(Chest. 2005;128:1040-1043.)
© 2005
American College of Chest Physicians
Salvage of Infected Prosthetic Grafts of the Great Vessels via Muscle Flap Reconstruction*
Amitabha Mitra, MD;
Julie Spears, MD;
Vince Perrotta, MD;
James McClurkin, MD and
Avir Mitra, BA
* From the Departments of Plastic and Reconstructive Surgery (Dr. Mitra, Spears, and Perrotta, and Mr. Mitra) and Cardiothoracic Surgery (Dr. McClurkin), Temple University School of Medicine, Philadelphia, PA.
Correspondence to: Avir Mitra, BA, Department of Plastic Surgery, Temple University Hospital, 3322 North Broad St, Philadelphia, PA 19140; e-mail: avirmitra{at}gmail.com
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Abstract
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Objective: The infection of an aortic prosthetic graft presents a difficult challenge for surgeons. Conservative treatments such as debridement and antibiotic irrigation routinely fail, and patient survival rates are low. Literature has indicated that flap procedures often provide better treatment. In the present article, we report our experience utilizing pectoralis major muscle flaps, occasionally coupled with latissimus dorsi, rectus abdominis, and/or serratus anterior flaps, to wrap infected grafts and fill dead space.
Patients: Between 1990 and 2004, 10 patients were brought to our attention with infections of prosthetic grafts of the great vessels (7 men and 3 women; mean age, 53 years). Infections in nine patients involved an ascending aortic graft, while one patient had an infected pulmonary artery graft.
Design: Following diagnosis and exploration, an initial debridement is performed, followed by 48 h of antibiotic irrigation. A definitive muscle flap procedure is then utilized to fill dead space and clear the infection, followed by an appropriate antibiotic regimen.
Results: The infections in all 10 patients were cleared using the muscle flap procedure. Two patients required a tapered-dose regimen of oral steroids, one of whom also required a secondary flap procedure due to the advanced stage of infection. Two other patients later died due to unrelated complications; however, autopsies revealed that operative sites had healed successfully. Patients were followed up for a period of 2 months to 2 years, and recurrence was not found.
Conclusions: Our outcomes suggest that muscle flap procedures, specifically utilizing the pectoralis major and regional muscles, should be kept in mind in the management of life-threatening infections of aortic grafts. Due to the limited number of patients in this study, we feel more research with a larger volume of cases is warranted.
Key Words: ascending aorta • bypass surgery • great vessel infection • infected graft • muscle flap
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Introduction
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Acute infection of grafts of the aorta and the great vessels following bypass surgery occurs in approximately 1 to 6% of postoperative patients.123 Treatment remains a challenge for surgeons, and chances for successful outcome are considered low.45 Most literature67 advocates antibiotic treatment and irrigation, followed by graft removal or replacement if necessary. However, this approach often yields a poor outcome due to anastomotic difficulty in the friable infected area; Soyer et al8 and Chiba et al9 reported mortality rates ranging from 14 to 80%. As a result, several surgeons have utilized the greater omentum and other tissue and muscle flaps to fill dead space. Such procedures have been significantly more successful, elevating survival rates as high as 70%.101112131415
In this article, we report our experience using the pectoralis major muscles to cover infected grafts and fill dead space in 10 patients with greater vessel infections. In certain cases, we utilized the rectus abdominis, latissimus dorsi, and/or serratus anterior muscles in conjunction with the pectoralis major muscle to ensure adequate coverage. We theorized that the rich vascularization of the muscle would be helpful in eradicating recalcitrant infections.
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Patients
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Between 1990 and 2004, 10 patients with infected grafts were brought to our attention. On diagnosis, the patients underwent surgical debridement and antibiotic irrigation for up to 48 h prior to the definitive flap procedure. The antibiotic management plan was organized by an infectious disease specialist in conjunction with the treating doctors. All 10 patients were followed up for 2 months to 2 years after the operation. Patient details can be found in Table 1
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Operative Technique
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Diagnosis
Our clinical experience prompts us to be cautiously aggressive regarding early evidence of graft infection. Clinical signs include continuation of sternal pain, presence of prolonged erythema, serosanguinous discharge, drainage, an unstable sternum, fever, and unexplained lethargy. Diagnostic studies include CBC and differential counts, erythrocyte sedimentation rate, chest radiographs, blood or wound drainage culture, and CT scans.
Exploration:
Once the diagnosis is either established or suspected by the cardiothoracic surgeon and infectious disease specialist, an exploration and initial debridement is performed, followed by 48 h of antibiotic irrigation. Antibiotics are prescribed in conjunction with the advice of the infectious disease specialist.
Pectoralis Muscle Flap Procedure:
Once the patient’s medical status is stable and the wound amenable for reconstruction, a definitive muscle flap procedure is performed. The muscle of choice in our experience has been the pectoralis major turnover flap, in which vascular supply is based on perforators from internal mammary arteries. Depending on the extent and location of infection, either unilateral or bilateral pectoralis major muscle is used in a turnover fashion. The pectoralis major muscle is divided at the insertion and dissected out as close to the perforators as possible up to the outer edge of the sternum. The muscles are then delivered in their ipsilateral side and are inserted through the existing midsternal opening to the right and left of the aortic graft. The flap is placed in an hourglass fashion, covering the root of the aorta and the ascending aorta on one side, as is shown in Figure 1
. A few sutures are placed in the anterior aspect of the flap. If both pectoralis muscles were used, they are sutured together anterior to the aorta. If one is used, we anchor the flap to nearby viable structures, such as the posterior aspect of the sternum. The sutures serve to anchor the flap(s), while the rest of the muscle can fall in the posterior aspect of the graft unanchored, thus wrapping the prosthetic graft in a 360° coverage. This process aims to eliminate any dead space in the anterior mediastinum.
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Figure 1.. Diagram of the bilateral pectoralis major muscle flap procedure. The muscles are dissected at the clavicle and up to the sternum, turned over, and entered through the mediastinal opening. The muscle flaps are sutured to each other anterior to the infection, wrapped around the infection, and allowed to fall posterior to the infection.
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Additional Muscle Flaps:
In some cases, obliteration of dead space required use of the rectus abdominis, latissimus dorsi, or serratus anterior muscle flaps in addition to pectoralis major muscles. Latissimus dorsi or serratus anterior flaps were introduced via rib resection. Latissimus dorsi flaps were used as an overlay flap covering the lower part of the infected graft while pectoralis covered the upper part of the graft.
Drains and Postoperative Care:
Close suction drainage and pre-, intra-, and postoperative antibiotics are routine. Drains are placed in the mediastinum as well as in the chest wall space in mid-sternum-based incisions. Appropriate antibiotics based on cultures taken at the time of surgery were used and discontinued when clinically indicated. We discontinue postoperative antibiotics when the wound looks well healed without erythema, and the patient presents no fever or high WBC count. Following discharge, we followed up the patients for 2 months to 2 years.
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Results
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The 10 patients in the study were discharged with healed wounds following the muscle flap procedure. Follow-up has shown no recurrence in these patients. Individual results are described in detail in Table 1. Two patients later died, one due to cardiac causes and the other due to renal failure; however, autopsies revealed successful coverage of the grafts with no evidence of infection. Antibiotics were discontinued within 3 months in all cases.
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Discussion
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The superiority of vascularized muscle flaps over skin flaps has been well-documented in the literature.16171819 Our results lend support to the use of muscle flaps in the clearing of recalcitrant aortic graft infections. The choice of muscle flaps depends on availability, area of infection, and location of infection; we relied heavily on the turnover pectoralis major flap. If the infection was especially large or more distal, we utilized a secondary muscle group to ensure proper covering. Options include latissimus dorsi, rectus abdominis, and serratus anterior muscles.
Based on our experience of a limited amount of cases, we recommend that, on diagnosis, a muscle flap procedure be performed as soon as possible. Antibiotic irrigation and debridement alone did not heal infections in our patients; however, these treatments were useful in conjunction with a definitive muscle flap, as they often make the environment suitable for muscle flap. Most specialists prescribe 2 years of antibiotic treatment.15 In our experience, continuation of antibiotics depended on a common sense clinical approach with close monitoring of the wound and drainage. Lack of fever, erythema, or high WBC count indicate a well-healed wound. Appropriate antibiotics were administered based on cultures taken at the time of surgery. Long-term follow-up is important in this group of patients, as prosthetic graft infection can present itself years after surgery.
Infection of prosthetic grafts of the ascending aorta is a difficult challenge with an uncertain outcome. Although removal and replacement of the graft is ideal, the presence of active infection and friability of the anastomotic site make this option technically difficult. The muscle wraparound procedure is a helpful tool. The use of unilateral or bilateral pectoralis major muscle wraps, along with latissimus dorsi, rectus abdominis, and/or serratus anterior muscle wraps in certain cases, increased the survival rate of our patients. Early diagnosis, administration of proper antibiotics, and early surgical intervention involving use of a vascularized muscle flap seem to be key. We feel that more research into this procedure is warranted, as a larger survey of cases would be helpful in further assessing its potential.
Received for publication July 23, 2004.
Accepted for publication February 27, 2005.
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References
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- Wilson, SE (2001) New alternatives in management of the infected vascular prosthesis. Surg Infect (Larchmt) 2,171-175
- Seeger, JM, Pretus, HA, Welborn, MB, et al Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal. J Vasc Surg 2000;32,451-459[CrossRef][ISI][Medline]
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Abstract
Introduction
