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Ann Thorac Surg 1998;65:1135-1137
© 1998 The Society of Thoracic Surgeons
a Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
Accepted for publication November 2, 1997.
Address reprint requests to Dr Palma, Department of Surgery, Escola Paulista de Medicina Federal University of São Paulo, Rua Botucatu, 740, São Paulo, SP 04023-900, Brazil
e-mail: (jhpalma.dcir{at}epm.br)
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Abstract |
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Introduction |
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A 26-year-old man was referred to São Paulo Hospital of Escola Paulista de Medicina because of a traumatic rupture of the thoracic aorta, close to the origin of the subclavian artery, after a car accident. He underwent a left posterolateral thoracotomy, and the lesioned portion of the aorta was replaced with a 4-cm-long Dacron prosthesis, with the aid of femorofemoral bypass. The procedure was uneventful, and the patient was discharged on the 7th postoperative day (Fig 1). Cefazolin was administered as antibiotic prophylaxis for 48 hours.
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The chest radiography showed a marked enlargement of the mediastinum. Bronchoscopy revealed fresh blood and clots in the left lung, and the diagnosis was an aortopulmonary fistula resulting from a ruptured suture caused by graft infection. Chest computed tomography and magnetic resonance imaging suggested rupture at the proximal anastomosis of the graft.
Broad-spectrum antibiotic administration was begun and because of the imminent risk of total rupture a new emergency operation was decided upon. The operation was performed again through a left posterior lateral thoracotomy incision, and when the chest was opened, hard adherences made difficult the access to the graft, which was surrounded by oozing inflammatory tissues and clots. Characteristically, the prosthesis was not encapsulated.
Femorofemoral normothermic partial bypass and a bubble oxygenator (Macchi, São Paulo, Brazil) were used.
Because of infection in the prosthesis, a decision was made in favor of use of a biological graft. The great saphenous vein was harvested in the left leg, from the malleolus to the crus, and longitudinally opened. A spiral composite vein graft was fashioned over a 
-inch tube with a running suture and was 5 cm in extension. It was interposed in the thoracic aorta, replacing the infected graft. At the end of the procedure, the chest was closed with two intercostal tubes, and drainage and local irrigation with diluted povidone-iodine solution was instituted.
The total bypass time was 65 minutes and the postoperative course was complicated by excessive bleeding from the chest drainage caused by hemostatic disorders; this was corrected, but reintervention was necessary for clot evacuation. Hemoculture and culture from the graft confirmed infection by Acinetobacter baumannii, sensitive only to imipenen; administration of imipenen was intravenously maintained for 4 weeks. The patient was discharged 4 weeks after the operation and is on clinical follow-up in our service. The patient is well 36 months after the operation and has returned to his former job. Figure 2 depicts a computed tomogram at last follow-up, showing a normal aspect of the venous graft without dilatation when compared with previous computed tomographic controls.
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Comment |
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A prosthetic graft is subject to contamination from many sources, either at the time of the initial procedure or many months or even years after the graft is put in place. Prompt reintervention is necessary when prosthesis infection is diagnosed and requires graft removal, antibiotic therapy, and arterial reconstruction [2]. When the infected prosthesis is located in the thoracic aorta, the options for treatment are limited because of anatomic and physiologic aspects.
In situ graft replacement by another prosthetic graft is an option that has been proposed for the treatment of infected aortic prostheses [2, 3]. Excision of the aortic graft and use of extraanatomic bypass constitutes another treatment option [4].
Some authors recommend that dead space around a prosthesis be filled with healthy, well-vascularized tissue. This tissue may be available locally from thymus gland, mediastinal pleura, or lung or may be obtained by a pedicled flap of omentum or pectoral muscle [5].
The reuse of an in situ new synthetic graft involves the risk of infection reappearance. Biological grafts appear to be a logical option for treatment [6], and the use of a spiral vein conduit seems advisable. The acquisition and construction of the autogenous vein graft is simple and versatile, producing a grafted vessel with predictable caliber and length [7]. We do not know whether this solution would have had success if Staphylococcus aureus or another highly pathogenic germ were present.
In our patient, late follow-up and periodic chest computed tomograms revealed no dilatation of the venous graft. More extensive follow-up is needed to confirm the long-term durability of the spiral vein conduit.
In conclusion, spiral composite vein graft appears to be a good option for treatment of infected arterial grafts. The autogenous conduit is easy to harvest and construct.
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This article has been cited by other articles:
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  B. Toursarkissian, R. P. Smilanich, and M. T. Sykes Autologous Superficial Femoral Vein for the Repair of Suprarenal Mycotic Aneurysms: A Preferred Conduit?: A Case Report Vascular and Endovascular Surgery, March 1, 2001; 35(2): 157 - 161. [Abstract] [PDF]
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