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

This Article Abstract Full Text (PDF) 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): Joren C. Madsen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mathes, D. W. Articles by Madsen, J. C. Search for Related Content PubMed PubMed Citation Articles by Mathes, D. W. Articles by Madsen, J. C.

Ann Thorac Surg 2000;70:1410-1412
© 2000 The Society of Thoracic Surgeons

---

Case report

Successful in situ treatment of an infected ascending aortic graft

^a Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
^b Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
^c Department of Surgery, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

Address reprint requests to Dr Madsen, Department of Surgery, Massachusetts General Hospital, 55 Fruit St, EDR 105, Boston, MA 02114
e-mail: madsen{at}helix.mgh.harvard.edu

	Abstract

Top Abstract Introduction Comment References

 
Infection of an ascending aortic prosthesis is a grave complication associated with a high mortality. In most cases, extraanatomic bypass and removal of the infected vascular graft are not possible. Furthermore, the standard approach to this problem, which includes excision and replacement or debridement and repair of infected thoracic aortic grafts, carries a high early mortality. We report the successful treatment of this life-threatening complication using a conservative strategy in which the aortic prosthesis was salvaged by in situ disinfection followed by coverage with tissue flaps.

	Introduction

Top Abstract Introduction Comment References

 
Infection of an ascending aortic prosthesis is a grave complication, which in most cases is not amenable to extraanatomic bypass and removal of the infected vascular graft. The standard approach to this problem, which includes excision and replacement or debridement and repair of infected thoracic aortic grafts, carries a high early mortality [1]. By applying the principles of prompt and aggressive serial debridement, in situ irrigation with an antimicrobial solution, and transposition of healthy tissue, we were able to avoid a high-risk operation and salvage an infected thoracic aortic prosthesis in a patient who has had no infectious sequela or suture line complications in more than 3 years.

The patient is a hypertensive 36-year-old man who underwent repair of an atrial septal defect and pulmonary valvulotomy at the age of 18 years. In April 1997 he presented to an outside hospital with acute substernal chest pain, fever, and a positive urine white blood cell count (WBC) screen. A routine chest roentgenogram demonstrated widening of the mediastinum and a chest computed tomographic (CT) scan confirmed the presence of a type A ascending aortic dissection. He was transferred to Massachusetts General Hospital (MGH) and underwent immediate redo sternotomy and replacement of his ascending aorta with a #34 Hemashield tube graft (Boston Scientific, Boston, MA) under hypothermic circulatory arrest. The patient received perioperative cefazolin and vancomycin. He was well until postoperative day (POD) 4, when he developed a fever to 101°F and was noted to have foul-smelling drainage from his sternal incision. Both the sternal drainage and blood cultures grew Proteus vulgaris. His antibiotic regimen was broadened to include vancomycin, ofloxacin, ceftazidime, and gentamycin, and he was taken to the operating room (OR) for mediastinal exploration. Purulent fluid was found throughout the mediastinum. The fluid, which cultured positively for P vulgaris, had puddled around the aortic prosthesis and was in direct contact with the exposed suture lines. After copious irrigation and debridement of devitalized tissue, the omentum was transferred from the abdomen to cover the graft, and irrigation catheters were placed for topical infusion of gentamycin solution. However, he remained febrile with a leukocytosis, despite tailoring his antibiotic regimen according to culture and sensitivity data. He was returned to the OR on POD 12 and his sternum was found to be necrotic. The sternum was resected completely and the chest was left open. The patient defervesced over the next 2 weeks on wet-to-dry dressing changes to the mediastinum.

On POD 25 the patient was taken back to the OR with the intention of closing the chest defect with bilateral pectoralis major flaps. However, pus was encountered between the omental flap and the aortic graft, necessitating partial resection of the omental flap and further wound debridement. The aortic prosthesis was completely exposed, and an irrigation-drainage system was constructed by placing a sump drain at the base of the wound, behind the aortic graft, and placing a Bardex catheter (Bard Medical Division, Covington, GA) high in the superior aspect of the incision. Over the next 13 days, the aortic graft was continuously irrigated with a 1% povidone-iodine drip (20 to 30 cc/h). Serum iodine concentrations (normal = 4 to 8 mg/dL) and liver function tests were monitored to avoid iodine toxicity. On POD 40 the aortic graft was covered with an extended omental flap based on the right gastroepiploic artery and bilateral pectoralis major flaps based on the internal mammary artery. The muscle flaps were covered with a split-thickness skin graft. The patient remained afebrile and was discharged from MGH 17 days later. He was treated with an additional 30 days of intravenous aztreonam, followed by a lifelong course of oral trimethoprin/sulfamethoxazole. Follow-up chest CT scans have shown no evidence of mediastinal collections or false aneurysms. Today, more than 38 months after the first operation, the patient is doing well, is gainfully employed, and has a cosmetically acceptable wound.

	Comment

Top Abstract Introduction Comment References

 
We report a patient whose thoracic aortic graft was contaminated by a purulent mediastinitis. This secondary graft infection is distinguished from a primary graft infection or prosthetic endocarditis, which usually results from hematogenous contamination. The reported incidence of graft infections of all types after thoracic aortic operations ranges from 0.9% to 1.9% [1]. The established principles regarding the management of an infected vascular prosthesis include explantation of the infected graft, extraanatomic bypass of blood through a clean field, radical debridement of all infected/necrotic tissues, and systemic antibiotics. However, extraanatomic bypass, the cornerstone of management for infected vascular grafts, is less realistic for infected thoracic aortic grafts because of anatomic and physiologic considerations. Instead, the standard surgical approach to this problem has been excision and in situ replacement of the infected prosthesis with another synthetic graft or, preferably, a homograft. Partial graft excision and repair have been used for longer patent grafts in cases in which the infection was localized to a limited portion of the graft. However, these techniques are associated with high mortality rates. Indeed, one of the largest and most recent series of thoracic aortic graft infections treated by complete or partial excision of the prosthesis reported an in-hospital mortality of 42% [2]. We have performed a MEDLINE search and tabulated the world literature (reports in English published after 1966) on the treatment of infected thoracic aortic grafts (Table 1). This review confirmed the high mortality associated with surgical excision and in situ replacement with a prosthetic graft.

A recent report demonstrated the successful treatment of similar cases using iodine to treat the graft and mediastinal bed before tissue transposition [6]. However, instead of a controlled constant infusion of iodine solution over the graft, these authors packed the open chest with sponges, soaked in a 10% iodine solution, every 8 hours for 48 hours. The disadvantage of this technique is its potential for iodine toxicity. Indeed, 1 of 6 patients treated with iodine-soaked sponges required hemofiltration because of severe hepatic dysfunction because of iodine toxicity [6]. Theoretically, using a constant infusion system and a lower concentration of PVP-iodine (1% solution) and monitoring iodine levels, as we did, should serve to minimize the danger of iodine intoxication.

In summary, by applying the principles of prompt and aggressive serial debridement, antibiotic disinfection, and transposition of healthy tissue, we were able to avoid a high-risk operation and salvage an infected thoracic aortic prosthesis in a patient who has had no infectious sequela or suture complications in more than 3 years. Based on this case and others [3–6], we suggest that aggressive debridement, in situ irrigation with an antimicrobial solution, and tissue transposition may be the treatment of choice for an infected thoracic aortic prosthesis, even if suture lines are exposed, provided that (1) the graft infection is secondary to mediastinal contamination with an organism of relatively low virulence and (2) a high-risk operation is not mandated by an anatomic lesion such as a false aneurysm or anastomotic leak. In cases of primary graft infection or of infected grafts associated with false aneurysms, graft explantation and homograft placement are preferable.

	References

Top Abstract Introduction Comment References

 

1. Hargrove W.C., Edmunds L.H.J. Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg 1984;37:72-77.[Abstract]
2. Coselli J.S., Koksoy C., LeMaire S.A. Management of thoracic aortic graft infections. Ann Thorac Surg 1999;67:1990-1993.[Abstract/Free Full Text]
3. Sakurai H., Tamaki S., Hara S., Nishizawa T., Murayama H., Murase M. A case successfully treated by conservative management for mediastinitis and infected composite graft due to methicillin-resistant coagulase negative Staphylococcus. Ann Thorac Cardiovasc Surg 1998;4:226-229.[Medline]
4. Kawashima T., Kamisawa O., Ohki S., Hasegawa N., Konishi H., Fuse K. A case of successful treatment of mediastinitis and prosthetic graft infection after aortic arch and thoracoabdominal aortic reconstruction. Nippon Kyobu Geka Gakkai Zasshi 1997;45:220-224.[Medline]
5. Asano S., Murayama H., Ishida A., Nakagawa Y., Ito M., Sudo Y. A case report of mediastinitis due to methicillin resistant Staphylococcus aureus after total aortic arch replacement. Nippon Kyobu Geka Gakkai Zasshi 1996;44:814-819.[Medline]
6. Nakajima N., Masuda M., Ichinose M., Ando M. A new method for the treatment of graft infection in the thoracic aorta. Ann Thorac Surg 1999;67:1994-1996.[Abstract/Free Full Text]
7. 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]
8. Miller D.W.J., Johnson D.D. Omental pedicle graft in the management of infected ascending aortic prostheses. Ann Thorac Surg 1987;44:614-617.[Abstract]
9. Coselli J.S., Crawford E.S., Williams T.W.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]
10. Soyer R., Bessou J.P., Bouchart F., et al. Surgical treatment of infected composite graft after replacement of ascending aorta. Ann Thorac Surg 1994;58:425-428.[Abstract]
11. Krabatsch T., Hetzer R. Infected ascending aortic prosthesis. Eur J Cardiothorac Surg 1995;9:223-225.[Abstract]
12. Chavanon O., Thony F., Lebeau J., Blin D. Exposed prosthesis of a complex reconstruction of the ascending aorta and aortic arch in a sternal wound infection. Eur J Cardiothorac Surg 1998;13:98-100.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. A. LeMaire and J. S. Coselli Options for managing infected ascending aortic grafts. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 839 - 843. [Full Text] [PDF]

				Y. Nishimura, Y. Okamura, T. Hiramatsu, H. Mori, H. Hayashi, and S. Komori Successful in situ Treatment of Infected Aortic Arch Prosthesis by Omental Wrapping Asian Cardiovasc Thorac Ann, October 1, 2006; 14(5): e93 - e95. [Abstract] [Full Text] [PDF]

				A. Mitra, J. Spears, V. Perrotta, J. McClurkin, and A. Mitra Salvage of Infected Prosthetic Grafts of the Great Vessels via Muscle Flap Reconstruction Chest, August 1, 2005; 128(2): 1040 - 1043. [Abstract] [Full Text] [PDF]

				Y. Kawachi, A. Nakashima, T. Onzuka, and T. Yamauchi False aneurysm of the ascending aorta concomitant with chronic mediastinitis after tube graft replacement in octogenarian Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 450 - 453. [Abstract] [Full Text] [PDF]

				E. Neri, O. Coffin, T. Toscano, M. Massetti, F. Bizzarri, G. Capannini, G. Frati, and C. Sassi Replacement of infected prosthesis on the ascending aorta with an abdominal aortic autograft in a young patient J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 194 - 195. [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Joren C. Madsen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mathes, D. W. Articles by Madsen, J. C. Search for Related Content PubMed PubMed Citation Articles by Mathes, D. W. Articles by Madsen, J. C.