Vacuum-assisted closure system for the treatment of mediastinitis after total aortic arch replacement.

A 77-year-old man developed deep sternal wound infection with Enterobacter cloacae 4 days after total aortic arch replacement for distal aortic arch aneurysm. Reexploration and open drainage of the mediastinum was carried out for 4 days, and the vacuum-assisted closure system was applied and continued for 10 days. During the treatment, granulation formation and neovascularization was apparently enhanced which lead us to perform omental transfer and chest closure on the 18th postoperative day. The patient has been free from recurrent sign of mediastinal infection or graft infection for the 19 months of the follow-up period.     

An effective vacuum-assisted closure treatment for mediastinitis with aortic arch replacement

Little experience exists with the vacuum-assisted closure (VAC) therapy in the high-risk group of patients with perigraft abscess containing a large amount of prosthetic vascular grafts. We report our experience in the VAC therapy for patients with mediastinitis after aortic arch replacement. Between February 2003 and December 2006, five patients with a mean age of 72.2 years developed postoperative mediastinitis after aortic arch replacement, and were treated with the VAC system. In all the patients the mediastinal fluid and tissue examinations turned out to be negative for microbiological cultures, and successful closure of the midline incision was achieved with concomitant omental transfer after a mean duration of 22.6 days of VAC treatment. Four of the five patients survived to discharge and have been free from recurrent sign of mediastinal or graft infection at long-term follow-up. Our study indicates that the VAC treatment may reduce early mortality of life-threatening deep sternal wound infection complicated by a prior aortic arch replacement and become a preferred therapeutic option for the patients to whom another replacement is too risky.     

Successful treatment of MRSA mediastinitis after aortic arch replacement.

An aortic arch graft replacement was successfully performed for a true aneurysm on the distal aortic arch. However, Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis occurred after surgery. Following reoperation for debridement and irrigation of the mediastinal space, antibiotics were administered and continuous irrigation of mediastinal space with saline containing appropriate antibiotics and intermittently short duration irrigation with a large quantity of saline containing popidone-iodine were carried out with good results. This paper presents the successful treatment of mediastinitis after replacement of the aortic arch without removing the graft, followed by a brief review of the literature regarding infection of prostetic grafts for the thoracic aorta.     

Vacuum-assisted closure with a portable system for treatment of poststernotomy mediastinitis

The patient was a 50-year-old man with diabetes who was on insulin. Complications of mediastinitis developed after coronary bypass surgery, which had been performed for unstable angina. Upon hospital admission, the patient was treated with antibiotics, and the wound was cleaned on a daily basis. However, because the patient’s fever persisted, the wound was completely opened surgically and found to be deep and large. Because the patient’s condition was relatively stable, minimally invasive vacuum-assisted closure was selected. We fabricated a portable vacuum-assisted closure system that imposed few limitations on individual movement. Vacuum-assisted closure treatment resulted in both rapid abatement of fever and improved granulation. Dressings were changed once a week; the wound was closed 4 weeks after vacuum-assisted closure and healed completely. Vacuum-assisted closure may be an effective therapy for postoperative mediastinitis, and our portable vacuum-assisted closure system may significantly reduce patient distress as well as direct medical care.     

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis

A new technique using vacuum-assisted closure was successfully applied in 3 patients with poststernotomy mediastinitis. After surgical debridement, this vacuum-assisted closure technique has made it possible to avoid the need for secondary surgical closure (including direct secondary surgical closure and secondary surgical closure by use of vascularized muscle flaps). A healed stable sternotomy wound can be achieved using this new technique.     

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient.

INTRODUCTION: Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. PATIENTS AND METHODS: Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. RESULTS: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. DISCUSSION: All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.     

Vacuum-assisted closure in the paediatric patient with post-cardiotomy mediastinitis

Mediastinitis has a high mortality and is a major cause for concern in the neonatal cardiac surgical population. Vacuum-Assisted Closure (V.A.C.) is a newly established technique for expediting healing in the management of wounds resistant to established treatments; this includes the treatment of post-cardiotomy mediastinitis in the adult cardiac surgical patient. We describe the previously unreported use of the V.A.C. device for the successful treatment of post-cardiotomy mediastinitis in an infant. The device also improved the mechanics of respiration. We discuss potential risks and benefits of V.A.C. and suggest guidelines for its use.     

Results of a total aortic arch replacement for an acute aortic arch dissection

OBJECTIVES: Recently, the immediate results of a surgical repair for an acute aortic arch dissection have dramatically improved. However, a total aortic arch replacement is recommended in a limited number of patients with an intimal tear located in the aortic arch. We have performed a total aortic arch replacement for all such patients with an acute aortic arch dissection since September 1995. METHODS: During the past 4 years, 27 consecutive patients who had an aortic arch dissection underwent a total aortic arch replacement. Twenty-five patients underwent an emergency operation. In 5 patients the intimal tear was located in the aortic arch, but in the rest of the patients, it was located in the ascending aorta or the proximal descending aorta. To obliterate any false channels, gelatin-resorcin-formol glue was used. RESULTS: The hospital mortality was 11%, and no cerebral complications were observed. Postoperative aortography and computed tomography showed no evidence of any persisting false channels in 15 patients (65%). During the follow-up period (ranging from 5 months to 4 years), two patients underwent a reoperation because of the recurrence of a dissection at the sinus of Valsalva. All patients, except for one who died after a reoperation, are still alive and free from any serious events at this writing. CONCLUSIONS: Resecting both the ascending and transverse aorta, irrespective of whether the intimal tear is located in the aortic arch, may be an acceptable alternative at experienced centers because of its low mortality and good midterm results.     

Predictors of early and late outcome after total arch replacement for atherosclerotic aortic arch aneurysm

Objectives

This study aimed to identify predictors of early and late outcome after total arch replacement (TAR) for atherosclerotic aortic arch aneurysm.

Methods

TAR with separate arch vessel grafting and selective cerebral perfusion was performed in 130 patients. The median age at operation was 72.9 ± 6.1 years (57–86 years). Emergency operation was performed in 9 patients (6.9 %) and the frozen elephant trunk technique was used in 51 patients (39.2 %).

Results

The in-hospital mortality rate was 3.8 %. Chronic renal failure (CRF) was identified as an independent predictor of in-hospital mortality (p = 0.0001). Permanent neurological dysfunction occurred in nine patients (6.9 %). Clot or atheroma in the aneurysm (p = 0.01) and the duration of selective cerebral perfusion (p = 0.011) were identified as independent predictors of permanent neurological dysfunction. Long-term survival rates were 82.0 % at 3 years, 70.0 % at 5 years, and 52.4 % at 8 years postoperatively. CRF (p = 0.0190), age (p = 0.0147), and permanent neurological dysfunction (p = 0.0048) were identified as independent predictors of long-term mortality.

Conclusions

Prevention of permanent neurological dysfunction is crucial for long-term survival after TAR. Older patients with renal dysfunction may have reduced long-term survival after TAR.     

Contemporary results of total aortic arch replacement

BACKGROUND AND AIM: Aneurysmal dilatation of the aortic arch is uncommon, and the complex anatomy involved imposes unique technical challenges. The results of surgical intervention reported from large centers are improving; however, the degree to which these results are reproducible by other surgeons is less clear. We therefore reviewed our recent experience with total aortic arch replacement. METHODS: Between July 1, 1997 and July 1, 2001 19 patients underwent complete aortic arch replacement, with or without concomitant procedures. We retrospectively reviewed perioperative results retrieved from the computerized database and clinical records. RESULTS: The mean age of the study population was 68 +/- 8.3 years (range 52 to 82), with women predominating (11 women, 8 men). All patients had hypertension. Patient history indicated active or past tobacco abuse in 16 patients (80%); cerebrovascular disease in 3, and peripheral vascular disease in 7 patients. Associated procedures included an elephant trunk in 12 (63%), replacement of the upper descending thoracic aorta in 5 (26%), concomitant coronary artery bypass in 5 (26%), and aortic root replacement in 3 (16%). One patient underwent replacement of the entire aorta from sinotubular ridge to iliac bifurcation in a single procedure. Brachiocephalic reconstruction with a "Y-graft" permitting early antegrade cerebral perfusion was performed in 12 patients. Retrograde cerebral perfusion was performed in ten patients (53%). Perioperatively, death occurred in two patients (11%) and stroke in two (11%). CONCLUSIONS: With cautious application, techniques developed in high-volume centers can also achieve satisfactory results when used at centers with a more modest case volume.     

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery

Purpose  

To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis.     

Technical advances in total aortic arch replacement

BACKGROUND: We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair. METHODS: One hundred fifty patients, median age 66 years (range, 27 to 85), underwent total arch replacement between 1988 and 2002; 75 were female. We retrospectively compared the results of three patient groups roughly comparable with regard to preoperative risk factors: 45 patients using HCA beginning in 1988; 67 patients using HCA/SCP beginning in 1994; and 38 patients utilizing a trifurcated arch graft in conjunction with SCP through the axillary artery (HCA/SCP/T) since 2000. The groups were well matched with regard to median age (66, 68, and 66 years), urgency (emergent 11%, 13%, 5%; urgent 24%, 9%, 18%; and elective 64%, 78%, 76%), and several other known risk factors (p = not significant). RESULTS: An adverse outcome-hospital death or permanent stroke-occurred in 14%: in 16% with HCA, in 16% with HCA/SCP, and in 8% with HCA/SCP/T. Transient neurologic dysfunction among patients surviving without stroke was lower with HCA/SCP/T (11%) than with HCA (33%) or HCA/SCP (17%). Mean duration of HCA was 52 +/- 16 minutes with HCA alone versus 45 +/- 10 minutes with HCA/SCP and 31 +/- 7 minutes with HCA/SCP/T (p < 0.0001 for groups HCA and HCA/SCP combined versus HCA/SCP/T). Mean duration of SCP was 57 +/- 25 minutes with HCA/SCP versus 62 +/- 24 minutes with HCA/SCP/T (p = not significant). Comparison of the groups of patients who had comparable preoperative risk factors for adverse outcome showed a trend toward lower adverse outcome and transient neurologic dysfunction rates using HCA/SCP/T; a significant reduction in respiratory (p < 0.001), infectious (p = 0.015) and cardiac (p = 0.005) complications in HCA/SCP/T compared with the earlier groups; and significantly shorter durations of intensive care (p < 0.0001) and hospitalization (p = 0.004). CONCLUSIONS: Our results suggest that HCA/SCP is superior to HCA alone for preventing cerebral injury during operations on the aortic arch. By further reducing embolic risk as well as duration of HCA, HCA/SCP/T with axillary artery cannulation may be the optimal technique for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.     

Vacuum-assisted closure for postcardiac surgery mediastinitis in a patient on hemodialysis

A 66-year-old man on hemodialysis underwent off-pump coronary artery bypass grafting. He was discharged in good condition on postoperative day (POD) 16. A high-grade fever and a purulent discharge emerged on POD 30. Methicillin-resistant Staphylococcus aureus was identified by culturing material from the wound. On admission, vacuum-assisted closure (VAC) therapy was applied for 80 days. Finally, good wound healing allowed us to perform simple wound closure without using muscle flaps or omentoplasty. VAC therapy is a useful and safe procedure for postcardiac surgery mediastinitis.     

Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique

Open in a separate window OBJECTIVESThis study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique.METHODSTwo-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke.RESULTSOverall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke.CONCLUSIONSStroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.     

Simultaneous total arch replacement and abdominal aortic surgery

It is common to encounter patients with coexisting aortic arch aneurysm and abdominal aortic lesions. We conducted simultaneous total arch replacement and abdominal aortic surgery in 3 patients having such lesions. Mean operative time was 511 minutes and no in-hospital mortality occurred. Postoperative respiratory failure was observed in an 80-year-old patient who recovered and all three patients were discharged in good condition. No other postoperative complication was seen. Simultaneous total arch replacement and abdominal aortic surgery may thus offer advantages to patients with such double aortic lesions if it can be conducted safely.     

Three-graft technique for ascending aorta and total aortic arch replacement

We have developed a procedure for total aortic arch replacement using three separate Hemashield grafts and establishing deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion followed by antegrade cerebral perfusion. This method is technically simple and yields secure anastomoses.