|Year : 2021 | Volume
| Issue : 1 | Page : 66-68
Pedicled omental wrapping of ascending aortic graft following mediastinitis
Yatin Arora, Velayoudam Devagourou, Ratnesh Kumar
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||02-Oct-2020|
|Date of Decision||12-Mar-2021|
|Date of Acceptance||05-Apr-2021|
|Date of Web Publication||24-Apr-2021|
CN Centre CTVS, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
A 51-year-old male patient post-Aortic valve replacement (#25 SJM) underwent redo supra-coronary ascending aorta replacement for ascending aortic aneurysm developed a peri-graft purulent collection 2 months later post surgery. He was successfully treated by debridement of infected tissues, antiseptic irrigation with povidone, and omental wrapping of graft. The patient was discharged after full course of antibiotics. Quick diagnosis with debridement, irrigation, and omental wrapping can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta for preventing catastrophic complications
Keywords: Antiseptic irrigation, ascending aorta graft, mediastinitis, omental wrapping
|How to cite this article:|
Arora Y, Devagourou V, Kumar R. Pedicled omental wrapping of ascending aortic graft following mediastinitis. J Pract Cardiovasc Sci 2021;7:66-8
|How to cite this URL:|
Arora Y, Devagourou V, Kumar R. Pedicled omental wrapping of ascending aortic graft following mediastinitis. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 Jun 22];7:66-8. Available from: https://www.j-pcs.org/text.asp?2021/7/1/66/314486
| Introduction|| |
Poststernotomy mediastinitis is devastating complication, which causes nonignorable mortality and morbidity. Mediastinitis following graft replacement of the ascending aorta poses an immense challenge and is associated with a high mortality rate. In case graft is also infected, the ideal treatment is to remove the prosthesis and to replace it with a homograft, however, such treatment cannot be performed sometimes because tissue might be too friable and such procedure might become extremely risky.
| Case Report|| |
A 51-year-old male patient had an aortic valve replacement in 2005 (#25 SJM) (St. Jude Medical, St. Paul, Minnesota, USA) presented with ascending aortic aneurysm underwent supracoronary replacement with 28 mm gel weave graft (Vascutek, a Terumo Company, Renfrewshire, Scotland) with removal of aortic valve pannus. Postoperative recovery was uneventful and was discharged at postoperative day 9. Two months later, the patient presented with high-grade fever with purulent discharge from lower sternal wound. The patient was readmitted, workup showed a total leukocyte count of 21,000/mm3, the patient had tachycardia with a heart rate of 140/min sinus rhythm with respiratory rate of of 38/min, and contrast-enhanced computed tomography (CT) chest showed an 8.1 cm × 4.7 cm perigraft collection with air foci in it. The patient was taken for emergency surgery, purulent collection was drained along with debridement of infected tissue done with placement of two drains were kept: one drain was used for irrigation with povidone-iodine and one was used for drainage, it was irrigated for 5 days. Broad-spectrum antibiotics were started, pus culture came out to be methicillin-resistant Staphylococcus aureus, and antibiotics were switched according to sensitivity to linezolid and piperacillin and tazobactam. The patient was taken for omental wrapping and sternal refixation.
The sternum was reopened. The pericardial cavity was washed with warm saline, and any debris, which was left, was debrided. A skin incision was extended 5 cm inferiorly toward the umbilicus. The peritoneum was opened and the greater omentum was visualized and lifted and mobilized till transverse colon. Since there were dense adhesions between the heart and the diaphragm, hence tunneling of the omentum through the diaphragm was not possible, therefore omentum was taken through the anterior rectus sheath close to the diaphragm [Figure 1]. The pedicled omentum was wrapped around the ascending aortic graft especially covering the suture line and was loosely fixed to surrounding tissue with sutures [Figure 2].
|Figure 1: Intraoperative picture showing pedicled omentum mobilized till transverse colon.|
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The rectus sheath was closed leaving small gap so that not to strangulate the omentum as well as not to cause hernia.
Drains were repositioned and the sternum was closed with steel wires. The patient was extubated the next day. Antibiotics were continued for 3 weeks.
| Discussion|| |
In the present era, problems, in sternal wound healing, especially mediastinitis, are rare complications in cardiac surgery. However, if they happen especially in patients with prosthetic graft in situ, they are associated with high mortality and morbidity requiring prolonged hospitalization. Graft infections after surgery of the thoracic aorta occur at a rate of 0.9%–2%.
Although many radical options have been available for these patients, using well-vascularized tissues such as muscle flaps or omentum should be a part of armamentarium of a surgeon.
Each patient has to be individualized, and it is not feasible to generalize the treatment.
However, radical excision and replacement by a homograft represent the ideal treatment, however, mortality and morbidity of this technique are very high.
Since in mediastinitis, tissue becomes quite friable, especially if patients present late or diagnosed late, hence in these patients, more conservative approach of debridement irrigation and omental wrapping may be helpful. The mainstay of modern treatment of infected aortic grafts relies heavily on principles described by Hargrove and Edmunds which include explantation and replacement of the infected material, tissue debridement, irrigation of cavity, broad-spectrum antibiotic therapy, and obliteration of dead space by autologous tissue, such as greater omentum.
Many studies talk about prophylactic usage of covering of omentum on prosthetic aortic graft, especially where chances of graft infection are high.
Characteristics of omentum which act as ideal covering are as follows:
- It provides a rich blood circulation with a high absorptive capacity, and this helps the clearance of bacteria and foreign material
- It can also promote angiogenic activity in structures to which it is closely applied, thus supporting both ischemic and inflamed tissues.
Kuniyoshi et al. described five patients of prophylactic coverage of omentum in the treatment of mycotic aneurysm and have shown that it improves long-term results and prevents infection of graft and prevents catastrophic complications. Yamashiro et al. provide a larger study of 16 patients in which they used prophylactic usage of the omentum in mycotic aneurysm and clearly demonstrated the survival advantage in these patients. Samoukovic et al. demonstrated the technique in a patient with infected prosthetic aortic graft and showed good result.
In the index case, there were dense adhesions between the diaphragm and the heart hence the omentum was not tunneled through a diaphragm instead pedicle omentum was taken through the anterior rectus.
This technique serves the purpose of providing a vascular tissue which creates a barrier between graft and mediastinum preventing graft infection nd most importantly, if suture line is exposed, covering with omentum may prevent the catastrophic complication of aortic blowout.
| Conclusion|| |
Mediastinitis in the presence of an ascending aorta prosthetic graft remains a serious complication, with a high mortality. Intensive debridement of the infected tissue, local antiseptic irrigation with omental wrapping of the graft may be helpful in this difficult complication.
Since this is case report, patient consent is taken so ethics clearance is not needed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardiothorac Surg 2013;43:1177-82.
Kuniyoshi Y, Koja K, Miyagi K, Uezu T, Yamashiro S, Arakaki K. Graft for mycotic thoracic aortic aneurysm: Omental wrapping to prevent infection. Asian Cardiovasc Thorac Ann 2005;13:11-6.
[Figure 1], [Figure 2]