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Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch
© Kubota et al.; licensee BioMed Central Ltd. 2012
Received: 4 January 2012
Accepted: 17 April 2012
Published: 14 May 2012
Resection of the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexy is the standard procedure for treating infected aortic aneurysms, but the question of which graft material is optimal is still a matter of controversy. We recently treated a patient with an infected thoracic aortic aneurysm. The aneurysm was located in the proximal aortic arch. Because the patients had previously undergone abdominal surgery, the aortic arch were replaced in situ with a branched equine pericardial roll grafts. The patient is alive and well 23 months after the operation.
Preparing a three branched equine pericardial sheet
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Intraoperative microscopic examination of the thrombus in the pseudoaneurysm revealed a large number of leukocytes. The pericardial effusion also contained a large number of leukocytes.
Dacron grafts, rifampicin-soaked Dacron grafts, and homografts are the choices to cure infected aortic aneurysm [2–4]. Although cryopreserved homografts are excellent material to treat infected aortas, it is difficult to be in time for urgent operation. Yamamoto et al. described successful in situ replacement of the thoracic descending aorta with an equine pericardial roll graft for an aortobronchial fistula caused by the infection due to α–streptococcus . Omentopexy was not performed in their patient, because omental mobilization was considered impossible due to a past history of laparotomy for an esophageal hiatal hernia. In our case, we also did not use the omentum because abdominal adhesions were expected and the lesion was thought to be too distant to wrap the graft. Yamamoto et al. also described two cases of successful in situ replacement with an equine pericardial roll graft to treat a ruptured infected abdominal aortic aneurysms . In presented case, no pathogen was detected. It may have been due to the long preoperative period of intravenous antibiotic therapy. The type of pathogen also affects the prognosis. A case who showed the colonized and damaged inner layer of the equine pericardial roll graft by methicillin-resistant Staphylococcus aureus 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 concluded that treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases by complete removal of the infected prosthetic material and extensive debridement as well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segments provides excellent results with regard to durability and freedom from reinfection and reoperation . They also mention that this new concept is an additional alternative to cryopreserved homografts that extends the armamentarium for treating patients with highly complex conditions. Considering these excellent result of self-made xenopericardial tube graft as “rescue” procedure, we propose a question that why not use the xenopericardial tube graft for “initial” treatment.
However, As far as we investigated, we could not find any reports of aortic arch reconstruction with a self-made branched equine pericardial roll graft. A pericardial sheet is soft but firm and easy to suture. It was made to be cylindrical not preoperatively but intraoperatively to obtain a good operative field. The diameter of the roll graft was easy to match to the transected aorta. Because the side length of the pericardium was 10 cm, an each margin to sew up was calculated as 10–3 π/2 = 0.3 cm. The graft dilatation, stenosis, 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 antiplatelet agents is a matter of controversy. We propose that, 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.
Because this technique is simple and less invasive than the standard procedure, it may have the potential to serve as one of the choices of treatment for infected aneurysms of the thoracic aorta. By accumulating clinical cases, when its long-term durability will be confirmed, it may demonstrate the advantages of xenopericardial branched graft as one of the choices of treatment for infected aortic aneurysms.
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