Equine pericardial roll graft replacement of infected pseudoaneurysm of the ascending aorta
© Kubota et al.; licensee BioMed Central Ltd. 2012
Received: 8 December 2011
Accepted: 19 May 2012
Published: 14 June 2012
The standard procedure for treating infected aortic aneurysms is to resect the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexy. However, the question of which graft material is optimal is still a matter of controversy. We recently treated a patient with an infected ascending aortic aneurysm. Because of previous abdominal surgery, the omentum was unavailable. The ascending aorta was replaced in situ with equine pericardial roll grafts. The patient is alive and well 29 months after the operation.
KeywordsEquine pericardium Biomaterial Infection Aortic aneurysm Surgery Pseudoaneurysm
How should we treat the infected thoracic aorta surgically? Usually, after complete resection of the infected aorta and debridement of the surrounding tissue, in situ graft replacement and omentopexy is performed. As a graft material, Dacron grafts, rifampicin-soaked Dacron grafts, cryopreserved arterial homografts are accepted clinically. Omentopexy is thought to be a most reliable barrier to prevent the recurrence of graft infection because unguarded foreign materials are easily propagated by bacteria. When the omentum is unavailable because of previous abdominal surgery, how should we treat the infected aorta? We experienced a case with a infectious pseudoaneurysm at the ascending aorta due to postoperative septicemia and the omentum was unavailable because of previous gastrectomy to treat gastric cancer. The aorta was replaced in situ with equine pericardial roll grafts without omentopexy.
Because the diameter of the transected aorta was about 3 cm, 10 cm × 10 cm pericardial sheets were used as is. An each margin to sew up was calculated as (10 - 3 π) / 2 = 0.3 cm. Biological glue containing a rifampicin was sprayed on the grafts and anastomoses. No foreign materials were used to reinforce the anastomoses.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Resection of the infected aorta, debridement of the surrounding tissue, graft replacement, and omentopexy is generally considered the standard treatment to cure infected aortic aneurysm. However, the most suitable graft materials to be used to replace the infected aorta are a matter of controversy. Dacron grafts, rifampicin-soaked Dacron grafts are accepted clinically [1–3]). Although cryopreserved arterial homografts are excellent material to treat infected aortas, but the supply in Japan is inadequate, and it is difficult to be in time for urgent operation. The autogeneous pericardium has been reported to treat infective endocarditis, but the surface area is not enough to reconstruct the great vessels ). Further, considering the importance of closing the pericardium to avoid the recurrence of the infection, it is better to preserve the autogeneous pericardium. Instead of these materials, an equine pericardium was used to reconstruct the ascending aorta based on the case reports described by Yamamoto et al ). They used the equine pericardium in the locally-infected field when repairing infected abdominal aortic aneurysm rupture and have confirmed excellent durability of the graft without graft infection in the long-term follow-up. They also reported a case of successful in situ replacement of the thoracic descending aorta with an equine pericardial roll graft with left lower lung resection for an aortobronchial fistula due to aortic rupture caused by the infection due to α–streptococcus ). Omentopexy was not performed in the patient, because omental mobilization was considered impossible due to a past history of laparotomy for an esophageal hiatal hernia.
As for xenopericardium, the feasibility of crimped bovine pericardial conduit to reconstract the aorta was reported ). Czerny et al. reported excellent result of the bovine pericardial tube graft to treat prosthetic graft or endovascular graft infection in 15 patients. They mention that xenopericardial tube graft may be superior to cryopreserved homografts because the likelihood of calcification seems to be less important and another advantage of customized xenopericardial tissue is the availability, which turns out to be problematic with homografts ). A pericardial sheet is soft and easy to handle. It could be made to be cylindrical intraoperatively by rolling it up and gave us a good operative field. The graft dilatation, mural thrombus formation, and recurrence of the infection are concerns during long-term follow up. Enhanced computed tomography may be the most suitable examination for follow-up. The need for treatment with anticoagulant or antiplatelet agents is also a matter of controversy. We propose that, as we reported previously, patients who have undergone surgical reconstruction of the arch vessels, be treated with an anticoagulant or antiplatelet drug to prevent strokes and graft stenosis due to mural thrombi . The type of pathogen as well as the graft material affects the prognosis. Yamamoto et al. alerted that the inner layer of the equine pericardial roll graft in a patient who underwent in-situ replacement of an infected ruptured abdominal aorta was colonized and damaged by methicillin-resistant Staphylococcus aureus (MRSA) ). They suggested that, under MRSA sepsis, the equine pericardium might not have an enough barrier against bacterial colonization, resulting in a possibility of structural instability due to tissue destruction.
In conclusion, the equine pericardial roll graft replacement without omentopexy to treat the infected aortic pseudoaneurysms is a simple procedure. By accumulating clinical cases, when its long-term durability will be confirmed, it may demonstrate the advantages of this material as one of the choices of treatment for infected aortic aneurysms.
The authors wish to acknowledge Prof. Hideaki Yoshino for his support.
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