Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study

doi:10.1016/j.avsg.2009.07.020

Annals of Vascular Surgery

Volume 24, Issue 3, April 2010, Pages 336-341

https://doi.org/10.1016/j.avsg.2009.07.020 Get rights and content

Background

To look at wound complications with either a transverse or vertical groin incision in vascular surgery.

Methods

All patients undergoing vascular procedure requiring access to femoral vessels were randomized to either a vertical or transverse incision. Patients were followed up for 28 days after the procedure and examined for wound infection, wound breakdown, development of lymphatic leak and lymphatic collection.

Results

88 patients (116 groins) were randomised to either incision. Of these, 55 groins had transverse incisions and the remaining had vertical incisions. There was no significant difference in the patient's age, sex, smoking, diabetes, operative times and use of prosthetic material. 29/61 (47.5%) of vertical incisions and 7/55 (12.7%) of transverse incisions had wound complications (p<0.001). There were 13(11%) wound infections in the 116 groins by day 28. There were 3 wound infections in the transverse group and 10 infections in the vertical group (p=0.062). There were 17 (27.9%) lymphatic leaks in the vertical incisions compared to 7(12.7%) in the transverse incisions (p=0.044). The majority of infections were diagnosed after patient discharge from hospital.

Conclusion

Wound complications are higher with vertical incision. Many infections are diagnosed after patient discharge. We recommend transverse incisions for access to the femoral vessels in the groin.

Introduction

Open access to the femoral vessels is traditionally through a vertical incision. Although this approach gives good surgical access, wound healing can be complicated by sepsis, lymphatic leaks, and wound breakdown. This can ultimately lead to the feared complication in vascular surgery of graft sepsis.¹

Some predisposing factors for wound infection in vascular surgery are well known, including emergency surgery, diabetes, and the presence of a groin incision.¹ The effect of the type of groin incision (vertical or transverse/oblique) on wound complications has been debated. There are a limited number of studies that have looked at the effect of the type of wound incision on wound infection and lymphatic problems.2, 3 These studies have been limited by either a short follow-up² or by being a retrospective case analysis.³ These studies also did not look at the adequacy of the surgical access between the different incisions. We therefore conducted a prospective randomized study addressing these problems.

Section snippets

Method

Patients undergoing vascular surgery requiring exposure of the femoral artery at two institutions (Westmead and Liverpool Hospitals) were randomized to either a vertical or a transverse incision. Patients were excluded from the study if they had undergone previous vascular surgery in the index groin or died before the completion of the study period. Patients were randomized to their incision based on the last digit of the hospital number either even or odd. For bilateral groin incisions, based

Results

Ninety consecutive patients (119 groins) were eligible for the study. One patient (two groins) was excluded before randomization due to the surgeon's request, and one patient (one groin) was excluded from the final analysis due to death at day 4. Therefore, 88 patients (116 groins) were randomized and included in the final analysis. Of these, 55 groins underwent transverse incisions and 61 had vertical incisions.

The operations in this study were performed by two vascular trainees and by six

Discussion

Groin incisions are prone to complications, including infection, wound dehiscence, lymphatic leaks, and hematoma. This has been shown in prospective studies to range from 10% to 33%.5, 6 Groin incisions over many years have consistently shown to be a risk factor for wound infection as well as graft infections.7, 8, 9, 10 Traditional groin incisions have been vertical. This follows the path of the femoral vessels and allows for good surgical access as well as the ability to extend the wound

Conclusion

Although this study is underpowered, it would appear to support the hypothesis that transverse incisions for femoral vessel access sustain fewer complications than vertical incisions, and this would support the conclusions of Chester et al. We therefore recommend that a transverse incision be the incision of choice in vascular surgery to access the femoral vessels. This may be of particular importance if prosthetic graft is to be used. The transverse incision is probably somewhat harder to use

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Lymphatic complications after vascular surgery are frequent, but their optimal management is still controversially discussed. Early surgical intervention with ligation of the leaking vessels seems to reduce recurrence rates and improve outcomes. The use of indocyanine green (ICG) fluorescence imaging can help identify leaking vessels, but its value in vascular procedures is still underreported.
Between January 2020 and December 2021, ICG lymphangiography was used in three patients who presented persistent lymphatic drainage after vascular procedures in the groin. Verdye ® ICG was injected at the anterior, medial, and lateral aspects of the thigh and the wound examined with an infrared laparoscopy camera. Leaking lymphatics were identified and oversewn or closed by a vessel-sealing device.
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Systematic review of groin incision surgical site infection preventative measures in vascular surgery
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Citation Excerpt :
The rate of 30-day surgical site infections (SSIs) following open infrainguinal arterial revascularization can range from 4.8% – 43%.1–4
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Clinical ResearchVertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study

Background

Methods

Results

Conclusion

Introduction

Section snippets

Method

Results

Discussion

Conclusion

J Infect

Am J Surg

Surgery

Ann Vasc Surg

Ann Vasc Surg

Guidelines for prevention of surgical site infection, 1999

Infect Control Hosp Epidemiol

Clinical Research
Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study