TY - JOUR
AU - Yamauchi,, Toshihiko
AB - Abstract An 81-year-old man developed impending rupture of a false aneurysm of the ascending aorta concomitant with chronic mediastinitis lasting for 10 years after tube graft replacement. He had undergone various infection-related mediastinal surgical procedures. He was successfully treated by debridement of infected tissues, patch repair of the false aneurysm, and transposition of the right latissimus dorsi muscle flap. The postoperative course was uneventful except for seromas. A chest computed tomographic scan performed 5 and 24 months after surgery showed no signs of recurrent aneurysm formation. A conservative surgical treatment including muscle flap transposition was effective in octogenarian. False aneurysm, Ascending aorta prosthesis, Mediastinitis, Muscle transposition 1 Introduction False aneurysm of the ascending aorta-anastomosis after tube graft replacement is a life-threatening complication of thoracic aortic operation, particularly when it results from mediastinitis [1–3]. 2 Case report An 81-year-old man was referred to our department under a diagnosis of impending rupture of false aneurysm of the ascending aorta on 15th October 1999. He had undergone graft replacement of the descending thoracic aortic aneurysm caused by DeBakey III dissection on 8th December 1987. Wrapping of the ascending aorta and the aortic arch was also performed, because aortic dissection developed retrograde extension to the ascending aorta during operation. However, the ascending aortic aneurysm enlarged rapidly. A second operation, ascending aorta replacement with a 30 mm woven Dacron tube graft, was performed on 26th May 1988 via a median sternotomy. Postoperatively he suffered purulent mediastinitis caused by polymicrobial infection: methicillin-resistant Staphylococcusaureus, Escherichiacoli, and Candida. The sternum was left open and local irrigation with iodine solution was done for 4 months. He underwent a third operation, debridement of the sternum and pediculate grafting of the right major pectoral muscle to the anterior mediastinum, on 25th October 1988. His mediastinitis was incurable. Thereafter, various subsequent treatments were tried periodically for 10 years: pediculate grafting of the rectus abdominal muscle, the sternocleidomastoid muscle, or the greater omentum to the anterior mediastinum, and so on. He noticed an erythema of the precordial wound, swelling, and a bloody secretion in September 1999. Repeat contrast-enhanced computed tomographic (CT) scan and digital subtraction angiography revealed a false aneurysm of the ascending aorta with extravasation of a contrast medium (Fig. 1a) . He had no signs of active infection in laboratory data, however. Fig. 1 Open in new tabDownload slide Contrast-enhanced computed tomographic scan. (a) Preoperative findings showing false aneurysm and extravasation of contrast medium (white arrow). (b) Postoperative findings showing disappearance of the false aneurysm and muscle flap at the right precordium. Fig. 1 Open in new tabDownload slide Contrast-enhanced computed tomographic scan. (a) Preoperative findings showing false aneurysm and extravasation of contrast medium (white arrow). (b) Postoperative findings showing disappearance of the false aneurysm and muscle flap at the right precordium. He underwent stage-1 operation urgently on 17th October 1999. Under general anesthesia DC shock patches were put on the back and the left precordium. First, we exposed the bilateral femoral arteries and veins, the bilateral common carotid arteries, and the right internal jugular vein for cardiopulmonary bypass (CPB) (Fig. 2a) . After heparinization (300 units/kg) a pacing catheter was inserted into the right ventricle through the left femoral vein. A 50 cc occlusion balloon catheter (Edwards Lifescience, CA, USA) was placed at the previously implanted tube graft in the descending thoracic aorta. A 10 mm tube graft was anastomosed to the left femoral artery for the CPB infusion line. CPB was instituted using a 21Fr Bio-Medics long cannula (Medtronic, MN, USA) inserted into the right atrium through the right femoral vein. A second venous cannula was inserted into the right atrium through the right internal jugular vein to achieve full flow. Antegrade selective cerebral perfusion (SCP) was initiated via the right and left common carotid arteries using a Sarns 3.8 mm cannulae (3M Healthcare, Michigan, USA), a left ventricular vent cannula was inserted retrogradely through the right common carotid artery, and core cooling was then initiated. The SCP flow of 500 ml/min at a blood temperature of 15 °C was maintained using a roller pump separated from systemic circulation. A median chest skin incision of 10 cm through the previous precordial wound was made. We identified a capsulated abscess which attached to the false aneurysm. The mediastinum was debrided and irrigated. At a bladder temperature of 22 °C, the descending aorta was occluded by inflation of the occlusion balloon, ischemia was induced in the heart without cardioplegia, and systemic and brain circulation was continued using CPB. The false aneurysm was opened. A suture dehiscence of 3 cm was identified at distal anastomosis of the ascending aortic tube graft. The proximal suture line of the graft was not exposed. The aneurysm orifice was closed using two Dacron graft patches from inside and outside of the aorta with interrupted 3-0 polypropylene horizontal mattress sutures (Fig. 2b). At the completion of repair, air in the ascending aorta and the arch was evacuated by deflation of the occlusion balloon and the heart was reperfused. During rewarming the heart recovered beating by one time DC shock. The left ventricular vent cannula was removed at a bladder temperature of 34 °C. SCP was discontinued and the right and left common carotid arteries were repaired. The patient was weaned off bypass on small doses of inotropes at 37 °C. Protamine of 3 mg/kg was given and hemostasis was confirmed. Dead space around the patch graft was plugged with fibrin glue containing gentamicine and the wound was temporally closed. The total CPB time was 351 min with a myocardial ischemic time of 46 min and an antegrade SCP time of 232 min. The patient required mechanical ventilation support for 38 h. Fig. 2 Open in new tabDownload slide (a) Type and sites of cannulation and the mode of perfusion. (b) A ‘sandwich’ technique of the distal aortic suture. Fig. 2 Open in new tabDownload slide (a) Type and sites of cannulation and the mode of perfusion. (b) A ‘sandwich’ technique of the distal aortic suture. Five days later, stage-2 operation was done for mediastinal wound plasty in a left lateral decubitus position. The precordial skin suture was removed and the mediastinum was debrided and irrigated. An oblique skin incision on the right back region was made and the right latissimus dorsi muscle flap was elevated, preventing its vascular pedicle (the thoracodorsal artery and vein). The flap was transferred to the precordial region through a subcutaneous tunnel. The prosthetic tube graft and dead space of the mediastinum were covered with the muscle flap. A split-thickness meshed skin graft, removed from the anterior side of the thigh, was used to cover the flap (Fig. 3) . Drains were placed on the dissection planes. Two days after the stage-2 operation, the patient was returned to the ward without neurological deficits. The muscle flap healed completely and his postoperative course was uneventful except for seromas of the bilateral groin and the donor site of the muscle flap, which were controlled by a conservative therapy. A postoperative contrast-enhanced CT scan showed total elimination of the pseudoaneurysm in the ascending aorta (Fig. 1b). The pathohistological examination of the abscess capsule specimens showed severe inflammatory cell infiltrates with numerous abscess and massive fibrinoid necrosis and patchy foreign body granulomas. However, aerobic and anaerobic cultures from the abscess fluid revealed negative results. The patient received postoperative intravenous antibiotic treatment for 7 days and had no oral antibiotics thereafter. He was discharged home at postoperative day 32. Follow-up CT scans at 5 and 24 months after repair showed no evidence of recurrent aneurysmal disease. Fig. 3 Open in new tabDownload slide Mediastinal wound plasty by right latissimus dorsi muscle flap and split-thickness meshed skin graft in stage-2 operation. Fig. 3 Open in new tabDownload slide Mediastinal wound plasty by right latissimus dorsi muscle flap and split-thickness meshed skin graft in stage-2 operation. 3 Discussion It is difficult to perform operations for mediastinal false aneurysm concomitant with aortic graft infection. Given new symptoms and diagnosis of impending rupture of false aneurysm of the ascending aorta, the patient's doctor suggested surgery. His mediastinitis was chronic infection with no signs of active infection in laboratory data and the general condition of the 81-year-old man was good. No significant stenosis of the carotid arteries and the femoral arteries was identified by preoperative examination. Careful consideration of the risks suggested that conservative operation was optimal. Strategies to cure graft infection remain controversial: preservation of the original graft versus graft explantation, tissue flap versus direct closure, or lifelong need for antibiotics versus limited use [1,2,4,5]. If disinfection of the infected graft is adequate, the original graft may be preserved [4–8]. For the minimal invasive approach to repair the false aneurysm we used the complicated technique of CPB. Although profound hypothermia and circulatory arrest may be another strategy, we have generally used the SCP technique for brain protection [9]. We did not select direct suture repair of the disrupted anastomosis but sandwiched a native aortic wall between two Dacron patch grafts by interrupted horizontal mattress sutures to increase the suture-holding capacity of the native aorta. Antibiotic-impregnated fibrin sealant may be a useful adjunct in the concept of preservation of the original graft suspected of infection [5]. The available flap was the latissimus dorsi muscle alone [10]. In the operation of pedicled muscle flap grafting a skillful plastic surgeon was very useful for mediastinal wound closure. We discontinued antibiotics at 7 days after operation because of negative culture of abscess fluid. Coselli et al. [1] recommended a lifelong need for appropriate antibiotic prophylaxis in patients with graft infection. References [1] Coselli J.S. , Koksoy C. , LeMaire S.A. . Management of thoracic aortic graft infections , Ann Thorac Surg , 1999 , vol. 67 (pg. 1990 - 1993 ) Google Scholar Crossref Search ADS PubMed WorldCat [2] Katsumata T. , Moorjani N. , Vaccari G. , Westaby S. . Mediastinal false aneurysm after thoracic aortic surgery , Ann Thorac Surg , 2000 , vol. 70 (pg. 547 - 552 ) Google Scholar Crossref Search ADS PubMed WorldCat [3] Vogt P.R. , Rocca H.B. , Carrel T. , von Segesser L.K. , Ruef C. , Debatin J. , Seifert B. , Kiowski W. , Turina M.I. . Cryopreserved arterial allografts in the treatment of major vascular infection: a comparison with conventional surgical techniques , J Thorac Cardiovasc Surg , 1998 , vol. 116 (pg. 965 - 972 ) Google Scholar Crossref Search ADS PubMed WorldCat [4] Nakajima N. , Masuda M. , Ichinose M. , Ando M. . A new method for the treatment of graft infection in the thoracic aorta: in situ preservation , Ann Thorac Surg , 1999 , vol. 67 (pg. 1994 - 1996 ) Google Scholar Crossref Search ADS PubMed WorldCat [5] Vogt P.R. , Turina M.I. . Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts , Ann Thorac Surg , 1999 , vol. 67 (pg. 1986 - 1989 ) Google Scholar Crossref Search ADS PubMed WorldCat [6] 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: successful treatment by a pectoral muscle flap , Eur J Cardiothorac Surg , 1998 , vol. 13 (pg. 98 - 100 ) Google Scholar Crossref Search ADS PubMed WorldCat [7] Luciani N. , Lapenna E. , De Bonis M. , Possati G.F. . Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition , Eur J Cardiothorac Surg , 2001 , vol. 20 (pg. 418 - 420 ) Google Scholar Crossref Search ADS PubMed WorldCat [8] Mathes D.W. , Yaremchuk M.J. , Isselbacher E.M. , Madsen J.C. . Successful in situ treatment of an infected ascending aortic graft , Ann Thorac Surg , 2000 , vol. 70 (pg. 1410 - 1412 ) Google Scholar Crossref Search ADS PubMed WorldCat [9] Kawachi Y. , Toshima Y. , Nakashima A. , Arinaga K. , Komesu I. . Emergency surgery results in life-threatening thoracic aortic disease , Jpn J Thorac Cardiovasc Surg , 2002 , vol. 50 (pg. 158 - 164 ) Google Scholar Crossref Search ADS PubMed WorldCat [10] Tizian C. , Borst H.G. , Berger A. . Treatment of total sternal necrosis using the latissimus dorsi muscle flap , Plast Reconstr Surg , 1985 , vol. 76 (pg. 703 - 707 ) Google Scholar Crossref Search ADS PubMed WorldCat © 2002 Elsevier Science B.V. All rights reserved Elsevier Science B.V.
TI - False aneurysm of the ascending aorta concomitant with chronic mediastinitis after tube graft replacement in octogenarian
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1016/S1010-7940(02)00340-8
DA - 2002-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/false-aneurysm-of-the-ascending-aorta-concomitant-with-chronic-veOd0270VK
SP - 450
EP - 453
VL - 22
IS - 3
DP - DeepDyve
ER -