Should a non-functioning Femoral Arteriovenous (AV) graft be surgically removed?

Management of Non-Functioning Femoral AV Grafts

A non-functioning femoral AV graft should be surgically removed if there is evidence of infection, but can be left in place if it is simply thrombosed without signs of infection or other complications.

Decision Algorithm for Non-Functioning Femoral Grafts

Immediate Removal Required

Remove the graft urgently if any of the following are present:

• Active infection with systemic signs (bacteremia, sepsis, fever) - requires antibiotics plus total graft excision 1
• Local infection with purulent drainage or abscess formation - requires surgical exploration and removal of infected graft material 1
• Bleeding or threatened rupture at the graft site - indicates graft degeneration requiring urgent intervention 1
• Severe degenerative changes with overlying skin compromise (poor eschar formation, spontaneous bleeding, rapid pseudoaneurysm expansion) 1
• Subclinical infection manifested as unexplained anemia requiring high epoetin doses or systemic inflammatory response - may require indium-labeled white blood cell or gallium scan for diagnosis 1

Removal Strongly Considered

Consider removal in these scenarios:

• Chronic non-healing ulcers with sinus formation along the graft conduit route - this was the most common presentation (89.6%) in infected femoral grafts 2
• Persistent symptoms despite conservative management in a thrombosed graft
• Patient has alternative access options available (functioning fistula or upper extremity graft) 3

Can Be Left in Place

Observation is acceptable if ALL of the following are true:

• Graft is simply thrombosed without any signs of infection 1
• No skin changes or degenerative complications 1
• No systemic symptoms (fever, bacteremia, elevated inflammatory markers) 1
• Patient is not a candidate for new access creation 3, 4

Critical Evidence Supporting This Approach

Infection Mandates Removal

The KDOQI guidelines are unequivocal: infected AV grafts require both antibiotic therapy AND surgical removal because the graft material acts as a foreign body that prevents infection resolution 1. Untreated access infections lead to bacteremia, sepsis, hemorrhage, and death 1.

• For extensive infection: total graft resection plus antibiotics is required 1
• For localized infection: incision and resection of the infected portion may suffice 1
• Initial antibiotics should cover Gram-negative, Gram-positive organisms, and Enterococcus 1

Femoral Grafts Have Unique Infection Risks

Research shows that femoral grafts carry particularly high infection rates:

• In one series, 50% of femoral graft losses were due to infection (27% of all grafts placed) 4
• Among patients with infected prosthetic femoral grafts, 38.5% developed graft infection requiring removal 2
• However, another study showed that with appropriate patient selection, femoral grafts can have acceptably low infection rates comparable to upper extremity access 5

Thrombosed Grafts Without Infection

The guidelines do not mandate removal of simply thrombosed grafts that lack infection or other complications 1. The focus is on treating stenosis and thrombosis to restore function, not automatic removal 1.

Common Pitfalls to Avoid

• Do not delay removal of infected grafts - mortality and morbidity increase substantially with delayed treatment 1, 3
• Do not assume superficial infection can be treated with antibiotics alone if the graft material is involved - surgical intervention is required 1
• Do not leave retained graft material in cases of infection - subclinical infection from retained material causes persistent inflammation and epoetin resistance 1
• Be aware that graft removal is highly morbid - 36.2% complication rate, 30% readmission at 30 days, and only 52% of eligible patients receive new access within 1 year 3

Specific Considerations for Femoral Grafts

Femoral grafts present unique challenges:

• Higher thrombosis rates (46% thrombotic events) but comparable patency to upper extremity access when properly selected 5
• Presentation of infection is often indolent - chronic ulcers with sinus formation rather than acute sepsis 2
• Graft occlusion occurs in 95.8% of infected femoral grafts 2
• Removal is relatively straightforward - average operative time 35 minutes with minimal blood loss when infection is present 2

Post-Removal Management

After infected graft removal:

• Vessel stumps should be ligated when technically feasible (68.8% of cases) 2
• Plan for alternative access - though many patients (48%) do not receive definitive access within the first year 3
• Close follow-up is essential to reassess for potential new access creation 3
• Amputation and severe limb ischemia are rare after femoral graft removal (no cases in one series of 47 patients) 2