Interact CardioVasc Thorac Surg 2008;7:646-647. doi:10.1510/icvts.2008.178699
© 2008 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Vascular thoracic |
Extraanatomical ascending-abdominal aorta bypass with stump closure for aortic graft infection
Kei Aizawa*,
Shin-ichi Ohki,
Hiroaki Konishi and
Yoshio Misawa
Department of Cardiovascular Surgery, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
Received 27 February 2008;
received in revised form 7 April 2008;
accepted 8 April 2008
*Corresponding author. Tel.: +81 285 587368; fax: +81 285 446271.
E-mail address: tcvai{at}jichi.ac.jp (K. Aizawa).
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Abstract
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A 42-year-old man, who 25 years previously underwent grafting of the descending aorta because of traumatic rupture after a traffic accident, was admitted to our hospital complaining of fever and hemoptysis. Computed tomography (CT) scans showed a low density area around the prosthetic graft. We diagnosed a graft infection. We undertook extraanatomical ascending-abdominal aorta bypass with stump closure of the descending aorta, with omentopexy around the stump. Postoperative course was uneventful and he has been free from infection for one year. Extraanatomical bypass was an effective strategy for treatment of a graft infection.
Key Words: Graft infection; Thoracic aorta; Extraanatomical bypass; Omentopexy
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1. Case report
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A 42-year-old man complaining of fever and bloody sputum for several months was admitted to our hospital. He had suffered traumatic rupture of the descending thoracic aorta 25 years previously because of a traffic accident and underwent graft replacement for the descending aorta. He had also suffered bacteremia from an esophageal fistula. As well, he underwent closure of fistula associated with omentopexy, and had a splenectomy for a splenic abscess one year prior to this admission.
On examination, his blood pressure was 120/72 mmHg, heart rate 78 regular beats per minute, and body temperature of 37.1 °C. White blood cell (WBC) count was 15,500/µl and c-reactive protein (CRP) level 2.99 mg/dl. Bacteria were not identified from blood culture.
Computed tomography (CT) scans showed a low density area around the prosthetic graft (Fig. 1). The clinical diagnosis was prosthetic graft infection. Antibiotic therapy [Vancomycin Hydrochloride (VCM) and Piperacillin/Tazobactam (TAZ/PIPC)] was initiated. WBC and CRP levels then deteriorated and the fever abated. Although an operation was scheduled, the patient began to spit blood in large quantities and suffered suffocation on the twelfth day of hospitalization. After immediate tracheal intubation, a bronchoscopy revealed a bleeding polypous lesion at the left B6 area that seemed to be the source of the hemoptysis. An emergent operation was scheduled; midline laparotomy was performed and an omental graft harvested. A median sternotomy was performed and an 18-mm Dacron graft was placed from the ascending aorta to the abdominal aorta. A left-sided thoracotomy was then performed. There was a little adhesion between the lung and pleura. Bleeding was seen at the distal anastomosis. The infected graft was removed and the proximal and distal stumps were sutured. Omentopexy was performed for just the distal stump, because half of the omentum was used in the operation one year prior to this one. Pleura was used for proximal stump coverage. VCM and TAZ/PIPC were used for postoperative antibiotic therapy. As a fever with skin eruption caused by TAZ/PIPC was observed, we stopped TAZ/PIPC and used cefepime dihydrochloride (CFPM) and the symptoms subsided. Intravenous antibiotic therapy was continued for six weeks followed by oral antibiotic therapy for three months. Postoperative CT-scans showed clear distal and proximal stump and no evidence of a recurrence of the infection (Fig. 2).
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Fig. 1. Computed tomography (CT) scan shows a low density area around prosthetic graft (white arrow). Graft infection was diagnosed.
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Fig. 2. Computed tomography (CT) scans performed after operation show no evidence of formation of pseudo aneurysms or a recurrence of the infection.
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The patient was discharged 54 days after the operation without any complications and has been free from recurrence for one year.
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2. Discussion
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Thoracic aortic graft infection is a rare event; its frequency ranges from 0.9 to 1.9%, but it has a high mortality rate of between 25 and 75% [1]. The cause of the graft infection in this case was thought to be an esophageal-graft fistula. Paul et al. reported the effectiveness of a cryopreserved homograft for an infected aortic graft [2], but such grafts are not commercially available for use in Japan. Thus, we performed an extraanatomical bypass between the ascending and abdominal aorta. The infected graft was removed and the proximal and distal stumps covered by omental or pleural flaps. From a long-term viewpoint, with good infection control, the risk of rupture of a stump or the formation of a pseudo aneurysm is not high [3]. Aleksic et al. reported a case of extra anatomic ascending-abdominal aorta bypass performed for a reinfected homograft after thoracic aortic rupture that was free from infection for seven years [1]. Though the effectiveness of an omental flap is reported [4, 5], in our case, half of the omentum had been used in an operation one year before this bypass surgery; thus, pleura was used for proximal stump coverage. In the case of perforation or ulcer formation of the esophagus, esophageal resection and reconstruction are required [5]. However, in our case, preoperative esophageal endoscopy showed no perforation or ulcer formation of the esophagus. To control infection, intensive antibiotic therapy is indispensable and should be started preoperatively. Specific antibiotics can be determined from blood or tissue cultures. As bacteria were not identified from either blood or tissue cultures, we used two antibiotics intravenously to cover a broad spectrum. The term for antibiotic therapy is a controversial issue, with suggested ranges from 4 to 8 weeks to lifelong [6]. We used intravenous antibiotics therapy for six weeks followed by oral administration for three months.
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References
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- Aleksic L, Leyh R, Schorn B. Extra-anatomic management of homograft reinfection after thoracic aortic rupture. Thoracic Cardiovasc Surg 2006;54:428–430.[CrossRef][Medline]
- Vogt R, Turina MI. Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts. Ann Thorac Surg 1999;67:1986–1989.[Abstract/Free Full Text]
- Katz SG, Andros G, Kohl RD. Salmonella infections of the abdominal aorta. Surg Gynecol Obstet 1992;175:102–106.[Medline]
- Paul DE, Keagy BA. Management of aortobronchial fistula with graft replacement and omentopexy. Ann Thorac Surg 1990;50:972–974.[Abstract]
- Oppell UO, Groot M, Theirfelder C, Zilla P, Odel JA. Successful management of aortoesophageal fistula due to thoracic aortic aneurysm. Ann Thorac Surg 1991;52:1168–1170.[Abstract]
- Muller BT, Wegener OR, Grabits K. Mycotic aneurysm of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106–113.[Medline]
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Abstract
1. Case report