17.3 The temporary Intra-wound use of nanocystalline silver* to aid primary closure of infected arteriovenous graft wounds in patients with end-stage renal disease          

Gregory K. Patterson, MD, FACS, CWS; Erkan Alci, MSIII, BS; Derren Harrison, PA-C; South Georgia Surgical Associates

Infected wounds with foreign body such as vascular graft material, are extremely difficult to deal with, especially in patients with end-stage renal disease. We report a series of 3 patients over a recent period who presented with infected arteriovenous (AV) graft utilized in hemodialysis. With a graft infection such as these, the patients often undergo removal of the foreign material & the wounds are many times left open, to close in a secondary fashion or even with delayed primary closure some 5 to 7 days later. This often delays further vascular access while the wound is closing and can lead to contamination of other temporary vascular access devices.

Three patients presented with obvious infection of these grafts. Two patients had infected pseudoaneurysms and 1 patient had swelling and epidermolysis. One patient was frankly septic. One patient had undergone removal of an infected graft several weeks prior and had a small remnant of graft material left on the brachial artery as a patch repair. Two patients under went repair of the brachial artery utilizing a reverse saphenous vein bypass directly in the infected field for distal upper extremity salvage. The other patient had a salvageable portion of the graft remaining.

In all 3 cases primary lose closure was preformed after removal of the infected foreign graft material, debridement and washout of the wounds were preformed. In all 3 patients nanocrystalline silver based dressings were utilized by cutting these into 0.5 to 1.0 cm wide strips. These were placed into the wound, in between the skin suture material. These classic external dressings acted as "internal wicks" removing wound exudate and delivering silver for antimicrobial treatment in to the depth of the wounds. The "wicks" were removed between post-operative Day 5 to 7. In all 3 cases wound healing was achieved without further intervention. One patient died approximately 30 days later from complications from multiple myeloma.

*Nanocrystalline silver dressings Ð Acticoat^ª, Smith & Nephew Wound Management, Largo, Fla