Ann Thorac Surg 2005;79:1425-1427
© 2005 The Society of Thoracic Surgeons
How to do it
Using Fascia Lata to Treat Infective Aortic False Aneurysm
Ichiya Yamazaki, MD, PhD*,a,
Yukio Ichikawa, MD, PhDa,
Masanori Ishii, MD, PhDa,
Toshiyuki Hamada, MDa,
Hirokazu Kajiwara, MD, PhDa
a Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
Accepted for publication December 10, 2003.
* Address reprint requests to Dr Yamazaki, 1-17-19 Nagahama, Kanazawa-Ku, Yokohama-shi 236-0011, Japan
pxc02607{at}nifty.ne.jp
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Abstract
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In patients with infective aortic false aneurysms, repair using artificial materials is in danger of becoming an additional focus for infection. We used harvested autologous fascia lata as a vascular patch in such operations on 2 patients with infected mediastinal false aneurysm after coronary artery bypass surgery. These patients have not had any recurrences of mediastinitis and false aneurysm for 4 to 6 years after the operations.
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Introduction
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Infective aortic false aneurysms are critical and difficult to treat [1–3]. Repair using artificial materials is liable to become an additional focus for infection. Although homograft aortic replacement is a good treatment for infected mediastinal false aneurysm [3], the ready availability of homograft material is limited. We used harvested autologous fascia lata as a vascular patch to cover the ruptured foramen of an aortic false aneurysm.
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Patient 1
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A 73-year-old woman underwent coronary artery bypass grafting. The left internal thoracic artery was applied to the left anterior descending artery and a reversed saphenous vein graft (SVG) was applied to the circumflex branch. She suffered from mediastinitis 1 month postoperatively, which was caused by methicillin-resistant Staphylococcus aureus. The anastomotic site of the SVG to the aorta ruptured 2 months postoperatively, and an emergency repair with an expanded polytetrafluoroethylene patch was made. After the procedure, the false aneurysm developed at the repaired site and the mediastinitis was persistent. Under hypothermic circulatory arrest, we excised all expanded polytetrafluoroethylene and suture material and covered the ruptured foramen of the aortic false aneurysm using autologous fascia lata as a vascular patch. The infected wound was repaired with a rotational muscular flap obtained from the pectoralis major. The SVG was already occluded with thrombus. The postoperative course was uneventful. She was discharged 1 month after the last operation without recurrence of mediastinitis and angina. After more than 6 years after the last operation, she is doing well, and recent computed tomography revealed no recurrence of aortic false aneurysm.
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Patient 2
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A 68-year-old woman underwent coronary artery bypass grafting. The right internal thoracic artery was applied to the left anterior descending artery, and the left internal thoracic artery was applied to the circumflex branch. The SVG was applied to the right coronary artery. As with patient 1, patient 2 suffered postoperative mediastinitis caused by methicillin-resistant Staphylococcus aureus, which was treated with continuous irrigation and closure of the wound with a rotational muscular flap obtained from the pectoralis major. Patient 2 was discharged 3 months after her coronary surgery. She had a high fever develop 2 months later. Computed tomography (Fig 1) revealed a periaortic mediastinal false aneurysm 6 cm in diameter at the anastomotic site of the SVG to the aorta. An urgent operation was performed. We approached the false aneurysm of the ascending aorta through a right thoracotomy. We closed the ruptured foramen of the aortic false aneurysm using autologous fascia lata as a vascular patch under hypothermic circulatory arrest (Fig 2). However, the back flow from the proximal end of the SVG was observed, and we ligated the SVG because there was no adequate site for the SVG reanastomosing in the operative field. Fortunately the recurrence of angina did not occur after the operation. There was no recurrent postoperative mediastinitis. She was discharged 1 month after this operation. She was followed-up by her home doctor without recurrence of false aneurysm for 4 years after the operation.
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Fig 1. Computed tomography shows large false aneurysm at the anastomotic site of the saphenous vein graft to the ascending aorta.
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Fig 2. Picture on the left is a ruptured foramen of the aortic false aneurysm. Image on the right demonstrates the closure of the ruptured foramen using autologous fascia lata as a vascular patch.
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Technique
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Before operating to treat the false aneurysm, an incision was made in the thigh region (Fig 3). After blunt dissection of the subcutaneous tissue and the fascia lata, sufficient fascia lata to serve as a vascular patch was harvested by electrocautery. After harvesting, the fascia lata was preserved in normal saline. The thigh incision was closed without insertion of a drain. To obtain an intension and a smooth outer surface, the harvested fascia lata was folded in two. The double-folded fascia lata was trimmed to match the size of the ruptured foramen of the aortic false aneurysm. The fascia lata was attached to the foramen by continuous sutures of polypropylene 4-0, and the defect was closed. When residual bleeding developed from the suture line, we stanched the bleeding by mattress sutures of polypropylene 3-0 or 4-0 with outer strips of small pieces of fascia lata.
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Comment
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Infective false aneurysm originating from the ascending aorta is a rare but life-threatening complication after cardiac operations [1–3]. We experienced 3 patients with ruptured pseudoaneurysm of the ascending aorta among the 1,124 patients who had already undergone coronary artery bypass grafting at our institution. One patient died before emergency reoperation started. The other 2 patients are described in this report. Koen and colleagues [1] reported that 2 patients died from ruptured pseudoaneurysm of the ascending aorta in a series of 1,000 consecutive coronary artery bypass grafts.
For repair of a pseudoaneurysm, hypothermic circulatory arrest is known to be useful and safe as a measure to avoid massive and fetal bleeding during re-sternotomy or dissection within the mediastinum to expose the pseudoaneurysms [3].
Repeat procedures for false aneurysms must provide secure aortic repair and eliminate infection. However, repair using artificial materials, such as expanded polytetrafluoroethylene, provides a very weak resistance to infection and involves a high risk of generating a new infection. Although homografts may be promising compared with other artificial materials [4], they are of limited availability. Autologous pericardium seems to be useful as a patch material to repair the infective aortic false aneurysms [5]; however, we can not use the autologous pericardium because the infective false aneurysms of our cases occurred after severe mediastinitis, and we had to harvest autologous pericardium from the infected site.
We have used fascia lata as a vascular patch in patients with infective aortic false aneurysms. This procedure was used in 2 patients, and these patients have not had any recurrence of false aneurysms or local infection. Fascia lata is easy to harvest and can be obtained in as little as 10 minutes by our method. The strength of the patch has not been a problem, and evidence of long-term durability is presented in our cases.
Fascia lata is widely used in plastic surgery operations in various fields [6]. In cardiovascular surgery, there are reports of using fascia lata for pericardial patches after open heart surgery and as the material of artificial heart valves in the 1960s and 1970s [7, 8]. However, there are few reports of using fascia lata as vascular patches, and their usefulness is evaluated in this article. We recommend fascia lata as a prosthesis for surgical treatment of infective cardiovascular diseases.
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References
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- Koen WJ, Bedard P, Akyurekli Y, Brais M. Causes of death in aortocoronary bypass surgery: experience with 1,000 patients. Ann Thorac Surg. 1977;23:357–360[Abstract]
- Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following aortic surgery. Chest. 1988;93:38–43[Abstract/Free Full Text]
- Ueno T, Ikeda K, Koga Y. Ruptured pseudoaneurysm of the aorta with encapsulated mediastinal abscess after coronary artery bypass grafting. Jpn J Thorac Cardiovasc Surg. 2003;51:319–321[Medline]
- Katsumata T, Westaby S. Homograft aortic replacement for infected mediastinal false aneurysm. Ann Thorac Surg. 1997;64:1464–1466[Abstract/Free Full Text]
- Fiore AC, Ivey TD, McKeown PP, Misbach GA, Allen MD, Dillard DH. Patch closure of aortic annulus mycotic aneurysms. Ann Thorac Surg. 1986;42:372–379[Abstract]
- Kageyama Y, Suzuki K, Matsushita K, Nogimura H, Kazui T. Pericardial closure using fascia lata in patients undergoing pneumonectomy with pericardiectomy. Ann Thorac Surg. 1998;66:586–587[Abstract/Free Full Text]
- Senning A. Fascia lata replacement of aortic valves. J Thorac Cardiovasc Surg. 1967;54:465–470[Medline]
- Kohanna FH, Adams PX, Cunningham JN Jr, Spencer FC. Use of autologous fascia lata as a pericardial substitute following open-heart surgery. J Thorac Cardiovasc Surg. 1977;74:14–19[Abstract]
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Abstract
Introduction
