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J Thorac Cardiovasc Surg 2007;134:1051-1052
© 2007 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, Bristol Heart Institute at The Bristol Royal Infirmary, Bristol, United Kingdom.
Received for publication February 9, 2007; accepted for publication February 23, 2007. * Address for reprints: Alan J. Bryan DM, FRCS (C/Th), Consultant Cardiac Surgeon, Bristol Heart Institute, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HN. (Email: Alan.Bryan{at}ubht.swest.nhs.uk).
Prosthetic graft infection (PGI) after surgery to reconstruct the thoracic aorta is a devastating complication. The reported incidence is between 1% and 3%.1 Treatment of this complication remains a challenge for surgeons, and chances of a successful outcome are considered low. Mortality rates range from 25% to 75%, and morbidity in surviving patients is high.2
Most reports advocate a management strategy that combines removal of all the prosthetic material, removal of surrounding tissue, and extra-anatomic arterial reconstruction.3-5 However, such a major surgical undertaking may not be possible in most cases because of the technically challenging nature of the surgery, and because most patients usually have multiorgan dysfunction caused by sepsis, making the procedure risky.
In this report, we define the outcome and management strategies for PGI after surgery to reconstruct the thoracic aorta. We report our experience of managing PGI with a more conservative approach.
From 1996 to 2005, all the names of patients undergoing prosthetic graft replacement of the thoracic aorta in a single unit were prospectively placed in a database. A retrospective review of case notes was performed.
A diagnosis of PGI was made in patients with signs of sepsis, namely, pyrexia, leukocytosis, and increased C-reactive protein coupled with evidence on computed tomography scanning of perigraft collection or air.
During the study period, more than 400 consecutive patients underwent graft replacement of the thoracic aorta. The following procedures were undertaken: aortic arch replacement (38 cases, 9.5%), composite aortic root replacement (162 cases, 40.5%), and interposition graft to the ascending aorta plus aortic valve replacement (200 cases, 50%). The mortality for the entire group was 13%.
Eight patients (2%) had PGI. They underwent the following procedures: aortic arch replacement (2 cases), composite aortic root replacement (3 cases), and interposition graft to the ascending aorta plus aortic valve replacement (3 cases). Demographic details for individual patients are shown in Table 1. The mean age was 63 years (15); 6 were elective cases and 2 were urgent cases.
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Two patients had infection of aortic graft prosthesis without sternal wound involvement. One patient had Marfan syndrome and had originally undergone a composite aortic root replacement with a mechanical valve conduit. He presented 28 days after surgery with a Candida albicans PGI. This was complicated by false aneurysm of the ascending aorta. This patient underwent a successful redo aortic root replacement with a composite porcine xenograft.
The second patient underwent a composite aortic root replacement plus partial replacement of the aortic arch. She presented weeks after surgery with C. albicans PGI. It was elected to treat her conservatively with antifungal agents. She died of multiorgan failure secondary to mediastinal sepsis 10 weeks after the initial operation.
The median intensive therapy unit stay was 8 days (range 3–74 days). The median survival for the 6 patients discharged from the hospital was 5.8 years (range 0.25–7 years). There was 1 late death 6 years after the procedure. No patient had recurrence of sepsis affecting either the wound or the aortic prosthesis (Table 2).
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PGI after aortic reconstruction represents a difficult problem to mange. Redo surgery is technically challenging and mortality rates remain high, up to 42% even with an aggressive surgical strategy.1,2
In this report we showed that the incidence of PGI after surgery of the thoracic aorta is low (2%) and mostly related to sternal wound sepsis. When associated with sternal wound sepsis, a limited surgical strategy involving extensive mediastinal debridement and mediastinal irrigation resulted in a good outcome in the majority of cases. Removal of the infective prosthesis was not required. Cases in which the graft was infected without sternal wound involvement were unusual. In these cases, removal of the infected prosthesis and reconstruction of the aorta are recommended. In all cases, the best outcome was achieved with prompt surgery.
| See related editorial on page 839.
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References
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  S. A. LeMaire and J. S. Coselli Options for managing infected ascending aortic grafts. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 839 - 843. [Full Text] [PDF]
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