Eur J Cardiothorac Surg 1998;13:98-100
© 1998 Elsevier Science NL
Exposed prosthesis of a complex reconstruction of the ascending aorta and aortic arch in a sternal wound infection
Successful treatment by a pectoral muscle flap
Olivier Chavanona,
Frédéric Thonyb,
Jacques Lebeauc,
Dominique Blina
a Service de Chirurgie Cardiaque, CHU Grenoble, BP 217 Grenoble cedex 9, France
b Service de Radiologie, CHU Grenoble, BP 217 Grenoble cedex 9, France
c Service de Chirurgie Plastique et Maxillo-faciale, CHU Grenoble, BP 217 Grenoble cedex 9, France
Received 8 July 1997;
received in revised form 13 October 1997;
accepted 21 October 1997.
Corresponding author. Tel.: +33 476765462; fax: +33 476765264.
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Abstract
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A local wound infection developed in a 42-year-old female patient after replacement of ascending aorta, aortic arch and supra-aortic vessels, following aortic dissection. Because of the high risk of infection due to the vascular prosthesis and its location at the upper part of the sternum, a right pectoral muscular flap, detached from the humerus and vascularized by medial perforators originating from the internal mammary artery, was isolated. The postoperative course was uneventful and the patient remains well 16 months after the operation.
Key Words: Prosthesis • Ascending aorta • Aortic arch • Infection • Pectoral muscle flap
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Introduction
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Infected sternotomy wounds remain a major problem following open heart surgery, particularly when they occur on a mediastinal vascular prosthesis. Reconstructive techniques using muscles flaps are widely used in the treatment of mediastinitis and we report a successful treatment of this life-threatening complication using the pectoralis major muscle flap technique.
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Case report
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A 42-year-old female patient was admitted to hospital for an acute aortic dissection of the descending thoracic aorta as well as an 8 cm wide dissecting aneurysm of the ascending aorta and aortic arch. The patient immediately underwent an operation consisting of the replacement of the ascending aorta and aortic arch extending to the distal intimal tear on segment III and the replacement of supraaortic vessels by separate prosthesis (
Fig. 1
). This operation was performed by sternotomy under circulatory arrest, and perfusion of the brain was accomplished by selective cannulation of the innominate artery. Some difficulties appeared at the closure of the sternum as the patient presented a major kyphoscoliosis and a pectus deformity. The hospital course was uneventful presenting no pyrexia, and the patient was discharged 20 days after the operation.
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Fig. 1. Complex reconstruction of ascending aorta, aortic arch (Meadox, Hemashield, 28 mm) and supraaortic vessels (Meadox, Hemashield 6 mm for left subclavian artery and left common carotid artery, 12 mm for innominate artery).
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One month later the patient was readmitted to hospital for an erythema of the upper part of the sternotomy wound associated with a putrid secretion, and sternum instability. After aspiration, this secretion was put into culture, a broad spectrum antibacterial therapy was initiated then targeted to the bacterium revealed by culture—namely pseudomonas aeruginosa. CT scan showed a periprosthetic collection connected to the abscess via a trans-sternal opening, thus giving an aspect of sternal osteomyelitis. In the operating theatre, the wound was opened wide, the manubrium resected, and necrotic or infected tissues were debrided back to bleeding bone, the sternal wire having previously been removed. After abundant irrigation, a flap was created with the right pectoralis major muscle using a sub-clavicular incision. Blunt dissection was performed along the avascular planes on both sides of the muscle, preserving the perforating branches from the internal mammary artery. The thoracoacromial pedicle was cut after clamping it to check the viability of the flap, and the humeral attachment of the muscle was detached providing a large muscle flap. This flap was turned over and merely laid down in the defect along the prosthesis. Split-thickness meshed skin graft, removed from the internal side of the thigh, was used to cover the flap. Drains were placed on the dissection planes and the sub-clavicular incision was sutured. Recovery and primary healing were uneventful and the patient was discharged 14 days after surgery. Propionebacterium acnes developed in cultures obtained from debridement material, thus a 6 month antibiotherapy was prescribed. Sixteen months later, long-term cosmetic result was acceptable (
Fig. 2
) and CT scan indicated no signs of persistent infection.
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Discussion
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Infected vascular prosthesis involving ascending aorta and aortic arch are rare but life-threatening complications, associated to high mortality. Hargrove reported a 1.9 % rate of infection for thoracic prosthesis graft
[1]. Risk of prosthesis infection is higher in ascending aorta surgery than in common vascular surgery: extracorporeal circulation is well known for its temporary depression of the patient’s immune system
[2], this kind of surgery is often lengthy and prone to bleeding and transfusion, a periprosthetic liquid produced either by an extravasation issuing from the prosthesis or hematoma in the space left after resection of the aneurysm (this fluid accumulation provides an excellent nutrient medium for bacteria). Furthermore, in this case, kyphoscoliosis and pectus excavatum resulted in an unstable sternum, another risk factor for mediastinitis. Several approaches are used in the treatment of deep wound sternal infections but the exposure of an aortic prosthesis makes the problem more difficult. Classical procedures include radical debridement with extensive excision of all infected or necrotic tissues. But if the more logical therapeutical option seems to be explantation of the infected prosthesis with an extra-anatomical by-pass procedure (as in the management of peripheral vascular prosthetic infections), it is limited in surgery of the ascending aorta because of evident anatomical considerations. Ideal treatment would have been replacement by a homograft; however, arch reconstruction would have been very complex in this case. An alternative for rerouting the blood flow is the closure of the aortic root, coronary artery bypass grafts, and a valved conduit between the left ventricle and descending aorta. This remains a hazardous technique. Furthermore, assessing vascular prosthesis infection is rarely possible before explantation and culture. Explantation is an extremely difficult decision to take; it may be justified by an anatomical lesion such as a false aneurysm. If the procedure seems to be too risky, some authors have suggested irrigation with a povidone-iodine solution through an irrigating suction drainage
[3]. In this septic context, the use of a muscle flap for defect closure is very useful
[4] and has significantly reduced morbidity and mortality of wound infection. A well vascularized muscle flap fills in the defect, provides abundant tissue, completely obliterates the empty space, may help to control infection, and accelerates healing. Initially performed after a period of open treatment, a single stage procedure was recently developed
[5]. This results in shorter hospitalization, less secondary surgery, and simplified patient management.
Exposure of the vascular prosthesis and its location at the upper part of the sternum, led us to perform a right pectoral muscular flap (preserving its intercostal pedicles) both to heal the infection and to cover the prosthesis. Current techniques used to cover the upper part of a sternotomy consist mostly in uni or bilateral pectoral muscle advancement flaps which preserve the thoracoacromial pedicles and pectoral humeral attachments
[6]. The section of the pectoral humeral attachments and of the thoracoacromial pedicles provides more abundant tissue, the muscle being turned towards the superior portion of the mediastinum, completely filling in the empty space. Blood supply to the pectoralis major muscle via perforators from the IMA was not compromised since no homolateral internal thoracic artery was harvested in this case. Moreover, before section of the thoracoacromial pedicle, a clamp-test was performed to check flap viability. Other procedures have been performed in this infectious context with exposure of prosthetic aortic grafting, using a sternocleidomastoid muscle flap
[7], or the transposition of the greater omentum in the thorax
[8]
[9]
[10]. The pectoral muscle flap technique is simple and presents no peritoneal contamination risk contrary to an omental flap. A latissimus dorsi flap would have been too short in this case, because of the location and depth of the prosthesis.
This life-threatening complication, presenting exposure of a complex prosthetic reconstruction in an infected sternotomy, was successfully treated, this with a very acceptable cosmetic result. Prophylactic measures are very important as well as particularly meticulous wound closure.
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Acknowledgments
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We wish to thank Dr Katherine Mc Laughlin and Dr Pierre E. Colle for revision of the manuscript.
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References
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- Hargrove III W.C., Edmunds L.H. Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg 1984;37:72-77.[Abstract]
- Mora C. Cardiopulmonary Bypass. New York: Springer, 1995.
- Knight C.D., Jr., Farnell M.B., Hollier L.H. Treatment of aortic graft infection with povidone–iodine irrigation. Mayo Clin Proc 1983;58:472-475.[Medline]
- Jurkiewicz M.J., Bostwick III J., Hester T.R., Bishop J.B., Craver J. Infected median sternotomy wounds: Successful treatment by muscle flaps. Ann Surg 1980;191:738-743.[Medline]
- Hugo N.E., Sultan M.R., Ascherman J.A., Patsis M.C., Smith C.R., Rose E.A. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps. Plast Reconstr Surg 1994;93:1433-1441.[Medline]
- Pairolero P.C., Arnold P., Piehler J.M., McGoon D.C. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg 1983;86:809-817.[Abstract]
- Maurer F., Muller J., Horst F., Seboldt H. The sternocleidomastoid flap for treatment of a septic sternum defect. Thorac Cardiovasc Surg 1995;43:236-238.[Medline]
- Coselli J.S., Crawford E.S., Williams T.W., Bradshaw M.W., Wiemer D.R., Harris R.L. Treatment of postoperative infection of ascending aorta and transverse aortic arch including use of viable omentum and muscle flaps. Ann Thorac Surg 1990;50:868-881.[Abstract]
- Krabatsch T., Hetzer R. Infected ascending aortic prosthesis: Successful treatment by thoracic transposition of the greater omentum. Eur J Cardio-thorac Surg 1995;9:223-225.[Abstract]
- Soyer R., Bessou J.P., Bouchart F., Redonnet M., Mouton-Schleifer D., Arrignon J. Surgical treatment of infected composite graft after replacement of ascending aorta. Ann Thorac Surg 1994;58:425-428.[Abstract]
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Abstract
Introduction
