Two-stage omental flap approach for ascending aortic graft infection

Ascending aortic graft (AAG) infection is considered a disastrous complication and a serious challenge for cardiovascular surgeons. When accompanied by mediastinitis, it poses a serious threat to the patient[1,2]. AAG has an incidence of 1-2%, and the mortality is high as 25-88%[3,4]. For a long time, it has been considered as one of the few inoperable complications of cardiovascular surgery[1]. Currently, there is little evidence on the optimal approach to this life-threatening complication, however, omental flaps may be considered as a promising option. Here we present an example.

A 68-year-old female patient, with clinical history of a supracoronary tube graft prosthesis due to a type A aortic dissection a year before, presented with wound dehiscence and foreign body reaction. She was taken to surgery for wire removal. Ten months later she consulted presenting a non-fetid wound secretion associated with sternal hemorrhage. An aorto-cutaneous fistula was suspected and a chest computed tomography showed a periaortic hematoma with anastomotic leak, mediastinal widening, and an aortic maximum diameter of 36 mm. A 7-cm pseudoaneurysm of the proximal anastomosis in close relation with the sternum in communication with the skin was found. A second 6-cm pseudoaneurysm in the distal anastomosis with signs of infection was also found. The infected aortic graft was removed with extensive debridement, and aortic prosthesis replacement was performed (Maquet Intergard Silver) (Figure 1A and B). Circulatory arrest time was 40 min, total cardiopulmonary bypass time was 200 min, including 45 minutes of ischemia. Mediastinal packing was performed, and the patient was sent to the intensive care unit (ICU). For the second step of the procedure 72 hours later (delayed approach), mediastinal lavage and omental flap translocation were done (Figure 1C and D). Omental flap pedicle isolation was performed by freeing an 8-10 cm wide strip off the transverse colon, keeping it attached to the stomach by the right gastroepiploic artery with perfusion through the arc of Barkow and passed through a retrosternal tunnel to the front of the pericardium (Figure 2A and B). Blood cultures were positive for Candida parapsilosis. The patient had a successful recovery and was eventually discharged. At one-year follow-up, the patient has not required reintervention and is in good health.