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Ann Thorac Surg 1999;67:1994-1996
© 1999 The Society of Thoracic Surgeons

A new method for the treatment of graft infection in the thoracic aorta: in situ preservation

^a First Department of Surgery and Plastic Surgery, School of Medicine, Chiba University, Chiba, Japan
^b Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan

Address reprint requests to Dr Nakajima, First Department of Surgery, School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, 260 Japan

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Material and methods Comment References

 
Background. We have developed a new method to control graft infection by a combination of two procedures, extensive disinfection followed by tissue flap implantation, allowing preservation of the original graft.

Method. Soon after the diagnosis of graft infection was confirmed, the wound was re-explored, and debridement, irrigation and packing with sponges soaked with 10% iodine solution were employed. This procedure was repeated every 8 hours for the first 48 hours. For the second step, tissue flaps using omentum or muscle were implanted around the graft as well as in dead space, and the wound was closed primarily.

Materials. A total of 6 patients were treated: 4 in the acute and 2 in the chronic phase of infection. The original procedures were a Bentall procedure + arch replacement (1), ascending aorta replacement + arch (3) and replacement of the descending aorta (2). In descending aorta cases, an extended thoracoplasty was concomitantly added to eliminate dead space in the pleural cavity.

Results. Graft infections were controlled in all 6 patients. One hospital death unrelated to infection was encountered. Five patients were discharged, but 1 died of a stent-graft complication. The follow-up period ranged from 4 months to 10 years.

Conclusion. Our method of extensive disinfection followed by tissue flap coverage of the graft proved to be highly effective in controlling the serious complication of graft infection associated with surgery of the thoracic aorta.

	Introduction

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Graft infection following surgery of the thoracic aorta is a most serious complication, with a high mortality and morbidity. Various methods of treatment have been reported with some success in the literature, but because of the grave nature of the condition, the final outcome of individual procedures is not consistent. We have introduced a new strategy for the treatment of graft infection following aortic surgery, and have obtained satisfactory results. The concept is to preserve the original graft by mean of extensive disinfection, followed by simultaneous implantation of tissue flaps. In this report, we describe the details of the procedure and present the outcome of our experience.

	Material and methods

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A total of 6 patients, 5 males and 1 female, with ages ranging from 38 to 72 years (mean 54), were treated using the present method. The original disease requiring surgery was a true aneurysm of the ascending aorta and aortic arch (1), type A acute dissection (1), atherosclerotic aneurysm of the arch (2), and a pseudoaneurysm caused by Behcet’s disease and nonspecific aortitis of the descending aorta, each in 1 patient. Signs of infection were noted during the acute phase less than 2 weeks after surgery in 4 patients, while in 2 patients infection was detected 2 weeks after surgery. In all, bacterial cultures were positive either from wound discharge, or from specimens taken at the time of re-exploration, or both. These positive bacterial cultures were of Staphylococcus epidermidis (3), Staphylococcus aureus (1), methicillin resistant Staphylococcus aureus (MRSA) (1), Serratia (1) and Pseudomonas aeruginosa (1). The original reconstructive procedures employed in these patients were a Bentall procedure with replacement of the entire arch (1), replacement of the ascending aorta and the entire arch (3) and partial replacement of the proximal segment of the descending aorta (2).

Strategy to control graft infection
The basic concept of our new treatment is prompt re-exploration of the wound and graft as soon as the diagnosis of graft infection is established, followed by thorough debridement of infected and necrotic tissue. After extensive topical disinfection, a tissue flap is implanted around the original graft, and also in dead space so as to eliminate cavity formation. By applying vital healthy tissue, one can also expect a biological disinfectant effect.

Details of the procedures
When graft infection is strongly suspected or has been positively confirmed, the patient is brought to the operating room and the wound is completely re-explored through the previous incision. Thorough debridement and irrigation with 1% iodine solution are undertaken. After these maneuvers, sponges soaked with 10% iodine solution are packed around the graft as well as in surrounding tissue spaces, and the patient is returned to the ICU with the wound left open but covered with an aseptic drape. In the ICU, the same procedure of irrigation and packing is repeated every 8 hours for a 48 hour period. Meanwhile, the patient is maintained intubated, with respiratory support and total sedation. After 48 hours of the disinfection procedure, the patient is brought back to the OR, the same maneuver is repeated, appropriate tissue flaps are applied around the graft and in dead space, and the wound is closed primarily. For the irrigation, a 10% dilution of the original iodine solution is used, while undiluted iodine solution is utilized for packing.

Tissue flap implantation
For the patients who had surgery with graft replacement in the region from the ascending aorta to the aortic arch, omentum transposition alone was used in 3 patients, while in 1 patient omentum and pectoralis major muscle were simultaneously implanted. For patients who had surgery of the descending aorta, omentum and intercostal muscle were utilized in 1, and pectoralis major and intercostal muscles were employed in the other. In both of them, extended thoracoplasty, with the wide resection of ribs from II to VII, was added to reduce the thoracic cavity so as to eliminate dead space.

Serum iodine concentration during the procedure and after treatment
The serum concentration of iodine was measured during the disinfection procedure as well as after treatment. While normal serum concentration ranges from 4–8 mg/dl, serum iodine concentration in patients was elevated to 5000 mg/dl at 24 hours and 4570 mg/dl at 48 hours after initiation of treatment. This level decreased to 378 mg/dl at 4 days and 92 mg/dl at 7 days after treatment, however.

Outcome
The infection was controlled in all 6 patients. Five patients were discharged from the hospital without signs of infection. There was 1 hospital death, however. This patient died of toxic megacolon 80 days after re-exploration, most probably due to excessive long-term antibiotic administration. The autopsy confirmed that there was no sign of residual infection or of bacteria in tissue specimens. One patient died after 4 months of follow-up. This patient was originally treated for pseudoaneurysm formation in the descending aorta, considered a nonspecific aortitis. He then developed another pseudoaneurysm at the proximal anastomotic site of the graft, but no sign of active infection was found either in clinical or laboratory data. The pseudoaneurysm was treated this time by stent-graft implantation. The patient died suddenly following dislodgment of the stent and total occlusion of the descending aorta. The autopsy could not be performed. The remaining 4 patients were doing well during the follow-up period, which ranged from 15 months to 10 years. From the standpoint of controlling the postoperative graft infection, 100% success was achieved.

	Comment

Top Abstract Introduction Material and methods Comment References

 
Graft infection following surgery of the thoracic aorta is most serious. Our previous 3 cases of graft infection following a Bentall operation were treated with the conventional approach of reconstruction, and all died with uncontrollable fulminant sepsis. Graft infection following thoracic aortic surgery poses quite difficult problems. First of all, infection in the presence of a synthetic graft in the mediastinum or pleural cavity is hard to control. Secondly, creation of an extra-anatomical bypass may be technically feasible but is not very realistic. The resection of an infected graft with in situ reconstruction in the midst of an infection is not acceptable, although we have no experience in using an allograft as an alternative to synthetic material.

A review of reports in the literature allows classification of possible strategies for treatment as 1) antibiotic therapy, 2) debridement, 3) local antiseptic irrigation and lavage, 4) resection of graft and replacement, and 5) tissue transposition. The selection of reported procedures was variable: either a single category was employed, or a combination [1–6].

We first applied our new treatment to the patient with a Bentall operation with simultaneous replacement of the entire aortic arch. The details of this success were reported in the Japanese literature [7] but as far as we know, no similar treatments have as yet been reported. We think that the new strategy of treatment for graft infection reported herein is logically consistent. First, complete disinfection has to be achieved in order to preserve the graft. Secondly, tissue implantation is essential and mandatory. We believe viable and healthy tissues like omentum possess a biological antibacterial effect [2]: the implant should be wrapped around the graft to protect it and create a barrier to infection at the same time it is used to eliminate dead space. Toward this end, we performed extended thoracoplasty as a concomitant procedure in the treatment of descending aortic infection.

For the disinfection procedure, we utilized maximal possible debridement of necrotic, infected tissue, followed by irrigation and packing with sponges soaked with iodine solution. For the former maneuver, we used a 1% solution (10% of the original solution), while for the latter a 10% (undiluted solution) was employed. We repeated this procedure every 8 hours for a duration of 48 hours. The disadvantage of using an iodine solution of high concentration is its toxicity [8]. The first patient treated with the present method had to undergo hemofiltration because of severe hepatic dysfunction. His serum concentration of iodine was markedly elevated for the initial 48-hour period. To avoid iodine intoxication, it is desirable that too high a concentration of iodine solution should not be utilized, but the most appropriate concentration, one which is effective as a bactericidal agent at the same time that it is safe for the individual, remains to be determined.

	References

Top Abstract Introduction Material and methods Comment References

 

1. Hargrove W.C., Edmunds L.H. Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg 1984;37:72-77.[Abstract]
2. Seguin J.R., Loisance D.Y. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest 1985;88:684-686.[Abstract/Free Full Text]
3. Miller D.W., Johnson D.D. Omental pedicle graft in the management of infected ascending aortic prosthesis. Ann Thorac Surg 1987;44:614-617.[Abstract]
4. Coselli J.S., Crawford E.S., Safi H.J., et al. Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps. Ann Thorac Surg 1990;50:868-881.[Abstract]
5. Soyer R., Bessou J.P., Arrignon J., et al. Surgical treatment of infected composite graft after replacement of ascending aorta. Ann Thorac Surg 1994;58:425-428.[Abstract]
6. Hetzer T.K. Infected ascending aortic prosthesis: successful treatment by thoracic transposition of the greater omentum. Eur J Cardiothorac Surg 1995;9:223-225.[Abstract]
7. Harakawa I., Nakajima N., Ando M. A report of successful treatment of mediastinitis and graft infection after ascending and aortic arch reconstruction. Jap J Thorac Surg 1990;38:2112-2116.
8. Glick P.L., Guglielmo B.J., Turley K., et al. Iodine toxicity in a patient treated by continuous povidine-iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478-480.[Abstract]

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