Case: A 77-year-old male came to our hospital because of a fever and chest pain. The patient had one month previously undergone subtotal gastrectomy and omentectomy to treat early gastric cancer. His leukocyte count was 10,500/μl, and his serum C-reactive protein level was elevated to 21.6 mg/dl. A blood culture was positive for methicillin-sensitive Staphyrococcus aureus (MSSA). Computed tomography of the chest revealed a rapidly growing pseudoaneurysm and abscess formation around the pseudoaneurysm (Figure 1-A). Systemic examination revealed no obvious primary focus of the infection; teeth, urinary, or respiratory system. Previous abdominal operation, and central venous and urinary catheter insertion were possible to be the origin of the infection. Urgent ascending aortic replacement without omentopexy was performed.
Operative procedure
On July 16, 2009, the pericardium was opened through a median sternotomy. There was a large purulent pericardial effusion. Cardiopulmonary bypass was established with cannulations via the right femoral artery, superior vena cava and inferior vena cava. When the patient’s tympanic membrane temperature had fallen to 20 degrees centigrade, the ascending aorta was opened with the patient in circulatory arrest, and it was transected just immediately proximal to the orifice of the innominate artery (Figures 1-B, 2-A). The aortic segment containing the aneurysm was removed. A 10 cm × 10 cm equine pericardial sheet (XGA-400; Edwards Lifesciences, Irvine, CA, USA) was sutured to the posterior side of the transected aorta and rolled up by continuous suturing from posterior to anterior with 4-0 polypropylene (Figure 1-B). When the corners of the pericardial sheet met, the suture was tied, and the same thread was used to stitch the two sides of the pericardial sheet continuously to form a cylinder (Figure 2-C). The graft was clamped, the cardiopulmonary bypass was resumed, and the patient was warmed. The abscess and surrounding tissue were debrided. Because the abscess cavity behind the posterior side of the ascending aorta extended to just above the main trunk of the left coronary artery, the proximal ascending aorta was transected obliquely, the pericardial sheet was trimmed, and a beveled anastomosis was created by using a 4-0 polypropylene continuous suture (Figure 2-D, Figure 3-A). The aortic cross clamp time was 62 minutes and the circulatory arrest time was 40 minutes.
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.