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Prophylactic Groin Flaps in Vascular Surgery: A Cohort Study Evaluating Efficacy, Indications, and Treatment Algorithm
John P. Fischer, MD, Jonas A. Nelson, MD, Shareef Jandali, MD, Michael N. Mirzabeigi, MS, Paul Foley, MD, Stephen J. Kovach, MD, Liza C. Wu, MD, Joseph M. Serletti, MD, Suhail Kanchwala, MD.
University of Pennsylvania, Philadelphia, PA, USA.

BACKGROUND:
Vascular surgery-related groin complications represent a significant healthcare burden and lead to catastrophic outcomes, including graft sepsis, limb-loss, and death. To prevent this, our institution elects early muscle flap coverage for complicated groin wounds. We have taken further steps to prevent complications at the initial vascular procedure by performing “prophylactic” flaps. The purpose of this study is to examine which factors predict groin complications, to evaluate the benefit of prophylactic flaps, to devise a risk assessment tool, and to determine economic impact.
METHODS:
The authors performed a retrospective cohort study on patients undergoing open vascular groin surgery at the University of Pennsylvania between 2005 and 2010. Patients who underwent intitial prophylactic muscle flaps were compared to open groin surgery patients. Endpoints assessed included: pre-operative co-morbidities, procedure and flap type, anesthetic factors, operative and post-operative course, and early post-operative complications. A scoring system for preoperative risk stratification was devised.
RESULTS:
68 prophylactic flaps in 53 patients were compared to 199 open groin procedures in 178 patients. Prophylactic patients had higher rates of COPD (25% vs. 13%, p=0.015), smoking (47% vs. 26%, p=0.001), HL (81% vs. 60%, p=0.002), and risk scores (5.1 vs. 2.7, p<0.0001), yet they had lower rates of complications (16% vs. 52%, p<0.001), seroma (0% vs 8%, p=0.037), infection (1.5% vs. 39%, p<0.001), breakdown (8.8% vs. 19%, p<0.05), and lymphocele (1.5% vs. 15%, p=0.002). Regression analysis revealed groin complications were significantly associated with COPD, obesity, ASA, smoking, redo, and prosthesis. Multivariate regression demonstrated obesity, smoking, redo, and prosthesis were significant. A risk factor score (0-7) was derived: obesity (1), smoking (2), redo (2), and prosthesis (2). Patients were stratified as: Low (0-2), Intermediate (3-4), and High Risk (≥5) (Table 1).
A cost analysis demonstrated that complications created an extra 330 hospital days, 500 days more of antibiotics, and 43 unanticipated flaps at an estimated total cost of $350,000 (Menzin et al., 2010) . Unanticipated groin flaps cost the hospital $129,000 directly, whereas prophylactic flaps cost $15,000. Prophylactic flaps provided a 69% relative reduction in groin complications, and for every 2.8 prophylactic flaps performed we prevented one groin complication.
CONCLUSIONS:
The purpose of this study was to examine the role of prophylactic flaps in select vascular surgery patients. We derived a risk stratification system able to predict groin complications and guide pre-operative assessment. Based on our analyses, patients with higher scores are at greater risk for groin complications and also have more unanticipated flaps. We believe the use of muscle flaps must be considered in Intermediate and High Risk Groins. In our study, groin complications created a large economic burden for our institution through longer hospital stays and days on antibiotics. However, prophylactic flaps reduced complications and created direct cost savings of $75,000/year while being fast, safe, and inexpensive.
score0-23-4≥5
n104100.0%64100.0%31100.0%
complications3937.5%4164.1%2374.2%<0.001
seroma98.7%34.7%412.9%0.363
lymphocele1514.4%914.1%619.4%0.77
hematoma54.8%11.6%26.5%0.44
groin infection 2524.0%3250.0%2167.7%<0.001
superficial1817.3%3250.0%1858.1%<0.001
deep1211.5%69.4%1032.3%0.011
breakdown1413.5%812.5%1651.6%<0.001
flap (any)1716.3%1320.3%1341.9%0.015

Table1. Penn Groin Assessment Scale (PGAS) showing risk stratified patients and associated complication rates


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