It may justifiably be argued that a retrospective analysis of uncontrolled groups is not a valid way of making judgements regarding infection. However, unlike a groin incision, statistical analysis at least reinforces what is suspected intuitively in the case of emergency procedures and also groin complications; (i.e. that infection is more common in emergency situations and also in cases where a complication develops in a groin wound). In emergency cases conditions are far from optimal and patients are usually sicker at the time of operation than in elective cases. In the case of groin complications the higher incidence of infection may be a cause or an effect. Prophylactic antibiotics. This is a subject which seems governed as much by surgical fashion as scientific fact.
Management of Infected Grafts No operative treatment. There were 4 cases and all died of septicemia at 15, 21, 22 days and 12 months after their respective operations. In these cases either the cause of illness was not recognized until portmortem examination or death occurred before operation could be undertaken. Simple ligation andlor excision. Two patients had ligation and local excision of a limb of the prosthesis. This led to severe ischemic ulcers in one patient and aboveknee amputation and death from septicemia in the other patient. One further patient had a simple ligation and drainage of one limb of an aorto-femoral bypass and continues to have a sinus with drainage. Axillo-femoral bypass. Five patients had axillo-femoral bypasses. Two patients died-both during the course of staged procedures. One patient had a right axillofemoral TABLE 2. Factors Affecting Rate of Infection bypass inserted to bypass an infected right limb of a graft No. with and, while recovering from this and awaiting removal of Total number infection Rate of infection the prosthesis, died with a massive hemorrhage from an aortoduodenal fistula. Groin Incision 315 10 - 3.2% The other patient had an axillofemoral graft inserted to Present Absent 325 3 - O.9o bypass an infected left limb of an aortic graft and while Groin complication recovering from this and awaiting removal of the graft, Present 22 4 -18.2% 293 6 - 2.0%o bled from the right limb of the aortic prosthesis requiring Absent Antibiotics emergency operation with total removal of the graft and Prophylactic Used 510 11 - 2.2% insertion of a right axillofemoral bypass. The patient Not used 44 1 - 2.3% Type of Procedure developed acute tubular necrosis and died. Aneurysm 53 4 - 7.5% In the 3 surviving patients in this group one had the Emergency Elective Aneurysm 314 5 - 1.6% graft excised and bilateral axillofemorals inserted at the
852
JAMIESON, DEWEESE AND ROB
The rate of infection in our series in those cases in whom it was certain that prophylactic antibiotics had been used was 2.2% (11 infections in 510 cases). It will be noted that this is at the low end of reported infection rates of 1% to 6%.4 7-9.16 In the two other large series reported infection rates were 1.32% in 1662 cases16 and 1.34% in 890 cases.7 Neither of these groups used prophylactic antibiotics. In spite of the low rates of infection both authors recommend prophylactic antibiotics for future use-Szilyagi and his group if the groin is to be incised and Fry et al. on the basis of work done in dogs.10 Therefore although there is no scientific evidence to support prophylactic antibiotics in patients (there is some evidence in laboratory created situations in dogs,6'10 most authorities continue to recommend prophylactic antibiotics when an aortic prosthesis is to be inserted.'4 Management of the infected graft. There is no single agreed method in managing these cases although the introduction of alternative bypass routes has led to their increasing use with excision of the graft. In 1959 Schramel et al.'3 described ligation and local excision for an infected limb of a graft. In 1961 Blaisdell et al.' first described removal of an infected dacron graft with bypass from the thoracic aorta to the extremities. Then in 1963 Blaisdell and Hall2 described the axillaryfemoral bypass and Shaw and Baue'5 described the obturator foramen bypass. Also in 1963 Carter et al." described vigorous local treatment of infected limbs of grafts with excellent results. If there is no evidence that the suture lines of the graft are infected (i.e. no bleeding) nor the pseudo-intima, (i.e. no thrombosis) then local treatment may still be appropriate."'14"16 Leaving the main body and opposite limb of the graft in place and removing only the infected limb has also been carried out with successful results.4'5 However, the only certain way to know that infection will be eradicated is to totally remove the prosthesis. This can be done at one operation with the insertion of bilateral axillo-femorals preceding the removal of the prosthesis or it can be done as a staged procedure concentrating in the first operation on the infected side, (providing it is a limb and not the main body of the graft which is involved). The total excision of the prosthesis and other side axillofemoral graft can be carried out at a separate operation. Improving results with the axillofemoral bypass procedure has led to it being more widely used and in this situation it is often the procedure of choice.""2
Ann.
Surg..
June
1975
Conclusion A series of 664 cases with 2.3% rate of infection of aorto-ilio-femoral grafts is presented. The high mortality of this complication underlines the necessity for prevention which explains why most authorities recommend prophylactic antibiotics, although there is no scientific evidence which shows that they lead to a lower rate of infection. Conservative methods of management sometimes eradicate infection, but the only certain cure is obtained by removing the graft totally. The development and success of axillofemoral bypass technics has led to its use in the management of infected prostheses.
References 1. Blaisdell, F., DeMatter, G. and Gauder, P.: Extra-peritoneal Thoracic Aorta to Femoral Bypass Graft on Replacement for an Infected Aortic Bifurcation Prosthesis. Am. J. Surg., 102:583, 1961. 2. Blaisdell, F. and Hall, A.: Axillary-Femoral Artery Bypass for Lower Extremity Ischemias. Surgery, 54:563, 1963. 3. Carter, S., Cohen, A. and Whelan, T.: Clinical Experience With the Management of the Infected Dacron Graft. Ann. Surg., 158:249, 1963. 4. Conn, J.H., Hardy, J.D., Chavez, C.M. and Fain, W.R.: Infected Arterial Grafts. Experience in 22 Cases with Emphasis on Unusual Bacteria and Technics. Ann. Surg., 171:704, 1970. 5. Diethrich, E.B., Noon, G.P., Liddicoat, J.E. and DeBakey, M.E.: Treatment of Infected Aorto-Femoral Prostheses. Surgery, 68:1044, 1970. 6. Foster, J.H., Berxine, T. and Scott, H.W. Jr.: An Experimental Study of Arterial Replacement in the Presence of Bacterial Infection. Surg. Gynecol. Obstet., 108:141, 1959. 7. Fry, W.J. and Lindenauer, S.M.: Infection Complicating the Use of Plastic Arterial Implants. Arch. Surg., 94:600, 1967. 8. Haffert, P.W., Gensler, S. and Haimovici, H.: Infection Complicating Arterial Grafts. Arch. Surg., 90:427, 1962. 9. Javid, H., Julian, O.C., Dye, W.S. and Hunter, J.A.: Complications of Abdominal Aortic Grafts. Arch. Surg., 85:142, 1962. 10. Lindenauer, S.M., Fry, W.J., Schaub, G. and Wild, D.: The use of antibiotics in the prevention of vascular graft infections. Surgery, 62:487, 1967. 11. Mannick, J.A., Williams, L.E. and Nabseth, D.C.: The Late Results of Axillo-Femoral Grafts. Surgery, 68:1038, 1970. 12. Moore, W., Hall, A. and Blaisdell, F.: Late Results of AxillaryFemoral Bypass Grafting. Am. J. Surg., 122:148, 1971. 13. Schramel, R.J. and Creech, O.: Effects of Infection and Exposure on Synthetic Arterial Prostheses. Arch. Surg., 78:271, 1959. 14. Scott, W.H., Barker, W.F., Cannon, J.A., et al.: Management of Infected Wounds and Grafts-a Panel Discussion. Chapter 27 in Management of Arterial Occlusive Disease. Dale, W.A. (ed.) Year Book Med. Publish., 1971. 15. Shaw, R. and Baue, A.: Management of sepsis complicating arterial reconstructive surgery. Surgery, 53:75, 1963. 16. Szilyagi, E.D., Smith, R.G., Elliott, J.P. and Virandecid, M.P.: Infection in Arterial Reconstruction with Synthetic Grafts. Ann. Surg., 176:321, 1972.
TNFECTED ARTERIAL GRAFTS are an uncommon and ex1tremely serious complication of aorto-iliac surgery.
From the Department of Surgery, University of Rochester, Rochester, New York.
One way analysis of variance has been used to find an F ratio between groups being compared. Results In the 664 cases there were 15 cases of an infected graft-a rate of 2.3%. In 7 cases the infecting organisms, were Staphylococci and in 5 of these cases it was one limb only of the graft which was involved. In 6 cases the infecting organisms were E. coli and in 4 cases it was the main body of the graft which was involved. There were two cases of Klebsiella infection, one involving the body and one involving a limb of a graft. Pseudomonas and Streptococcus was also cultured once each from the above cases. The outcome of infection was determined in 12 cases and 7 of these patients died.
The incidence of infection has been reported in the range 1% to 6%.4 7-9.16 Opinion still varies regarding the use of prophylactic antibiotics in preventing infection and in the management of the graft once infection has occurred. This report analyzes a retrospective survey of 664 cases of patients who underwent surgery with arterial prosthetic insertion between the years 1955 and 1973 at Factors Affecting the Rate of Infection (Table 2) the University of Rochester Medical Center. Groin incision. There were 315 cases with a groin inciMaterial sion and 10 infected grafts in this group. There were 325 Operations were performed because of occlusive arte- cases without a groin incision and three infected grafts in rial disease in 297 cases. Of these, 153 cases had an this group. It could not be determined whether there was aortofemoral bypass, 43 had an aorto-iliac bypass and a groin incision or not in 24 cases. This difference is not 101 had an iliofemoral bypass. Operations were per- significant at 5% level of probability. formed because of aortic aneurysmal disease in 362 In the groin, if a swelling occurred which subsequently cases. Of these, 61 had an aortofemoral bypass and 301 drained blood or serous fluid this was designated a groin an aorto-iliac bypass (Table 1). 54 of these bypasses were complication. Of the 315 cases with a groin incision 293 performed as emergency procedures and the rest were had no groin complication and there were 6 infected elective bypasses. The operations were performed by grafts in this group. In the 22 cases who did have a groin both the attending and the resident staff and followup complication there were four infected grafts and this is a was done on the patients every 6 months. The great significantly greater number than in the uncomplicated majority of the grafts were woven or knitted Dacron in group at a 1% level of probability. type. Early in the series a few nylon grafts were used. Prophylactic antibiotics: It is a policy at this institution to give all patients prophylactic antibiotics if an aortic prosthesis is to be inserted. Early in the series penicillin Submitted for publication January 23, 1975. Reprint requests: Dr. G. G. Jamieson, Department of Surgery, The and streptomycin was the most popular combination of University of Adelaide, Adelaide 5000 South Australia. drugs but now keflin and kanamycin are nearly always 850
VOl. 181-No. 6
TABLE 1. Classification of Operations Performed
Type of Operation
851 same operation and the other two had staged procedures. They had an axillofemoral bypass on the side of an infected aortic prosthesis and excision of the infected limb at the first operation and then some weeks later they had
INFECTED ARTERIAL GRAFTS
Reason for Operation Occlusive arterial disease Aortic aneurysm
Aorto-iliac bypass Aortofemoral bypass Iliofemoral bypass
43 153 101
301 61
Totals
297
362
used. Antibiotics are started prior to operation and continued for 5-7 days postoperatively. As this policy was not always followed early in the series, 44 patients did not receive prophylactic antibiotics and one prosthesis became infected. There were 510 patients to whom it is known prophylactic antibiotics were given. Eleven of these prostheses became infected. Although the infection rate of the two groups is the same it is not valid to compare them. Emergency or elective case: In 314 cases of elective aneurysm surgery there were 5 infected prostheses. In 53 cases of emergency operation for aneurysm there were 4 infected prostheses. This is a significantly greater number at the 1% level of probability.
an axillofemoral bypass on the opposite side and the remainder of the aortic prosthesis removed.
Discussion Mortality. The extremely serious nature of an infected graft is attested to by the high reported mortality rates of 25% to 75%.4 15,16 The mortality rate in our series is of a similar large order with 7 deaths in 12 cases. Groin incision. In this series a groin incision was associated with a larger number of infected grafts. In those patients with a groin incision there was a 3.2% incidence of infection and in those without a groin incision an 0.9o incidence of infection. Szilyagi et al.16 observed a 1.6% infection rate in patients with a groin incision as opposed to 0.7% infection rate in those without a groin incision in patients undergoing aorto-ilio-femoral surgery. Although these findings suggest that patients who have groin incisions are more apt to have infected grafts, the differences in both series are not significant at the 5% level of probability. It may justifiably be argued that a retrospective analysis of uncontrolled groups is not a valid way of making judgements regarding infection. However, unlike a groin incision, statistical analysis at least reinforces what is suspected intuitively in the case of emergency procedures and also groin complications; (i.e. that infection is more common in emergency situations and also in cases where a complication develops in a groin wound). In emergency cases conditions are far from optimal and patients are usually sicker at the time of operation than in elective cases. In the case of groin complications the higher incidence of infection may be a cause or an effect. Prophylactic antibiotics. This is a subject which seems governed as much by surgical fashion as scientific fact.
Management of Infected Grafts No operative treatment. There were 4 cases and all died of septicemia at 15, 21, 22 days and 12 months after their respective operations. In these cases either the cause of illness was not recognized until portmortem examination or death occurred before operation could be undertaken. Simple ligation andlor excision. Two patients had ligation and local excision of a limb of the prosthesis. This led to severe ischemic ulcers in one patient and aboveknee amputation and death from septicemia in the other patient. One further patient had a simple ligation and drainage of one limb of an aorto-femoral bypass and continues to have a sinus with drainage. Axillo-femoral bypass. Five patients had axillo-femoral bypasses. Two patients died-both during the course of staged procedures. One patient had a right axillofemoral TABLE 2. Factors Affecting Rate of Infection bypass inserted to bypass an infected right limb of a graft No. with and, while recovering from this and awaiting removal of Total number infection Rate of infection the prosthesis, died with a massive hemorrhage from an aortoduodenal fistula. Groin Incision 315 10 - 3.2% The other patient had an axillofemoral graft inserted to Present Absent 325 3 - O.9o bypass an infected left limb of an aortic graft and while Groin complication recovering from this and awaiting removal of the graft, Present 22 4 -18.2% 293 6 - 2.0%o bled from the right limb of the aortic prosthesis requiring Absent Antibiotics emergency operation with total removal of the graft and Prophylactic Used 510 11 - 2.2% insertion of a right axillofemoral bypass. The patient Not used 44 1 - 2.3% Type of Procedure developed acute tubular necrosis and died. Aneurysm 53 4 - 7.5% In the 3 surviving patients in this group one had the Emergency Elective Aneurysm 314 5 - 1.6% graft excised and bilateral axillofemorals inserted at the
852
JAMIESON, DEWEESE AND ROB
The rate of infection in our series in those cases in whom it was certain that prophylactic antibiotics had been used was 2.2% (11 infections in 510 cases). It will be noted that this is at the low end of reported infection rates of 1% to 6%.4 7-9.16 In the two other large series reported infection rates were 1.32% in 1662 cases16 and 1.34% in 890 cases.7 Neither of these groups used prophylactic antibiotics. In spite of the low rates of infection both authors recommend prophylactic antibiotics for future use-Szilyagi and his group if the groin is to be incised and Fry et al. on the basis of work done in dogs.10 Therefore although there is no scientific evidence to support prophylactic antibiotics in patients (there is some evidence in laboratory created situations in dogs,6'10 most authorities continue to recommend prophylactic antibiotics when an aortic prosthesis is to be inserted.'4 Management of the infected graft. There is no single agreed method in managing these cases although the introduction of alternative bypass routes has led to their increasing use with excision of the graft. In 1959 Schramel et al.'3 described ligation and local excision for an infected limb of a graft. In 1961 Blaisdell et al.' first described removal of an infected dacron graft with bypass from the thoracic aorta to the extremities. Then in 1963 Blaisdell and Hall2 described the axillaryfemoral bypass and Shaw and Baue'5 described the obturator foramen bypass. Also in 1963 Carter et al." described vigorous local treatment of infected limbs of grafts with excellent results. If there is no evidence that the suture lines of the graft are infected (i.e. no bleeding) nor the pseudo-intima, (i.e. no thrombosis) then local treatment may still be appropriate."'14"16 Leaving the main body and opposite limb of the graft in place and removing only the infected limb has also been carried out with successful results.4'5 However, the only certain way to know that infection will be eradicated is to totally remove the prosthesis. This can be done at one operation with the insertion of bilateral axillo-femorals preceding the removal of the prosthesis or it can be done as a staged procedure concentrating in the first operation on the infected side, (providing it is a limb and not the main body of the graft which is involved). The total excision of the prosthesis and other side axillofemoral graft can be carried out at a separate operation. Improving results with the axillofemoral bypass procedure has led to it being more widely used and in this situation it is often the procedure of choice.""2
Ann.
Surg..
June
1975
Conclusion A series of 664 cases with 2.3% rate of infection of aorto-ilio-femoral grafts is presented. The high mortality of this complication underlines the necessity for prevention which explains why most authorities recommend prophylactic antibiotics, although there is no scientific evidence which shows that they lead to a lower rate of infection. Conservative methods of management sometimes eradicate infection, but the only certain cure is obtained by removing the graft totally. The development and success of axillofemoral bypass technics has led to its use in the management of infected prostheses.
References 1. Blaisdell, F., DeMatter, G. and Gauder, P.: Extra-peritoneal Thoracic Aorta to Femoral Bypass Graft on Replacement for an Infected Aortic Bifurcation Prosthesis. Am. J. Surg., 102:583, 1961. 2. Blaisdell, F. and Hall, A.: Axillary-Femoral Artery Bypass for Lower Extremity Ischemias. Surgery, 54:563, 1963. 3. Carter, S., Cohen, A. and Whelan, T.: Clinical Experience With the Management of the Infected Dacron Graft. Ann. Surg., 158:249, 1963. 4. Conn, J.H., Hardy, J.D., Chavez, C.M. and Fain, W.R.: Infected Arterial Grafts. Experience in 22 Cases with Emphasis on Unusual Bacteria and Technics. Ann. Surg., 171:704, 1970. 5. Diethrich, E.B., Noon, G.P., Liddicoat, J.E. and DeBakey, M.E.: Treatment of Infected Aorto-Femoral Prostheses. Surgery, 68:1044, 1970. 6. Foster, J.H., Berxine, T. and Scott, H.W. Jr.: An Experimental Study of Arterial Replacement in the Presence of Bacterial Infection. Surg. Gynecol. Obstet., 108:141, 1959. 7. Fry, W.J. and Lindenauer, S.M.: Infection Complicating the Use of Plastic Arterial Implants. Arch. Surg., 94:600, 1967. 8. Haffert, P.W., Gensler, S. and Haimovici, H.: Infection Complicating Arterial Grafts. Arch. Surg., 90:427, 1962. 9. Javid, H., Julian, O.C., Dye, W.S. and Hunter, J.A.: Complications of Abdominal Aortic Grafts. Arch. Surg., 85:142, 1962. 10. Lindenauer, S.M., Fry, W.J., Schaub, G. and Wild, D.: The use of antibiotics in the prevention of vascular graft infections. Surgery, 62:487, 1967. 11. Mannick, J.A., Williams, L.E. and Nabseth, D.C.: The Late Results of Axillo-Femoral Grafts. Surgery, 68:1038, 1970. 12. Moore, W., Hall, A. and Blaisdell, F.: Late Results of AxillaryFemoral Bypass Grafting. Am. J. Surg., 122:148, 1971. 13. Schramel, R.J. and Creech, O.: Effects of Infection and Exposure on Synthetic Arterial Prostheses. Arch. Surg., 78:271, 1959. 14. Scott, W.H., Barker, W.F., Cannon, J.A., et al.: Management of Infected Wounds and Grafts-a Panel Discussion. Chapter 27 in Management of Arterial Occlusive Disease. Dale, W.A. (ed.) Year Book Med. Publish., 1971. 15. Shaw, R. and Baue, A.: Management of sepsis complicating arterial reconstructive surgery. Surgery, 53:75, 1963. 16. Szilyagi, E.D., Smith, R.G., Elliott, J.P. and Virandecid, M.P.: Infection in Arterial Reconstruction with Synthetic Grafts. Ann. Surg., 176:321, 1972.
