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Pitts L, Pasic M, Wert L, Nersesian G, Kaemmel J, Buz S, Knosalla C, Düsterhöft V, Starck C, Kempfert J, Jacobs S, Falk V. Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch. Eur J Cardiothorac Surg 2024; 65:ezae225. [PMID: 38814808 DOI: 10.1093/ejcts/ezae225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/06/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. METHODS All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. RESULTS The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). CONCLUSIONS Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Miralem Pasic
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Leonhard Wert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Julius Kaemmel
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Volker Düsterhöft
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
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Mori K, Umeno T, Kawashima T, Wada T, Genda T, Arakura M, Oda Y, Mizoguchi T, Iwai R, Tajikawa T, Nakayama Y, Miyamoto S. Breaking the Limit of Cardiovascular Regenerative Medicine: Successful 6-Month Goat Implant in World's First Ascending Aortic Replacement Using Biotube Blood Vessels. Bioengineering (Basel) 2024; 11:405. [PMID: 38671826 PMCID: PMC11048657 DOI: 10.3390/bioengineering11040405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
This study investigated six-month outcomes of first models of ascending aortic replacement. The molds used to produce the Biotube were implanted subcutaneously in goats. After 2-3 months, the molds were explanted to obtain the Biotubes (inner diameter, 12 mm; wall thickness, 1.5 mm). Next, we performed ascending aortic replacement using the Biotube in five allogenic goats. At 6 months, the animals underwent computed tomography (CT) and histologic evaluation. As a comparison, we performed similar surgeries using glutaraldehyde-fixed autologous pericardial rolls or pig-derived heterogenous Biotubes. At 6 months, CT revealed no aneurysmalization of the Biotube or pseudoaneurysm formation. The histologic evaluation showed development of endothelial cells, smooth muscle cells, and elastic fibers along the Biotube. In the autologous pericardium group, there was no evidence of new cell development, but there was calcification. The histologic changes observed in the heterologous Biotube group were similar to those in the allogenic Biotube group. However, there was inflammatory cell infiltration in some heterologous Biotubes. Based on the above, we could successfully create the world's first Biotube-based ascending aortic replacement models. The present results indicate that the Biotube may serve as a scaffold for aortic tissue regeneration.
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Affiliation(s)
- Kazuki Mori
- Department of Cardiovascular Surgery, Oita University, Oita 879-5593, Japan; (T.U.); (T.K.); (T.W.); (S.M.)
| | - Tadashi Umeno
- Department of Cardiovascular Surgery, Oita University, Oita 879-5593, Japan; (T.U.); (T.K.); (T.W.); (S.M.)
| | - Takayuki Kawashima
- Department of Cardiovascular Surgery, Oita University, Oita 879-5593, Japan; (T.U.); (T.K.); (T.W.); (S.M.)
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Oita University, Oita 879-5593, Japan; (T.U.); (T.K.); (T.W.); (S.M.)
| | - Takuro Genda
- Department of Clinical Engineering, Oita University Hospital, Oita 879-5593, Japan (T.M.)
| | - Masanagi Arakura
- Department of Clinical Engineering, Oita University Hospital, Oita 879-5593, Japan (T.M.)
| | - Yoshifumi Oda
- Department of Clinical Engineering, Oita University Hospital, Oita 879-5593, Japan (T.M.)
| | - Takayuki Mizoguchi
- Department of Clinical Engineering, Oita University Hospital, Oita 879-5593, Japan (T.M.)
| | - Ryosuke Iwai
- Institute of Frontier Science and Technology, Okayama University of Science, Okayama 700-0005, Japan;
| | - Tsutomu Tajikawa
- Department of Mechanical Engineering, Faculty of Engineering Science, Kansai University, Osaka 564-8680, Japan;
| | | | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University, Oita 879-5593, Japan; (T.U.); (T.K.); (T.W.); (S.M.)
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Morita S, Yaku H. A sealant with a hemostatic mechanism independent of the blood coagulation function was effective in both elective and emergency surgery for thoracic aorta. Gen Thorac Cardiovasc Surg 2023; 71:505-514. [PMID: 36917374 PMCID: PMC10421762 DOI: 10.1007/s11748-023-01918-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVES Matsudaito is a unique surgical sealant with a powerful hemostatic effect that works independent of a patient's blood coagulation function. Because of its mechanism, this sealant is expected to be particularly useful in patients with a poor blood coagulation function, such as in cases of acute aortic syndrome requiring emergency surgery. We, therefore, evaluated the hemostatic static effect of the sealant in both emergency and elective surgery of the thoracic aorta. METHODS We used data obtained from post-marketing surveillance of the sealant. Patients who underwent replacement of the thoracic aorta were enrolled. The hemostatic effect was evaluated as effective if a further hemostatic procedure was not performed after applying the sealant. RESULTS From 46 hospitals in Japan, a total of 542 patients (327 elective and 215 emergency cases) were enrolled. Hospital mortality was 4.0% and 11.6% in elective and emergency cases, respectively (p < 0.05). Among the 1039 anastomoses (609 elective and 430 emergency cases), effective hemostasis was confirmed in 436 (71.6%) elective and 259 (60.2%) emergency cases. The data from the clinical trial of the sealant showed a hemostatic rate of 44.4% in elective control cases without the sealant. CONCLUSION Given that the hemostatic rate in emergency surgery with the sealant seemed to be better than that in elective surgery without the sealant (determined from the clinical trial), we concluded that the sealant was effective in both emergency and elective thoracic surgery of the aorta.
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Affiliation(s)
- Shigeki Morita
- Department of Cardiovascular Surgery, National Hospital Organization Kyushu Medical Center, Fukuoka, Fukuoka, 810-8563, Japan.
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Li J, Stadlbauer A, Floerchinger B, Song Z, Goetz M, Lunz D, Schmid C. Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:62-66. [PMID: 36257544 DOI: 10.1055/s-0042-1757892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. METHODS Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. RESULTS All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. CONCLUSION OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.
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Affiliation(s)
- Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Zhiyang Song
- Institute of Mathematics, Ludwig-Maximilian University Munich, Munich, Germany
| | - Markus Goetz
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Takagi D, Wada T, Igarashi W, Kadohama T, Kiryu K, Yamamoto H. Enhanced strategy against mediastinitis with thoracic vascular graft infection: A combination of hydro-debridement with pulsed lavage and negative pressure wound therapies. J Card Surg 2022; 37:2741-2744. [PMID: 35771228 DOI: 10.1111/jocs.16705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/15/2022] [Accepted: 05/21/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We investigated the effects of hydrodebridement with pulsed lavage (HDPL) and negative pressure (NP) wound therapies, instead of excising the prosthetic graft, in patients with postoperative thoracic vascular graft infection (TVGI). METHODS Between 2020 and 2021, five TVGI patients aged 49.6 ± 19.4 years old underwent a combined therapy of HDPL and NP. The patients underwent a two-step procedure (first step: re-sternotomy and HDPL; second step: NP) every 3 or 4 days. After negative tissue culture, the patients underwent omentum flap wrapping and skin closure. RESULTS No hospital death was observed. The time to skin closure was 10.8 ± 3.4 days. The time to the day in which bacteria were not cultured was 3.5 ± 2.4 days. No recurrent infections occurred for 241 ± 186 postoperative days. CONCLUSION Our strategy for TVGI patients may contribute to (1) sufficient infection control, (2) physical rehabilitation, and (3) less invasiveness for high-risk patients.
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Affiliation(s)
- Daichi Takagi
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takuya Wada
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Wataru Igarashi
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takayuki Kadohama
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Kentaro Kiryu
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroshi Yamamoto
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
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Giammarino AT, Sarmiento IC, Scheinerman SJ, Winalski J, Lazzaro RS, Brinster DR, Hemli JM. Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report. J Med Case Rep 2022; 16:186. [PMID: 35534872 PMCID: PMC9087969 DOI: 10.1186/s13256-022-03380-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background Fungal prosthetic graft infections are associated with high mortality, typically requiring aggressive surgical debridement. We present an alternative, minimally invasive approach to address these challenging clinical cases. Case presentation A 76-year-old Caucasian male with prior aortic root and arch replacement presented with localized chest wall tenderness after being hit by a car door. Computed tomography angiogram incidentally identified fluid in the anterior mediastinum, surrounding his ascending aortic graft. Rather than undertaking a high-risk reoperative sternotomy and redo complex aortic reconstruction, we elected to proceed with a robotic-assisted, minimally invasive debridement of the aortic graft, coupled with an omental wrap, entirely within the closed chest. Microbiology was positive for Aspergillus species. The patient made an uncomplicated recovery and was discharged home on antifungal therapy, likely to continue indefinitely. Conclusions Infected prosthetic aortic grafts can be successfully managed with debridement and pedicled omental flap coverage via a minimally invasive approach within the closed chest, obviating the morbidity of a complex reoperative open procedure.
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Affiliation(s)
| | - Iam Claire Sarmiento
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - SJacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - John Winalski
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Richard S Lazzaro
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA.
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Filaire L, Mercier O, Seguin-Givelet A, Tiffet O, Falcoz PE, Mordant P, Brichon PY, Lacoste P, Aubert A, Thomas P, Le Pimpec-Barthes F, Molnar I, Vidal M, Filaire M, Galvaing G. Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database. Interact Cardiovasc Thorac Surg 2021; 34:378-385. [PMID: 34871387 PMCID: PMC8860414 DOI: 10.1093/icvts/ivab337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To report our experience on the management of superior vena cava graft infection. METHODS Between 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected. RESULTS Of 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%. CONCLUSIONS Superior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).
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Affiliation(s)
- Laura Filaire
- Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Centre, Clermont-Ferrand, France
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart and Lung Transplantation, Hôpital Marie Lannelongue, Paris, France
| | | | - Olivier Tiffet
- Department of Thoracic Surgery, North Hospital, Saint-Étienne, France
| | | | - Pierre Mordant
- Division of Thoracic and Vascular Surgery, Hôpital Bichat, Paris, France
| | - Pierre-Yves Brichon
- Department of Thoracic and Endocrine Surgery, University Hospital of Grenoble, Grenoble, France
| | - Philippe Lacoste
- Department of Thoracic and Cardiovascular Surgery, Nantes Hospital University, Nantes, France
| | - Axel Aubert
- Department of Thoracic Surgery, Clinique Belledone, Grenoble, France
| | - Pascal Thomas
- Department of Thoracic Surgery, Disease of the Oesophagus and Lung Transplantation, North Hospital, Marseille, France
| | | | - Ioana Molnar
- Department of Clinic Research, Jean Perrin Comprehensive Cancer Centre, Clermont-Ferrand, France
| | - Magali Vidal
- Infectious Diseases Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Marc Filaire
- Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Centre, Clermont-Ferrand, France
| | - Géraud Galvaing
- Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Centre, Clermont-Ferrand, France
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Chong JH, Zhang Y, Harky A, Field M. Management and Outcomes of Proximal Aortic Graft Infection: A Systematic Review. Heart Lung Circ 2021; 31:49-58. [PMID: 34602347 DOI: 10.1016/j.hlc.2021.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Proximal aortic graft infection (PAGI) is a rare but often fatal postoperative complication. Its management often relied on surgical preferences and resource availability of each centre, until the recent unifying guidelines published by the European Society for Vascular Surgery (ESVS). This paper aimed to amalgamate the published experience in managing PAGI and their outcomes. METHODS PubMed, Scopus and Cochrane Library databases were searched systematically. All primary studies besides single-patient case reports were included. Data extracted included study and patient characteristics, type of index surgery, type of microorganisms involved, definitive treatment modality, and any outcome measures reported. RESULTS Of the 20 studies included, 157 of the 290 PAGI patients underwent complete graft explantation and replacement, 106 underwent graft-preservation interventions (debridement and/or irrigation), and 25 had antibiotics alone. Adjunctive interventions included graft coverage, vacuum-assisted closure, use of infection-resistant graft materials, and lifelong suppressive therapy. In-hospital mortality was 20.8% (n=60), with postoperative sepsis and multiorgan failure (n=24) being the most common cause. Recurrent infection occurred in 10 post-discharge patients. Post-discharge mortality rate was 11.4% (n=33), with cardiac complications and stroke being the most common cause in surgically-treated and medically-treated patients, respectively. CONCLUSIONS Given the risk of mortality, the management approach of PAGI highly depends on the fitness of the patient. We believe that early referral to specialised aortic centres is essential to plan for optimal management strategies and improve patient outcomes. Further studies are also required to parse out the most effective adjunctive interventions to maximise patient outcomes.
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Affiliation(s)
- Jun Heng Chong
- GKT School of Medical Education, King's College, London, UK
| | - Yi Zhang
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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Poon SS, George J, Kumar P, Field M. In patients with thoracic aortic graft infection, is graft explantation and replacement superior to in situ graft preservation? Interact Cardiovasc Thorac Surg 2021; 34:291-296. [PMID: 34536009 DOI: 10.1093/icvts/ivab234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/15/2021] [Accepted: 07/04/2021] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether graft explantation and replacement are superior to graft preservation in patients with thoracic aortic graft infections. Altogether, more than 487 papers were found using the reported search; of these, 7 comparative studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Although thoracic aortic graft infection is uncommon following cardiac surgery, it still carries a significant risk of in-hospital mortality and poor long-term survival. Current findings in the literature are limited to retrospective cohort studies with relatively small sample sizes; also, there is a lack of randomized controlled trials on this topic. There was significant heterogeneity in patient groups and variation in surgical techniques across centres. In this context, a graft-sparing approach may be a safe therapy with comparable early mortality and late survival outcomes in carefully selected patients. The selection may include the absence of graft pseudoaneurysm, anastomotic leak and fistula; the presence of indolent infection in patients with poor clinical conditions; and significant frailty and comorbidities where the risks of surgical explantation exceed the benefits. The rate of reinfection is low following both graft replacement and the graft-sparing approach. Moreover, the use of a tissue flap improves the surgical outcomes.
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Affiliation(s)
- Shi Sum Poon
- Department of Cardiac Surgery, Morriston Hospital, Swansea, Wales, UK
| | - Joseph George
- Department of Cardiac Surgery, Morriston Hospital, Swansea, Wales, UK
| | - Pankaj Kumar
- Department of Cardiac Surgery, Morriston Hospital, Swansea, Wales, UK
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Shijo T, Matsuda H, Yokawa K, Inoue Y, Seike Y, Uehara K, Takahara M, Sasaki H. The impact of vascularized tissue flap coverage on aortic graft infection with and without infected graft excision. Eur J Cardiothorac Surg 2021; 60:1043-1050. [PMID: 34059918 DOI: 10.1093/ejcts/ezab179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Aortic graft infection (AGI) is a serious condition associated with a high mortality rate. However, optimal surgical options have not been identified. Therefore, we retrospectively reviewed AGI cases, including those in the thoracic and abdominal regions, with or without fistula formation, to investigate the various options for better outcomes. METHODS We reviewed 50 patients who underwent surgical interventions for AGI out of 97 patients with arterial infective disease. The mean patient age was 67 ± 17 years. Fourteen patients (28%) had a fistula with the gastrointestinal tract or lung. A combination of graft excision and vascularized tissue flap coverage was performed in 25 cases (50%). Tissue flap alone, graft excision alone and cleansing alone were performed in 9 (18%), 10 (20%), and 6 cases (12%), respectively. RESULTS Total in-hospital mortality rate was 32% (n = 16). In-hospital mortalities in patients with and without fistulas were 43% (6/14) and 28% (10/36), respectively (P = 0.33). Subgroup analysis among patients without fistula demonstrated that the in-hospital mortality rate of the patients with vascularized tissue flap (3/21, 14%) was significantly lower than that of the patients without vascularized tissue flap (7/14, 50%, P = 0.026). Overall 1- and 5-year survival rates were 66% and 46%, respectively. In multivariable analysis, an independent factor associated with in-hospital mortality was vascularized tissue flap (odds ratio 0.20, P = 0.024). CONCLUSIONS Vascularized tissue flaps could provide better outcomes for AGI. Graft preservation with vascularized tissue flaps could be a useful option for AGI without fistula.
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Affiliation(s)
- Takayuki Shijo
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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11
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Imamura Y, Kowatari R, Daitoku K, Goto S, Fukuda I. Multiorgan emboli due to an intraluminal thrombus from frozen elephant trunk. Cardiovasc Pathol 2021; 52:107316. [PMID: 33359179 DOI: 10.1016/j.carpath.2020.107316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/29/2022] Open
Abstract
The impact of kinking of the nonstented part of a frozen elephant trunk on the development of adverse effects is unclear. We report a case of an infected thrombus within the kinked nonstented portion of the frozen elephant trunk that resulted in multiorgan embolization. A 45-year-old man presented with a 1-month history of high-grade fever and fatigue. He had undergone emergent total arch replacement and frozen elephant trunk implantation for type A acute aortic dissection 7 years previously. Computed tomography showed an intraluminal thrombus within the kinked nonstented portion of the frozen elephant trunk. An autopsy also showed an intraluminal thrombus within the graft and diffuse microembolization in the abdominal organs. Therefore, in this case, kinking of the nonstented part of the frozen elephant trunk had resulted in an infected intraluminal thrombus, which subsequently caused multiorgan embolization.
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Affiliation(s)
- Yuki Imamura
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan
| | - Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan.
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan
| | - Shintaro Goto
- Department of Pathology, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan
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12
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Harky A, Othman A, Nistal De Paz C, Shaw M, Nawaytou O, Harrington D, Kuduvalli M, Field M. Systematic approach to diagnosis and management of infected prosthetic grafts in the proximal aorta. J Card Surg 2020; 36:145-152. [PMID: 33169445 PMCID: PMC7839687 DOI: 10.1111/jocs.15122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023]
Abstract
Objectives Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. Methods This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. Results Twenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). Conclusions Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.
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Affiliation(s)
- Amer Harky
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Center for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Ahmed Othman
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Carlos Nistal De Paz
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Matthew Shaw
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Omar Nawaytou
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Deborah Harrington
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Manoj Kuduvalli
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Center for Cardiovascular Science, University of Liverpool, Liverpool, UK
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13
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Zhou J, Sun J, Yao X, Zhao G, Sun F, Sheng W, Lu F, Zhan H, Liu C. Laparoscopic omental flap for the treatment of thoracic aortic graft infection: report of two cases and review of the literature. J Cardiothorac Surg 2020; 15:120. [PMID: 32471445 PMCID: PMC7257187 DOI: 10.1186/s13019-020-01146-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic aortic graft infection (TAGI) is a rare and serious complication after surgery for which the treatment is controversial and challenging. Rather than following the traditional surgical strategy of graft replacement and extensive debridement, we have chosen to preserve the graft and cover it by a laparoscopic omental flap. In this article, we describe the clinical manifestation, diagnostic modalities, and treatment of this disease and analyze the role of laparoscopic omental flaps in its treatment. CASE PRESENTATION We present two cases of thoracic aortic graft infections that had undergone surgical graft replacement for acute Stanford type A dissection. Their clinical manifestation of infection was atypical, with computed tomography suggesting infection of the grafts. Both patients were successfully treated with debridement, laparoscopic omental transposition, and antibiotics. The first case, a 55-year-old male, was found to have an infection at the aortic arch. The second case is a 52-year-old male who was found to have infection at the ascending aorta and arch. Surprisingly, both intraoperative cultures were negative. The infections were brought under control and the patients recovered steadily after surgery. Early follow-up results showed no signs of graft infection. CONCLUSION These findings suggest that graft replacement for the treatment of TAGI is not always necessary in selected patients. Conservative surgical treatment, including laparoscopic omental transposition, is effective and less invasive for treating TAGI.
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Affiliation(s)
- Jiawei Zhou
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junfeng Sun
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xingxing Yao
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guochang Zhao
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weiyong Sheng
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fanfan Lu
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haibo Zhan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Liu
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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14
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Spadaccio C, Hu H, Li C, Qiao Z, Ge Y, Tie Z, Zhu J, Moon MR, Danton M, Sun L, Gaudino MF. Thoracic aortic surgery: status and upcoming novelties. Minerva Cardioangiol 2020; 68:518-531. [PMID: 32319269 DOI: 10.23736/s0026-4725.20.05263-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Several novel technological developments and surgical approaches have characterized the field of aortic surgery in the recent decade. The progressive introduction of endovascular procedures, minimally invasive surgical techniques and hybrid approaches have changed the practice in aortic surgery and generated new trends and questions. Also, the advancements in the manufacturing of tissue engineered vascular grafts as substitutes for aortic replacements are enlightening new avenues in the treatment of aortic disease. This review will provide an overview of the current novel perspectives, debates and trends in major thoracic aortic surgery.
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Affiliation(s)
- Cristiano Spadaccio
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK - .,Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK - .,Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China -
| | - Haiou Hu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Zheng Tie
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Marc R Moon
- School of Medicine, Washington University, St Louis, MI, USA
| | - Mark Danton
- Department of Cardiac Surgery, Scottish Pediatric Cardiac Services, Royal Hospital for Children, Glasgow, UK
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Mario F Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
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15
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Omental Flap Coverage for Management of Thoracic Aortic Graft Infection. Ann Thorac Surg 2019; 109:1845-1849. [PMID: 31697905 DOI: 10.1016/j.athoracsur.2019.09.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/02/2019] [Accepted: 09/09/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Since the first reported use of prosthetic aortic grafts, infection has remained a feared complication. Pedicled omentum is the preferred flap in managing thoracic aortic graft infection (TAGI); however the literature is sparse. The authors present their experience with TAGI managed with pedicled omental flaps. METHODS A single-institutional review from 2007 to 2018 was performed to analyze postoperative outcomes of omental flap reconstruction, performed by 2 surgeons, after a confirmed diagnosis of TAGI. The primary outcomes of overall complication rate, 30-day mortality, and in-hospital mortality were evaluated with univariate analysis. RESULTS Twenty patients requiring omental flap reconstruction after TAGI met inclusion criteria. The patient cohort included 14 men and 6 women with a mean age of 60.6 ± 12.9 years and a mean Charlson comorbidity index of 3.3 ± 2.1. Nine patients (45%) received omental flap reconstruction at the time of incipient TAGI surgical management by the cardiothoracic surgery team, whereas 11 patients received delayed reconstruction (mean, 6.22 days [range, 1-27]). The most common complications were graft leak (20%) and pseudoaneurysm (25%), with only 1 patient developing recurrent infection. Overall 30-day mortality was 20%. Chronic obstructive pulmonary disease and delayed omental flap reconstruction were associated with 30-day mortality (P = .04). Four of 11 patients (36.4%) who received delayed omental flap reconstruction died within 30 days, whereas 0 of 9 patients (0%) in the immediate omental coverage group died within 30 days (P = .043). CONCLUSIONS High mortality rates associated with TAGI exemplify the challenges associated with this disease process and patient population. Pedicled omentum is a safe adjunct with promising results to the management of TAGI while significantly reducing the risk of reinfection.
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16
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Botianu PVH. Current indications for the intrathoracic transposition of the omentum. J Cardiothorac Surg 2019; 14:103. [PMID: 31182112 PMCID: PMC6558767 DOI: 10.1186/s13019-019-0924-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 05/28/2019] [Indexed: 12/30/2022] Open
Abstract
Background The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications. Methodology and review This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery. Conclusions OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.
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Affiliation(s)
- Petre V H Botianu
- Surgery IV Discipline, M5 Department, University of Medicine and Pharmacy from Tirgu-Mures, 540091 Bujorului 2A, Tirgu-Mures, Romania.
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17
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Bianco V, Kilic A, Gleason TG, Arnaoutakis GJ, Sultan I. Management of thoracic aortic graft infections. J Card Surg 2018; 33:658-665. [DOI: 10.1111/jocs.13792] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery; University of Florida; Gainesville Florida
| | - Ibrahim Sultan
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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18
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Abstract
BACKGROUND Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. METHODS A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. RESULTS Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. CONCLUSIONS Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.
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19
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Carrel T, Englberger L, Schmidli J. How to treat aortic graft infection? With a special emphasis on xeno-pericardial aortic tube grafts. Gen Thorac Cardiovasc Surg 2017; 67:44-52. [DOI: 10.1007/s11748-017-0839-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
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21
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Ramos A, García-Montero C, Moreno A, Muñoz P, Ruiz-Morales J, Sánchez-Espín G, Porras C, Sousa D, Castelo L, Del Carmen Fariñas M, Gutiérrez F, Reguera JM, Plata A, Bouza E, Antorrena I, de Alarcón A, Pericás JM, Gurguí M, Rodríguez-Abella H, Ángel Goenaga M, Antonio Oteo J, García-Pavía P. Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry. Eur J Cardiothorac Surg 2016; 50:1149-1157. [PMID: 27283156 DOI: 10.1093/ejcts/ezw190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/25/2016] [Accepted: 05/04/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. METHODS From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. RESULTS During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). CONCLUSIONS Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.
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Affiliation(s)
- Antonio Ramos
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Carlos García-Montero
- Department of Heart Surgery, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Alfonso Moreno
- Department of Infectious Diseases, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Maranon, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Josefa Ruiz-Morales
- Department of Infectious Diseases UGC, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Gemma Sánchez-Espín
- Department of Heart Surgery UGC, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Carlos Porras
- Department of Heart Surgery UGC, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Dolores Sousa
- Department of Infectious Diseases, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Laura Castelo
- Department of Infectious Diseases, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - María Del Carmen Fariñas
- Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Francisco Gutiérrez
- Department of Cardiovascular Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José María Reguera
- Department of Infectious Diseases, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Antonio Plata
- Department of Infectious Diseases, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Isabel Antorrena
- Department of Cardiology, Hospital Universitario La Paz, Madrid, Spain
| | - Arístides de Alarcón
- Department of Infectious Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - José Manuel Pericás
- Department of Infectious Diseases, Hospital Clinic-IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Mercedes Gurguí
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Hugo Rodríguez-Abella
- Department of Heart Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Ángel Goenaga
- Department of Infectious Diseases, Hospital Universitario Donosti, San Sebastián, Spain
| | - José Antonio Oteo
- Department of Infectious Diseases, Hospital San Pedro, Centro de Investigación Biomédica de La Rioja (CIBIR), Madrid, Spain
| | - Pablo García-Pavía
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
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22
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Perek B, Stefaniak S, Komosa A, Perek A, Katyńska I, Jemielity M. Routine transfusion of platelet concentrates effectively reduces reoperation rate for bleeding and pericardial effusion after elective operations for ascending aortic aneurysm. Platelets 2016; 27:764-770. [PMID: 27255305 DOI: 10.1080/09537104.2016.1184748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Patients with ascending aortic aneurysm undergoing complex surgical procedures are at increased risk of early postoperative excessive blood loss. The aim of this study was to analyze safety and efficacy of routine transfusions of platelet (PLT) concentrates in reduction of hemorrhagic postoperative complications. The study involved 396 consecutive patients (289 males and 107 females) with the mean age of 55.9 ± 13.6 years who underwent elective operations for aortic aneurysms. They were divided retrospectively into two groups, without (group A; n = 123) or with the routine use of PLTs (group B; n = 273). PLTs were transfused intraoperatively just after completion of cardiopulmonary bypass. Twelve patients in group A (9.8%) and 10 (3.7%) in group B required re-thoracotomy due to hemorrhage (p = 0.027). Routine transfusions of PLT concentrates reduced postoperative incidence of excessive pericardial effusion from 24.1% in group A to 2.1% in group B (p = 0.002). In a consequence, significantly less units (p < 0.0001) of red blood concentrates and fresh frozen plasma were transfused in group B than in group A. The rates of other adverse events in the early postoperative period did not differ between groups. Patients with pericardial effusion required 6.3 ± 2.7 additional days of hospitalization due to surgical re-intervention. Neither blood transfusion-related infections nor adverse reactions were noted. In conclusion, routine intraoperative transfusions of PLT concentrates in patients with ascending aortic aneurysms significantly reduced a need for re-intervention due to both early bleeding and late cardiac tamponade.
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Affiliation(s)
- Bartłomiej Perek
- a Department of Cardiac Surgery and Transplantology , Poznań University of Medical Sciences , Poznań , Poland
| | - Sebastian Stefaniak
- a Department of Cardiac Surgery and Transplantology , Poznań University of Medical Sciences , Poznań , Poland
| | - Anna Komosa
- b Ist Department of Cardiology , Poznań University of Medical Sciences , Poznań , Poland
| | - Anna Perek
- c Department of Anesthesiology and Intensive Therapy , Poznań University of Medical Sciences , Poznań , Poland
| | - Izabela Katyńska
- a Department of Cardiac Surgery and Transplantology , Poznań University of Medical Sciences , Poznań , Poland
| | - Marek Jemielity
- a Department of Cardiac Surgery and Transplantology , Poznań University of Medical Sciences , Poznań , Poland
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