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Acute aortic dissection type A discloses Corpus alienum
© Popov et al; licensee BioMed Central Ltd. 2009
Received: 25 November 2008
Accepted: 02 January 2009
Published: 02 January 2009
We report an unusual case of an aortic type A dissection with a corpus alienum which compresses the right ventricle. The patient successfully underwent an aortic root replacement in deep hypothermia with re-implantation of the coronary arteries using a modified Bentall procedure and the resection of the corpus alienum. Intraoperative finding reveals 3 greatly adhered gauze compresses, which were most likely forgotten in the operation 34 years ago.
The patient was transferred to the intensive care ward and discharged on the 10th postoperative day without treatment of the type A dissection. Postoperative microbiological tests showed no indication of bacterial colonization. During the hospital stay we started an antihypertensive therapy. However, after the first operation at our institute the patient wanted time to think it over concerning the forthcoming high-risk operation. Although we insistently informed the patient about the dangerous situation, she contacted us not until five weeks with the decision that we can perform the operation.
The patient was rescheduled six weeks later after the first operation at our institute to repeat the CT-scan. This showed a progression of the type A dissection with renewed hemorrhagic pleural effusion followed by promptly surgical treatment.
Acute type A aortic dissection is a catastrophic disease that requires immediate surgical intervention. The main goal of surgery in acute type A aortic dissection is to prevent death from intrapericardial hemorrhage by resecting and replacing the diseased aorta with a graft . Aggressive surgical approach involving extensive resection of dissected aorta for patients with aortic dissection became more popular over the recent years . However, in this case the surgical treatment was deferred, because the adhered gauze compresses was to be suspected infectious process. Moreover, it is well known that infections involving ascending aortic grafts are extremely difficult to eradicate and are frequently lethal . 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 . Several groups currently favour replacing infected ascending aortic prostheses with cryopreserved aortic homografts [4–7]. Retrospective data have suggested that, compared with using synthetic grafts, using cryopreserved homografts for treating vascular infections is associated with improved outcomes, including better elimination of infection, fewer postoperative complications, and longer disease-related survival . However, one commonly cited disadvantage of using homografts is their predisposition to progressive deterioration and ultimate need for re-replacement [9, 10]. Unfortunately, in many cases, a single homograft will not reach the distal ascending aorta or transverse arch . Extensive aortic replacement can be accomplished by using total arch homografts, but these are rarely available . Another treatment strategy to prevent recurrent infection is using a pedicled omental or muscle flap. Omentum is particularly popular because, in patients who have not had previous abdominal surgery, omentum can be easily accessed by extending the sternotomy incision into the abdomen for a short distance [12–16]. The blood supply to the omentum is preserved by basing the pedicle on the right gastroepiploic artery. In addition to filling dead space, the vascularised omental pedicle improves oxygen supply to the region, enhances immunologic response, increases antibiotic delivery, and absorbs wound secretions that can serve as substrates for bacterial growth [13, 16].
There are, however, many established options for managing the infected graft, but the literature on surgical treatment of ascending aortic graft infection fails to provide even the lowest level of evidence on which to base a concrete recommendation. Otherwise, the patient was not septic on admission. However, at that point of time the intraoperative situation was not clear concerning the potential infection, we decided in this special case to abort the emergency operation.
Delayed surgical treatment could be an acceptable alternative to prompt intervention in aortic dissection, provided a stable clinical condition can be achieved with conservative management consisting of rest, careful monitoring and periodic reassessment, if other conditions make the immediate operation very dangerous.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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