Ann Thorac Surg 2004;77:2194-2195
© 2004 The Society of Thoracic Surgeons
Case report
Successful treatment of ascending aortic graft infection after operation for acute aortic dissection with peripheral malperfusion
Masaaki Kato, MDa*,
Kazuhito Imanaka, MDa,
Shunei Kyo, MDa,
Hiroshi Ohuchi, MDa,
Haruhiko Asano, MDa,
Shinichi Takamoto, MDb
a Division of Cardiovascular Surgery, Department of Surgery, Saitama Medical School, Saitama, Japan
b Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine and Faculty of Medicine, University of Tokyo, Tokyo, Japan
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Kato, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Saitama Medical School, 38 Morohonngou Moroyama-chou Irima-gunn, Saitama 350-0495, Japan
e-mail: katomasa{at}saitama-med.ac.jp
 |
Abstract
|
|---|
Mediastinitis with infection of an ascending aortic graft is hard to heal and is a highly fatal complication. We had a patient in whom mediastinitis with infection of such a graft as well as an ascending aorta–femoral artery bypass graft developed after the initial operation for type A aortic dissection accompanied by peripheral malperfusion. We treated it successfully by inserting a stent into the true lumen of the thoracoabdominal aorta and using a cryopreserved homograft to replace the infected ascending aortic fabric graft.
|
Introduction
|
|---|
Infection involving a prosthetic aortic graft continues to be an infrequent but dreaded complication of operations on the aorta. One of the most important principles that evolved over the last three decades of the past century was that of total excision of all infected graft material and prosthetic revascularization through an alternative route. However, when an ascending aortic graft is infected, there is no other way except in situ replacement of the infected graft. We successfully removed all prosthetic grafts and performed reconstruction using a cryopreserved homograft and a metallic stent.
A 53-year-old woman was transferred to our hospital for acute type A aortic dissection and shock resulting from cardiac tamponade. Computed tomography showed that the dissection had extended to the common iliac artery, and the intimal tear was detected in the ascending aorta by transesophageal echocardiography. Emergent operation consisted of replacement of the ascending aorta with a tabular fabric graft (Gelweave: Sulzer Vascutek Ltd, Inchinnan, Renfrewshire, UK) and resuspension of the aortic valve for moderate aortic regurgitation. To perform the distal anastomosis, we used hypothermic circulatory arrest with retrograde cerebral perfusion. After cardiopulmonary bypass was discontinued, bilateral femoral pulsation disappeared. We immediately performed bypass grafting from the ascending aortic graft to the right femoral artery using a ringed polytetrafluoroethylene graft (Gore-Tex: W. L. Gore, Flagstaff, AZ) 10 mm in diameter (Fig 1A).
View larger version (28K):
[in this window]
[in a new window]
|
Fig 1. Initial operation for acute type A aortic dissection with peripheral malperfusion. (A) Replacement of the ascending aorta with a graft placement of ascending graft (AG) and bypass graft from the AG to the right femoral artery (A–F) were performed. (B) After the diagnosis of mediastintis with graft infection was made, a stent (S) was inserted into the true lumen of the narrowed thoracoabdominal aorta (N) and then the A–Z graft was removed. (C) Finally the AG was replaced with a cryopreserved homograft (H), and the mediastinitis healed.
|
|
Seven days after the initial operation, high fever and pericardial effusion were noted. Subxiphoid open drainage was performed on the eighth postoperative day. After cultures from the drainage discharge grew detecting methicillin–resistant Staphylococcus aureus, we made a diagnosis of mediastinitis with infection of the ascending aortic graft and the aorta–femoral artery bypass graft. Reexploration and mediastinal cleaning were carried out on the tenth postoperative day, and at the same time, the antibiotic regimen was changed from cefotiam dihydrochloride to vancomycin hydrochloride and arbekacin sulfate. Continuous closed mediastinal irrigation was maintained after this operation.
Because this treatment did not reduce the septic inflammation, we removed the graft between the ascending aortic graft and the right femoral artery after inserting a 20-mm diameter Gianturco stent (William Cook Europe A/S, Bjaeverskov, Denmark) into the true lumen of the supraceliac thoracoabdominal aorta (Fig 1B). Simultaneously, we reopened and washed the mediastinum. After this operation, the mediastinum was managed with open drainage and intermittent lavage four times a day. These operations resulted in control of the septic inflammation. During the period of mediastinal lavage, we encountered sustained (three times during 5 weeks) bleeding from the pulmonary artery at the rear of the ascending aortic graft. The pulmonary artery was reconstructed with a bovine pericardial patch (XAG-400; Edwards Lifesciences, Horw Switzerland) using cardiopulmonary bypass each time.
One month after mediastinal lavage was initiated, when culture of methicillin-resistant S. aureus were no longer grown from a swab from the mediastinum, we replaced the ascending aortic graft with a cryopreserved homograft (obtained from the homograft bank of Tokyo University) (Fig 1C). We replaced not only the fabric graft but also the felt reinforcement of the dissected aorta and the patch and pledget used to stop the bleeding from the pulmonary artery. Seven days after homograft replacement of the ascending aorta, we transplanted an omental flap to the mediastinum with the sternum left separated, and implanted a skin mesh 7 days later. The infection was completely controlled after the homograft replacement, and the patient was discharged 70 days after the initial operation.
|
Comment
|
|---|
Mediastinitis after treatment of acute type A aortic dissection is highly fatal because the magnitude of the initial operation reduces the immune defenses and infection of the aortic graft is concomitant [1, 2]. Since the introduction of homograft replacement of an infected graft, several successful treatments of this fatal disease have been reported [3, 4].
In addition to a homograft for in situ reconstruction of an infected ascending aortic graft, the most important factors for successfully treating mediastinitis with graft infection are the removal of all infected artificial substances (the aortofemoral bypass graft, the patch used to reconstruct the pulmonary artery, and, in the case of our patient, the felt for reinforcing the aortic wall) and the reduction of bacteria in the mediastinum. We implanted the bare stent into the narrowed true lumen of the thoracoabdominal aorta as a substitute for the infected aortofemoral bypass graft that had been implanted to avoid peripheral malperfusion at the initial operation. Stent usage for peripheral malperfusion complicated with aortic dissection has been reported by the Stanford group; who have obtained excellent results compared with conventional surgical therapy. Stent placement in our patient played a major role in complete removal of the infected artificial substances [5, 6].
We believe that homograft replacement and stent placement are an effective method and should be considered a standard operation for mediastinitis with graft infection that can occur after initial aortic replacement with an artificial graft for type A aortic dissection with peripheral malperfusion.
|
References
|
|---|
- Hargrove W.C., III, Edmunds L.H., Jr Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg 1984;37:72-77.[Abstract]
- Coselli J.S., Crawford E.S., Williams T.W., Jr, 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]
- Coselli J.S., Köksoy C., LeMaire S.A. Management of thoracic aortic graft infections. Ann Thorac Surg 1999;67:1990-1993.[Abstract/Free Full Text]
- Vogt P.R., Turina M.I. Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts. Ann Thorac Surg 1999;67:1986-1989.[Abstract/Free Full Text]
- Slonim S.M., Nyman U., Semba C.P., Miller D.C., Mitchell R.S., Dake M.D. Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J Vasc Surg 1996;23:241-251.[Medline]
- Fann J.I., Sarris G.E., Mitchell R.S., et al. Treatment of patients with aortic dissection presenting with peripheral vascular complications. Ann Surg 1990;212:705-713.[Medline]
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]
|
|
|
Top
Abstract
Introduction
