HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takahiro Katsumata Stephen Westaby Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Katsumata, T. Articles by Westaby, S. Search for Related Content PubMed PubMed Citation Articles by Katsumata, T. Articles by Westaby, S.

Ann Thorac Surg 1997;64:1464-1466
© 1997 The Society of Thoracic Surgeons

---

Case Report

Homograft Aortic Replacement for Infected Mediastinal False Aneurysm

Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Oxford, England

Accepted for publication April 28, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
The management of prosthetic graft infection is still challenging. We report in situ repair of an infected mediastinal false aneurysm by ascending aortic replacement with a fresh aortic homograft.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
The combination of vascular graft infection with suture line dehiscence and mediastinal abscess formation is particularly difficult to treat. Although extraanatomic apicoaortic bypass is a theoretical possibility, only a direct procedure to remove all infected tissue will result in cure. In this situation an aortic homograft is more likely to resist reinfection than synthetic conduits.

A 66-year-old man presented 14 months after ascending aortic replacement and root repair for acute type A dissection. His functionally normal native bicuspid aortic valve had been preserved. The early postoperative course was complicated by coagulopathy, which required surgical reentry, mediastinal packing, and sternal closure 36 hours later.

Over the next 12 months there were sporadic febrile episodes, which resolved without treatment. At 14 months an acute febrile illness was accompanied by retrosternal chest pain. The patient was then referred to hospital for investigation. Although blood cultures failed to grow an organism, both two-dimensional echocardiography and magnetic resonance imaging (Fig 1) demonstrated a periaortic mediastinal false aneurysm, with blood flow emanating from the aortic root. Blind antibiotic treatment was considered unlikely to provide clinical resolution, and an early operation was recommended.

View larger version (95K): [in this window] [in a new window]   Fig 1. . Preoperative magnetic resonance images showing a large mediastinal abscess surrounding the ascending aortic graft (arrow). Note the patent false channel in the dissected descending aorta.

All Dacron and suture material were excised. The infected root was debrided and distally the septum between true and false lumen was excised within the aortic arch. The mediastinal abscess cavity was widely deroofed. The ascending aorta was then re-replaced using a 25-mm fresh aortic homograft with the coronary arteries ligated and the aortic cusps excised. The remnant of the homograft anterior mitral leaflet was positioned posteriorly above the left coronary artery. The competent, nonstenotic native bicuspid valve was preserved again and the continuous suture line continued around the debrided parts of the root, which were buttressed by muscle of the homograft inflow. The right coronary ostium was sacrificed to achieve a secure inflow suture line, and a bypass graft was inserted. The distal homograft was then sutured to the native aortic arch at the level of the innominate artery, using the open-ended technique to ensure anterograde flow into both true and false lumens. The homograft was deaired and on resumption of cardiopulmonary bypass the repair was blood-tight (Fig 2). Cardiopulmonary bypass was discontinued without difficulty, and after the anterior mediastinum was washed with antiseptic solution, the chest was closed directly.

View larger version (193K): [in this window] [in a new window]   Fig 2. . A fresh aortic homograft has been implanted in situ after total excision of the Dacron prosthesis. The right coronary artery was revascularized with a saphenous vein graft.

	Comment

Top Footnotes Abstract Introduction Comment References

 
The homograft aortic valve [1, 2] is known to resist reinfection in endocarditis patients with root abscess formation. We therefore applied the same principle for ascending aortic replacement. With the homograft valve cusps excised, the patient's own right and noncoronary sinuses were replaced by those of the donor. The principles of aortic root repair were therefore followed but with a biological conduit. Although we and others [3–5] prefer to use aortic homografts to replace infected prosthetic material, there have been satisfactory results reported with the use of Dacron grafts [6, 7].

Infection, reoperation, prolonged perfusion, and hypothermia all predispose to abnormal bleeding. In an effort to minimize the effects of prolonged perfusion and hypothermia, we did not commence bypass before sternotomy despite the risk of hemorrhage. When profuse bleeding is encountered at this time, cardiopulmonary bypass can be established immediately with venous return from both the interior vena cava and cardiotomy suckers until an aortic cross-clamp (or endoaortic balloon) is applied.

In this case we preserved the well-functioning native bicuspid aortic valve for the second time in preference to performing aortic root replacement with a homograft. This would have entailed an extremely difficult mobilization and reimplantation of the coronary ostia at the site of previous aortic dissection repair. We anticipate that the patient's own bicuspid valve will still have similar durability to a donor aortic homograft.

	Footnotes

Top Footnotes Abstract Introduction Comment References

 
Address reprint requests to Mr Westaby, Oxford Heart Centre, John Radcliffe Hospital, Oxford OX3 9DU, England.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Kirklin JK, Kirklin JW, Pacifico AD. Aortic valve endocarditis with aortic root abscess cavity: surgical treatment with aortic valve homograft. Ann Thorac Surg 1988;45:674–7.[Abstract]
2. Donaldson RM, Ross DM. Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation 1984;70(Suppl 1):178–81.[Abstract/Free Full Text]
3. Pasic M. Mycotic aneurysm of the aorta: evolving surgical concept. Ann Thorac Surg 1996;61:1053–4.[Free Full Text]
4. Knosalla C, Weng Y, Yankah AC, Hofmeister J, Hetzer R. Using aortic allograft material to treat mycotic aneurysms of the thoracic aorta. Ann Thorac Surg 1996;61:1146–52.[Abstract/Free Full Text]
5. Vogt PR, von Segesser LK, Goffin Y, Pasic M, Turina MI. Cryopreserved arterial homografts for in situ reconstruction of mycotic aneurysms and prosthetic graft infection. Eur J Cardiothorac Surg 1995;9:502–6.[Abstract]
6. Chan FY, Crawford SE, Coselli JS, Safi HJ, Williams TW Jr. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193–203.[Abstract]
7. Pasic M, Carrel T, von Segesser L, Turina M. In situ repair of mycotic aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1993;105:321–6.[Abstract]

This article has been cited by other articles:

				I. Yamazaki, Y. Ichikawa, M. Ishii, T. Hamada, and H. Kajiwara Using Fascia Lata to Treat Infective Aortic False Aneurysm Ann. Thorac. Surg., April 1, 2005; 79(4): 1425 - 1427. [Abstract] [Full Text] [PDF]

				J. Wippermann, J. M. Albes, H. Brandes, and T. Wahlers Punch-hole aneurysm of the ascending aorta after coronary artery bypass surgery Interactive CardioVascular and Thoracic Surgery, September 1, 2003; 2(3): 385 - 386. [Abstract] [Full Text] [PDF]

				T. Katsumata, N. Moorjani, G. Vaccari, and S. Westaby Mediastinal false aneurysm after thoracic aortic surgery Ann. Thorac. Surg., August 1, 2000; 70(2): 547 - 552. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takahiro Katsumata Stephen Westaby Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Katsumata, T. Articles by Westaby, S. Search for Related Content PubMed PubMed Citation Articles by Katsumata, T. Articles by Westaby, S.