Contemporary outcome of the surgical management of prosthetic graft infection after a thoracic aortic replacement: is there a room to consider vacuum-assisted wound closure as an alternative?

Abstract

ObjectiveOnce a replaced prosthetic graft is infected, it is usually necessary to re-replace the thoracic aorta to achieve complete resolution of the infection. It is, however, an exceedingly invasive approach to perform such a repeat surgery on patients in a poor condition. We have managed both re-replacement of an infected prosthetic graft and conservative therapy with vacuum-assisted wound closure (VAC) without re-replacement. These two treatment modalities were retrospectively assessed.MethodsRetrospective clinical chart review was undertaken on 21 patients with prosthetic graft infection after thoracic aortic replacement between December 1999 and December 2012. Surgical outcomes were evaluated between the two groups: re-replacement group (group R, n = 14) and no-replacement group (group NR, n = 7).ResultsIn-hospital survival rates were 64.3 % in group R and 85.7 % in group NR. Mortality in group R included five patients, sepsis in two patients, and intraoperative aortic rupture, heart failure, and cerebral infarction in one. Mortality in group NR included one patient (sepsis). In terms of long-term outcome, one patient in group R and one patient in group NR died of rupture of a residual aortic aneurysm, and one patient in group NR died of renal disease during follow-up (52.8 ± 41.5 months for R and 43.2 ± 28.5 months for NR; mean ± standard deviation).ConclusionsRe-replacement of an infected prosthetic graft after a thoracic aortic operation still carries a significant risk for mortality. VAC therapy may provide an acceptable option for such a subgroup of patients with this serious condition.

Efficacy of vacuum-assisted closure therapy on rehabilitation during the treatment for surgical site infection after cardiovascular surgery

“…One of the most important advantages of VAC therapy is that it may be able to accelerate wound healing by continuous negative pressure [1,2]. In addition, VAC therapy may be a feasible option for the treatment of graft or device-related infections following cardiovascular operations [5,14,15]. Furthermore, it has been clinically noted that VAC therapy can facilitate rehabilitation during treatment for cardiovascular SSI, although studies describing this merit are scarce.…”

Resection and replacement of thoracic aortic graft infections

“…Aggressive management can carry significant short-term morbidity, and some patients may present in such tenuous condition that avoidance of the physiologic insult of reoperation is considered. Reports of successful graft preservation have used various multimodality approaches, incorporating local debridement with some combination of antimicrobial irrigation, [9][10][11] vascularized autologous tissue coverage, 8,12 negative pressure wound therapy, 18 and/or antibiotic-impregnated bead placement. 19,20 Akowuah and colleagues 11 have suggested improved success of graft preservation when a thoracic aortic graft is seeded secondary to an overlying deep sternal wound infection as opposed to the situation of primary graft infection, whereas other groups do not use this as a selection criteria when considering graft preservation.…”

Intraoperative vacuum-assisted closure following in situ graft replacement for an infected thoracic aortic graft

“…Removal of exudate from the mediastinal and perigraft cavities can facilitate successful management of the infection. [2][3][4] The enhanced neovascularization induced by the negative pressure during VAC therapy can also aid in recovery. 4,5 In addition, in our patient cohort the negative pressure of the VAC system, which is much higher than that of a conventional drain, caused no adverse events such as anastomotic rupture or increase in bleeding, despite the fact that VAC was applied immediately after cardiopulmonary bypass with hypothermia (in an unsettled coagulation state).…”

“…In all cases, after patients came to our department, emergency in situ aortic graft replacement was performed uneventfully, and then the VAC system was installed intraoperatively as previously described. 2,3 In brief, after 0.01% gentian violet solution was applied around the prosthetic graft, polyurethane foam (Hydrosite; Smith & Nephew Inc, Fla) was packed around the graft, and the front was also covered with polyurethane foam. Then a noncollapsible chest tube was placed in the middle of the incision, and the incision perimeter was covered with lap sponges (Kawamoto Co Ltd, Osaka, Japan).…”

“…The vacuum-assisted closure (VAC) system is a noninvasive treatment device used for pressure ulcers and other chronic wounds and is currently a treatment of choice for poststernotomy mediastinitis in many institutions. 2,3 The installation of a VAC system immediately after replacement of infected grafts with cardiopulmonary bypass has not been conclusively validated, however, because of concerns about increased blood loss or suture line rupture. This report describes consecutive 4 cases in which intraoperative installation of a VAC system was performed, followed by delayed sternal closure (DSC), for thoracic aortic graft infection requiring prompt in situ replacement.…”