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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Stilo F, Catanese V, Montelione N, Nenna A, Pilato F, Gabellini T, Chello M, DI Lazzaro V, Spinelli F. Subclavian artery revascularization with subclavian-carotid transposition for TEVAR and non-TEVAR patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:147-154. [PMID: 37162237 DOI: 10.23736/s0021-9509.23.11473-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Subclavian artery revascularization (SAR) has become an increasingly performed technique in patients undergoing thoracic endovascular aortic aneurysm repair (TEVAR), in order to optimize the proximal landing zone, or in patients with significant atherosclerotic diseases. SAR was usually achieved through carotid-subclavian bypass (CSB) which is daunted by graft and patency-related issues, or through subclavian carotid transposition (SCT) which has recently been reconsidered as a potential solution. Nowadays, multiple endovascular strategies including parallel grafts, chimney graft and branch-fenestrated repair, are available in patients unfit for open SAR. However, there is no consensus on the preferable technique in both TEVAR- and non TEVAR-patients. The purpose of this study was to evaluate our experience with SCT in terms of overall postoperative adverse events and mid-term patency rate. METHODS We performed a retrospective cohort study, including all patients who underwent SCT between June 2014 and March 2020 at our Division. Preoperative risk factors, symptoms, intraoperative details, postoperative outcomes and follow-up data were collected. RESULTS A total of 27 patients were included in this study. Indications for SCT included aortic arch debranching for TEVAR for thoracic aortic aneurysm and type B dissection and symptomatic subclavian steal syndrome (SSS). There were no major perioperative adverse events or major neurological complications; five minor adverse events occurred (18.5%) (3 Horner' Syndrome, 1 hematoma requiring reoperation,1 pneumothorax). Peripheral nerve injuries and lymphatic lesions were not recorded. On a mean follow-up of 21±16 months, SCT patency was confirmed in all patients and no deaths occurred. Comparison of baseline and operative characteristics and intraoperative details between groups of patients with or without adverse events did not found differences. CONCLUSIONS SCT should be considered a feasible, effective and safe technique for SAR, with low perioperative complications and optimal mid-term patency. This surgical technique appears to provide a lower risk of neurological events and mortality, particularly in TEVAR patients, reducing the complications caused by the coverage of the left subclavian artery.
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Affiliation(s)
- Francesco Stilo
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Catanese
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy -
| | - Nunzio Montelione
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Fabio Pilato
- Department of Neurology, Institute of Neurology, Sacred Heart Catholic University, Rome, Italy
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo DI Lazzaro
- Department of Neurology, Institute of Neurology, Campus Bio-Medico University, Rome, Italy
| | - Francesco Spinelli
- Department of Vascular Surgery, Campus Bio-Medico University, Rome, Italy
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Sandström N, Söderquist B, Wistrand C, Friberg Ö. The presence of skin bacteria in the sternal wound and contamination of implantation materials during cardiac surgery. J Hosp Infect 2023; 135:145-151. [PMID: 37004786 DOI: 10.1016/j.jhin.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Sternal wound infections (SWI) and aortic graft infections (AGI) are serious complications after cardiac surgery. Staphylococcus aureus and coagulase-negative staphylococci are the most common causes of SWI, while AGI are less studied. AGI may occur from contamination during surgery or postoperative haematogenous spread. Skin commensals, such as Cutibacterium acnes, are present in the surgical wound; however, their ability to cause infection is debated. AIM The aim of this study was to investigate the presence of skin bacteria in the sternal wound and to evaluate their possible ability to contaminate surgical materials. METHODS We included 50 patients that underwent coronary artery bypass graft surgery and/or valve replacement surgery at our centre from 2020 to 2021. Cultures were collected from skin and subcutaneous tissue at two time points during surgery, and from pieces of vascular graft and felt that were pressed against subcutaneous tissue. The most common bacterial isolates were tested for antibiotic susceptibility with disk diffusion and gradient tests. FINDINGS Cultures from skin had bacterial growth in 48% of patients at surgery start and in 78% after two hours, and cultures from subcutaneous tissue were positive in 72% and 76% of patients, respectively. The most common isolates were C. acnes and S. epidermidis. Cultures from surgical materials were positive in 80-88%. No difference in susceptibility was found for S. epidermidis isolates at surgery start compared to after two hours. CONCLUSIONS The results suggest that skin bacteria are present in the wound and may contaminate surgical graft material during cardiac surgery.
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Affiliation(s)
- N Sandström
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - B Söderquist
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Laboratory Medicine, Clinical Microbiology, and Infectious Diseases, Örebro University Hospital, Örebro, Sweden
| | - C Wistrand
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ö Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
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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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A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection. Regen Ther 2022; 21:519-526. [PMID: 36382133 PMCID: PMC9634152 DOI: 10.1016/j.reth.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/07/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Post-sternotomy surgical site infection (SSI) is a serious complication of cardiovascular surgery. Here, we proposed a new clinical classification and reconstructive strategy for this condition. Methods A retrospective study based on medical records was performed on 100 consecutive cases requiring wound management by plastic surgeons for post-sternotomy SSI at Kobe University Hospital between January 2009 and December 2021. We classified 100 cases into four categories according to the anatomical invasiveness of the infection (type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, aortic graft infection). The standard treatment plan comprised initial debridement, negative pressure wound therapy with continuous irrigation, and reconstructive surgery. Reconstructive methods and their outcomes (in-hospital mortality rate, follow-up period, and infection recurrence rate) were investigated for each SSI category. Results There were nine SSI cases in type 1, 28 in type 2, 25 in type 3, and 38 in type 4. The pectoralis major (PM) muscle advancement flap was mainly selected in types 1 and 2 (100 and 70.4%, respectively), while the omental flap or latissimus dorsi (LD) myocutaneous flaps were mainly selected in types 3 and 4 (77.3 and 81.8%, respectively) for reconstructive surgery. The in-hospital mortality rates for types 1, 2, 3, 4 were 44.4, 3.6, 12.0, and 15.8%, respectively. The mean follow-up periods for types 1, 2, 3, 4 were 542.8, 1514.5, 1154.5, and 831.1 days, respectively. Infection recurrence rates for types 1, 2, 3, 4 were 0, 11.5, 13.3, and 19.2%, respectively. All of these recurrent cases, except for 4 cases of type 4 that required surgical intervention, were treated with conservative wound management. Conclusion A volume-rich flap (omental or LD flap) was required to fill the dead space after debridement in mediastinitis (type 3) or aortic graft infection (type 4), whereas superficial SSI (type 1) or sternal osteomyelitis (type 2) received a less-invasive flap (PM muscle advancement flap). Our new classification method was based on the anatomical invasiveness of the infection, providing both a simple and easy diagnosis and definitive treatment strategy. A clinical classification for post-sternotomy surgical site infection is provided. The classification method is based on the anatomical invasiveness of the infection. It provides a simple and easy diagnosis and definitive treatment strategy. Reconstruction strategy was proposed to treat this condition.
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Arnaoutakis GJ, Ogami T, Aranda‐Michel E, Dai Y, Holmes R, Beaver TM, Serna‐Gallegos D, Martin TD, Navid F, Yousef S, Sultan I. Misdiagnosis of Thoracic Aortic Emergencies Occurs Frequently Among Transfers to Aortic Referral Centers: An Analysis of Over 3700 Patients. J Am Heart Assoc 2022; 11:e025026. [PMID: 35766274 PMCID: PMC9333395 DOI: 10.1161/jaha.121.025026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 05/24/2022] [Indexed: 11/16/2022]
Abstract
Background Acute aortic syndromes may be prone to misdiagnosis by nonreferral aortic centers with less diagnostic experience. We evaluated regional variability in these misdiagnosis trends among patients transferred to different regional quaternary care centers with presumed acute aortic syndromes. Methods and Results Two institutional aortic center databases were retrospectively reviewed for emergency transfers in patients diagnosed with acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm between 2008 and 2020. Transferring diagnoses versus actual diagnoses were reviewed using physician notes and radiology reports. Misdiagnoses were confirmed by a board-certified cardiothoracic surgeon. A total of 3772 inpatient transfers were identified, of which 1762 patients were classified as emergency transfers. The mean age was 64 years (58% male). Patients were transferred from 203 medical centers by ground (51%) or air (49%). Differences in transfer diagnosis and actual diagnosis were identified in 188 (10.7%) patients. Of those, incorrect classification of Type A versus B dissections was identified among 23%, and 30% of patients with a referring diagnosis of an acute aortic dissection did not have one. In addition, 14% transferred for contained/impending rupture did not have signs of rupture. All misdiagnoses were secondary to misinterpretation of imaging, with motion artifacts (n=32, 17%) and postsurgical changes (n=44, 23%) being common sources of diagnostic error. Conclusions Misdiagnosis of acute aortic syndromes commonly occurred in patients transferred to 2 separate large aortic referral centers. Although diagnostic accuracy may be improving, there are opportunities for improved physician awareness through standardized web-based imaging education.
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Affiliation(s)
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
| | - Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
| | - Yancheng Dai
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
| | | | | | - Derek Serna‐Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
- Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPA
| | | | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
- Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburghPAUSA
- Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPA
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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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Sollini M, Bartoli F, Boni R, Zanca R, Colli A, Levantino M, Menichetti F, Ferrari M, Berchiolli R, Lazzeri E, Erba PA. Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure. Front Cardiovasc Med 2021; 8:745556. [PMID: 34926606 PMCID: PMC8671629 DOI: 10.3389/fcvm.2021.745556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose: This study aimed to assess the diagnostic performances of multimodal imaging [i.e., white blood cell single-photon emission computed tomography/CT (99mTc-HMPAO-WBC SPECT/CT) and 18-fluoride-fluorodeoxyglucose positron emission tomography/CT ([18F]FDG PET/CT)] in patients with suspected infection after the Bentall procedure, proposing new specific diagnostic criteria for the diagnosis. Methods: Between January 2009 and December 2019, we selected within a cardiovascular infections registry, 76 surgically treated patients (27 women and 49 men, median 66 years, and range 29–83 years). All the patients underwent molecular imaging for a suspected infection after the replacement of the aortic valve and ascending aorta according to the Bentall procedure. We analyzed 98 scans including 49 99mTc-WBC and 49 [18F]FDG PET/CT. A total of 22 patients with very early/early suspected infection (<3 months after surgery) were imaged with both the techniques. Positive imaging was classified according to the anatomical site of increased uptake: to the aortic valve (AV), to both the AV and AV tube graft (AVTG) or to the TG, to surrounding tissue, and/or to extracardiac sites (embolic events or other sites of concomitant infection). Standard clinical workup included in all the patients having echocardiography/CT, blood culture, and the Duke criteria. Pretest probability and positive/negative likelihood ratio were calculated. Sensitivity and specificity of 99mTc labeled hexamethylpropylene amine oxime-WBC SPECT/CT (99mTc-HMPAO-WBC SPECT/CT) and [18F]FDG PET/CT imaging were calculated by using microbiology (n = 35) or clinical follow-up (n = 41) as final diagnosis. 99mTc-HMPAO-WBC scintigraphy and [18F]FDG PET/CT findings were compared with 95% CIs by using the McNemar test to those of echocardiography/CT, blood culture, and the Duke criteria. Results: Sensitivity, specificity, and accuracy of 99mTc-HMPAO-WBC were 86, 92, and 88%, respectively, with a slightly higher sensitivity for tube graft infection (TGI) as compared to isolated AV and combined AVTG. Overall, sensitivity, specificity, and accuracy of [18F]FDG PET/CT were 97, 73, and 90%, respectively. In 22 patients with suspected very early and early postsurgical infections, the two imaging modalities were concordant in 17 cases [10 true positive (TP) and 7 true negative (TN)]. [18F]FDG PET/CT presented a higher sensitivity than 99mTc-HMPAO-WBC scan. 99mTc-HMPAO-WBC scan correctly classified as negative three false-positive (FP) PET/CT findings. Conclusion: Our findings supported the use of 99mTc-HMPAO-WBC SPECT/CT and [18F]FDG PET/CT in patients with suspicion infection after the Bentall procedure early in the course of the disease onset to confirm the diagnosis and provide a comprehensive assessment of disease burden through the proposed criteria.
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Affiliation(s)
- Martina Sollini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco Bartoli
- Department of Translational Research and New Technology in Medicine and Surgery, Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Roberto Boni
- Unità Operativa Complessa Medicina Nucleare, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Roberta Zanca
- Department of Translational Research and New Technology in Medicine and Surgery, Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Andrea Colli
- Division of Cardiovascular Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Maurizio Levantino
- Division of Cardiovascular Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Mauro Ferrari
- Vascular Surgery, Department of Translational Research and Advanced Technology in Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Raffaella Berchiolli
- Vascular Surgery, Department of Translational Research and Advanced Technology in Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Elena Lazzeri
- Department of Translational Research and New Technology in Medicine and Surgery, Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Paola A Erba
- Department of Translational Research and New Technology in Medicine and Surgery, Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.,Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Centre, University Medical Center Groningen, Groningen, Netherlands
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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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Kirkbride RR, Rawal B, Mirsadraee S, Galperin-Aizenberg M, Wechalekar K, Ridge CA, Litmanovich DE. Imaging of Cardiac Infections: A Comprehensive Review and Investigation Flowchart for Diagnostic Workup. J Thorac Imaging 2021; 36:W70-W88. [PMID: 32852420 DOI: 10.1097/rti.0000000000000552] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Infections of the cardiovascular system may present with nonspecific symptoms, and it is common for patients to undergo multiple investigations to arrive at the diagnosis. Echocardiography is central to the diagnosis of endocarditis and pericarditis. However, cardiac computed tomography (CT) and magnetic resonance imaging also play an additive role in these diagnoses; in fact, magnetic resonance imaging is central to the diagnosis of myocarditis. Functional imaging (fluorine-18 fluorodeoxyglucose-positron emission tomography/CT and radiolabeled white blood cell single-photon emission computed tomography/CT) is useful in the diagnosis in prosthesis-related and disseminated infection. This pictorial review will detail the most commonly encountered cardiovascular bacterial and viral infections, including coronavirus disease-2019, in clinical practice and provide an evidence basis for the selection of each imaging modality in the investigation of native tissues and common prostheses.
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Affiliation(s)
- Rachael R Kirkbride
- Department of Cardiothoracic Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | | - Maya Galperin-Aizenberg
- Department of Radiology Hospital of the University of Pennsylvania and Perelman School of Medicine, Philadelphia, PA
| | - Kshama Wechalekar
- Department of Nuclear Medicine and PET, Royal Brompton and Harefield Foundation Trust Hospital, London, UK
| | | | - Diana E Litmanovich
- Department of Cardiothoracic Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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11
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Li L, Lao YH. Massive Hemoptysis Caused by an Aortobronchial Fistula Related to Pedicle Screw Impingement. Vasc Endovascular Surg 2021; 55:761-765. [PMID: 33759646 DOI: 10.1177/15385744211005656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of a 50-year-old man with a 10-year history of pedicle screw internal fixation in the thoracic spine and heroin abuse, who presented with sudden-onset massive hemoptysis with hemorrhagic shock and asphyxia. Urgent contrast-enhanced chest computed tomography (CT) characteristically showed thoracic aortic perforation, a paravertebral pseudoaneurysm, and an intrapulmonary hematoma. Emergency percutaneous thoracic endovascular aortic repair (pTEVAR) with the preclose technique using a vascular closure device under local anesthesia achieved success without any complications. The current case highlights the importance of understanding massive hemoptysis caused by an aortobronchial fistula related to pedicle screw impingement in clinical practice and the value of pTEVAR with the preclose technique under local anesthesia in the emergency setting.
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Affiliation(s)
- Long Li
- Division of Interventional Radiology, Department of Medical Imaging, Guangdong Provincial Corps Hospital of Chinese People's Armed Police Forces, Guangzhou, China
| | - Yong-Hao Lao
- Division of Interventional Radiology, Department of Medical Imaging, Guangdong Provincial Corps Hospital of Chinese People's Armed Police Forces, Guangzhou, China
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12
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García-Arribas D, Olmos C, Vilacosta I, Perez-García CN, Ferrera C, Jerónimo A, Carnero M, Ortega Candil A, Sáez C, García-Granja PE, Sarriá C, López J, San Román JA, Maroto L. Infective endocarditis in patients with aortic grafts. Int J Cardiol 2021; 330:148-157. [PMID: 33592240 DOI: 10.1016/j.ijcard.2021.02.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/30/2021] [Accepted: 02/10/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients. METHODS Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group. RESULTS Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03). CONCLUSIONS In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients.
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Affiliation(s)
- Daniel García-Arribas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain.
| | - Carmen Olmos
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Carlos Nicolás Perez-García
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Carlos Ferrera
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Adrián Jerónimo
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Manuel Carnero
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Aida Ortega Candil
- Servicio de Medicina Nuclear, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
| | - Carmen Sáez
- Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, C/ Diego de León, 62, Madrid 28006, Spain
| | - Pablo-Elpidio García-Granja
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, Valladolid 47003, Spain
| | - Cristina Sarriá
- Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, C/ Diego de León, 62, Madrid 28006, Spain
| | - Javier López
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, Valladolid 47003, Spain
| | - José Alberto San Román
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, Valladolid 47003, Spain
| | - Luis Maroto
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), C/ Prof. Martín Lagos, s/n, Madrid 28040, Spain
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13
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Adan A, Sinha A, Seyedzenouzi G, Bithas C, Waldman S, Noshirwani A. The perils of diagnosing and managing aortic root prosthetic graft infection. J Card Surg 2020; 36:153-155. [PMID: 33169425 DOI: 10.1111/jocs.15124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ahmed Adan
- Faculty of Health and Life Sciences, School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Aditi Sinha
- School of Medicine, St George's University of London, London, United Kingdom
| | | | | | - Simon Waldman
- Department of Surgery, Whiston Hospital, Prescot, United Kingdom
| | - Arish Noshirwani
- Department of Surgery, Whiston Hospital, Prescot, United Kingdom
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14
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Aranda-Michel E, Bianco V, Dufendach K, Kilic A, Habertheuer A, Humar R, Navid F, Wang Y, Sultan I. Midterm outcomes of subcoronary stentless porcine valve versus stented aortic valve replacement. J Card Surg 2020; 35:2950-2956. [PMID: 32789931 DOI: 10.1111/jocs.14943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/20/2020] [Accepted: 07/30/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Stentless porcine xenografts are versatile bioprosthetic valves with the advantage of improved hemodynamics that mimic the function of the native aortic valve. However, these bioprostheses are challenging to implant in the subcoronary position. METHODS All consecutive patients who underwent a bioprosthetic aortic valve replacement (AVR) were included from our institutional database. Cox regression analysis was preformed to determine significant predictors for mid term mortality as well as all cause, cardiac, and heart failure readmission. RESULTS Patients in the subcoronary stentless group were older and more likely to be female and were likely to have a higher Society of Thoracic Surgery risk of mortality. Survival was superior in the stented AVR cohort at 30-days (96.4% vs 90.5%; P < .001), 1-year (90.5% vs 71.6%; P < .001), and 5-year (74.5% vs 56.9%; P < .001) follow up. Acute kidney injury (16.22% vs 5.22%; P < .001) and blood product transfusion (70.27% vs 44.0%; P < .001) were higher in the stentless group. Multivariable analysis revealed subcoronary stentless implantation as a significant independent risk factor for mortality (hazards ratio: 1.92 [1.35,2.72]; P < .001). CONCLUSION Stentless porcine xenograft implantation with the Freestyle bioprosthetic in the subcoronary position can be successfully performed in select patients, but its use is associated with increased perioperative morbidity and mortality affecting midterm outcomes. Individual patient selection and surgeon experience are important to ensure favorable outcomes.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Keith Dufendach
- 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
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rishab Humar
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - 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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15
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Türköz R, Doğan A, Türkekul Y, Özker E. Successful treatment of thoracic aortic graft infection by omental flap following vacuum-assisted closure therapy. J Card Surg 2020; 35:2857-2859. [PMID: 32720391 DOI: 10.1111/jocs.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed METHOD: Herein, we present a 72-year-old case with mediastinitis and graft infection after type A aortic dissection operation and successful treatment using omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. CONCLUSION The patient had an uneventful postoperative course and remains infection-free to date.
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Affiliation(s)
| | - Abdullah Doğan
- Department of Cardiovascular Surgery, Acibadem Bakirkoy Hospital, Istanbul, Turkey
| | - Yasemin Türkekul
- Department of Cardiovascular Surgery, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Emre Özker
- Department of Wound Care, Altunizade Acibadem Hospital, Istanbul, Turkey
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16
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Kadohama T, Takagi D, Arai T, Yamamoto H. Multiple graft injury due to migrated nonbroken sternal wires 2 years after cardiac surgery. J Card Surg 2020; 35:1640-1641. [PMID: 32485059 DOI: 10.1111/jocs.14685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The migration of sternal wires into vital structures is a rare but potentially life-threatening complication and associated with infection in some cases. While a few cases have been reported the sternal wires were broken in those cases. To our knowledge, this is the first report of multiple, nonbroken, migrated sternal wires stabbing vascular grafts.
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Affiliation(s)
- Takayuki Kadohama
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Daichi Takagi
- Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takeshi Arai
- 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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17
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Andrade D, Vinck EE, Torres LN. Two-stage Omental Flap Approach for Ascending Aortic Graft Infection. Braz J Cardiovasc Surg 2020; 35:XII-XIV. [PMID: 32549117 PMCID: PMC7299588 DOI: 10.21470/1678-9741-2020-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Darío Andrade
- Fundación Clínica Shaio Department of Cardiovascular Surgery Bogota Colombia Department of Cardiovascular Surgery, Fundación Clínica Shaio, Bogota, Colombia
| | - Eric E Vinck
- Fundación Clínica Shaio Department of Cardiovascular Surgery Bogota Colombia Department of Cardiovascular Surgery, Fundación Clínica Shaio, Bogota, Colombia
| | - Laura Niño Torres
- Universidad del Rosario Department of Surgery Bogota Colombia Department of Surgery, Universidad del Rosario, Bogota, Colombia
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18
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Bianco V, Sultan I, Kilic A, Aranda-Michel E, Cuddy RJ, Srivastava A, Navid F, Gleason TG. Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2020; 159:1222-1227. [DOI: 10.1016/j.jtcvs.2019.03.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/02/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022]
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19
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Effect of Celiac Artery and Body Mass Index on Omental Flap for Infected Thoracic Aortic Graft? Ann Thorac Surg 2020; 110:1092. [PMID: 32147415 DOI: 10.1016/j.athoracsur.2020.01.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/23/2020] [Indexed: 11/22/2022]
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20
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Lipsitz EC. Commentary: Aortic graft infections-A potpourri of pathology without a panacea. J Thorac Cardiovasc Surg 2019; 162:9-10. [PMID: 31928819 DOI: 10.1016/j.jtcvs.2019.11.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Evan C Lipsitz
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY.
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21
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Uslu A, Kup A, Güner A, Çelik M, Kahyaoglu M, Güner EG, Uzun F, Kahveci G. Multimodality imaging of an aortic graft infection. Echocardiography 2019; 36:2271-2273. [PMID: 31758716 DOI: 10.1111/echo.14545] [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: 07/26/2019] [Revised: 10/28/2019] [Accepted: 11/03/2019] [Indexed: 12/01/2022] Open
Abstract
Aortic prosthetic vascular graft infections (PVGI) are rare complications of the aortic surgery, with an incidence of 0.5%-6%. Although rare, they carry mortality rates as high as 25%-88%. Improvement in diagnostic imaging modalities in the last two decades, together with early diagnosis, aortic PVGI associated mortality was reduced. These imaging methods include transesophageal echocardiography (TEE), computed tomography angiography (CTA), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). In this case report, we focus mainly on three imaging modalities as TEE, CTA, and 18F-FDG PET/CT and showed their role in the assessment of aortic PVGI.
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Affiliation(s)
- Abdulkadir Uslu
- Department of Cardiology, Kosuyolu Kartal Training and Research Hopital, Istanbul, Turkey
| | - Ayhan Kup
- Department of Cardiology, Kosuyolu Kartal Training and Research Hopital, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Çelik
- Department of Cardiology, Kosuyolu Kartal Training and Research Hopital, Istanbul, Turkey
| | - Muzaffer Kahyaoglu
- Department of Cardiology, Kosuyolu Kartal Training and Research Hopital, Istanbul, Turkey
| | - Ezgi Gültekin Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Fatih Uzun
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gökhan Kahveci
- Department of Cardiology, Kosuyolu Kartal Training and Research Hopital, Istanbul, Turkey
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22
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Stöllberger C, Mertikian G, Stahl D, Finsterer J. Fatal Recurrent Staphylococcus aureus Infection in a Patient With an Aortic Endostent Under Alirocumab. Infect Dis (Lond) 2019; 12:1178633719885387. [PMID: 31695403 PMCID: PMC6822197 DOI: 10.1177/1178633719885387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose: Aortic stent-graft infection (SGI) entails a high mortality. Alirocumab is a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), approved for treatment of therapy-refractory hypercholesterolemia. Proprotein convertase subtilisin/kexin type 9 might play a role in infections. Case report: A 68-year-old male suffered from fatigue, fever, and back pain. Twelve months previously, a 4-fold-fenestrated aortic endoprosthesis was implanted because of an aortic aneurysm. Four months later, alirocumab 150 mg was initiated. Staphylococcus aureus grew in several blood cultures, and he received cefazolin and fosfomycin. Fludeoxyglucose positron emission tomography computed tomography indicated an infected endoprosthesis. Puncture of the periprosthetic space under antibiotic therapy revealed different strains of Staphylococcus epidermidis. The therapy was changed to dalbavancin. The patient died suddenly 11 days later after complaining about back pain for several days. No autopsy was carried out. Conclusions: The most probable cause of the patient’s recurrent bacteremia with S aureus was an infection of the aortic prosthesis. Although this report is very speculative, it can be concluded that data about infections in patients under PCSK9 inhibitors should be collected systematically and more research is needed about the biological consequences of decreasing cholesterol to extreme low levels.
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23
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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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24
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Yamagami K, Tanaka Y, Tada H, Fujii H, Takamura M, Kawashiri MA. The First Report of Purulent Pericarditis Associated with Aortic Stent-graft Infection Caused by Methicillin-susceptible Staphylococcus aureus. Intern Med 2019; 58:3103-3106. [PMID: 31292391 PMCID: PMC6875457 DOI: 10.2169/internalmedicine.2994-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We herein report the first case of purulent pericarditis associated with aortic stent-graft infection in an 80-year-old Japanese man that was caused by methicillin-susceptible Staphylococcus aureus, which appropriate antibiotics failed to treat. The detailed clinical course and autopsy images revealed that purulent pericarditis associated with aortic stent-graft infection caused cardiac tamponade and eventually led to mortality. We therefore suggest that surgical procedures, including drainage, should be introduced for such cases.
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Affiliation(s)
- Kan Yamagami
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Japan
| | - Yoshihiro Tanaka
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Japan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, USA
| | - Hayato Tada
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Japan
| | - Hiroshi Fujii
- Division of Rheumatology, Kanazawa University Graduate School of Medicine, Japan
| | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Japan
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25
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McCann M, Stamp N, Larbalestier R. Massive prosthetic aortic abscess: an overarching plight 7 years post-Bentall's procedure. BMJ Case Rep 2019; 12:12/9/e230204. [PMID: 31494585 DOI: 10.1136/bcr-2019-230204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Infections of proximal aortic vascular grafts are a catastrophic complication of aortic surgery. Despite aggressive antimicrobial and surgical intervention, mortality and reinfection rates remain significant. Here, we describe a man aged 71 years with a medical history of bioprosthetic aortic valve with aortic arch replacement (modified Bentall's procedure), who developed a large periprosthetic abscess due to Staphylococcus aureus 7 years after his initial surgery. The patient's preference was to avoid redo surgery, however despite high-dose intravenous flucloxacillin and oral rifampicin therapy, there was rapid progression of the abscess, necessitating urgent surgery. Notwithstanding the burden of infection, the patient underwent successful surgical excision and graft re-implantation and remains independent and well, almost 2 years postoperatively.
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Affiliation(s)
- Michael McCann
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Nikki Stamp
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Perth, Western Australia, Australia
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26
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Kubota H, Endo H, Ishii H, Tsuchiya H, Ohura N, Takahashi Y. Branched xenopericardial roll graft replacement of an infected aortic arch graft. J Card Surg 2019; 34:31-34. [PMID: 30625256 PMCID: PMC6590405 DOI: 10.1111/jocs.13986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Which graft material is the optimal graft material for the treatment of aortic graft infections is still a matter of controversy. We used a branched xenopericardial roll graft to replace an infected aortic arch graft as a “rescue” operation. The patient is alive and well 37 months postoperatively without recurrence of the infection and any surgical complication. This procedure may have the possibility to serve as an option for the treatment of aortic arch graft infection.
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Affiliation(s)
- Hiroshi Kubota
- Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan
| | - Hidehito Endo
- Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan
| | - Hikaru Ishii
- Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan
| | - Hiroshi Tsuchiya
- Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan
| | - Norihiko Ohura
- Department of Plastic, Reconstructive and Aesthetic Surgery, Kyorin University, Tokyo, Japan
| | - Yu Takahashi
- Department of Cardiovascular Surgery, National Disaster Medical Center, Tachikawa, Japan
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