Latissimus Dorsi Muscle Flap Coverage for Open Surgical Repair of an Infected TEVAR.

P0187 

Abstract Submission 

Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Alexander Mills (4), Gustavo Oderich (1), Anthony Estrera (3)

(1) McGovern Medical School at UTHealth, Houston, TX, (2) Memorial Hermann, Houston, TX, (3) Memorial Hermann Heart and Vascular Institute, Houston, TX, (4) University of Texas Health Science Center at Houston (UTHealth Houston), N/A

Lucas Ribe    -  Contact Me
McGovern Medical School at UTHealth

Yuki Ikeno    -  Contact Me
McGovern Medical School at UTHealth

Rana Afifi    -  Contact Me
Memorial Hermann

Akiko Tanaka    -  Contact Me
Memorial Hermann Heart and Vascular Institute

Alexander Mills    -  Contact Me
University of Texas Health Science Center at Houston (UTHealth Houston)

Gustavo Oderich    -  Contact Me
McGovern Medical School at UTHealth

*Anthony Estrera    -  Contact Me
Memorial Hermann Heart and Vascular Institute

Lucas Ribe    -  Contact Me
McGovern Medical School at UTHealth

Objective:

We report a case of open repair of an infected thoracic endovascular aneurysm repair (TEVAR), executed through a thoracoabdominal exposure and subsequent coverage with Latissimus dorsi muscle flap.

Methods:

A 70- year- old male with a past medical history of stroke, paroxysmal atrial fibrillation, and hyperlipidaemia was referred to our institution for an infected TEVAR. He had a history of a Stanford type A aortic dissection necessitating emergent open ascending repair in 2013, followed by TEVAR in 2015 due to a 6- cm post-dissection aneurysm in the descending thoracic aorta (DTA). Persistent symptoms of fever, chills, muscle pain, and fatigue prompted further investigation, revealing a PET scan highly suggestive of an infected aortic stent graft. Following a multidisciplinary team meeting (MDT), the decision was made to proceed with open aortic repair.

Results:

A left posterolateral thoracotomy incision was performed through the sixth intercostal space, and the sixth rib was preserved. The latissimus dorsi and trapezius muscles were dissected and mobilized for retraction. Following one-lung ventilation, the chest was entered. The latissimus flap was harvested preserving its pedicle.
Due to significant inflammation, the placement of a proximal clamp was deemed unfeasible. Consequently, full cardiopulmonary bypass was performed, incorporating profound hypothermic circulatory arrest after systemic heparinization. The removal of the infected thoracic stent-graft was executed, accompanied by extensive debridement of periaortic tissues. Subsequently, a replacement of the descending thoracic graft was performed, employing a 28-mm dacron graft (Hemashield TM). The newly placed dacron graft received complete coverage with a latissimus dorsi muscle flap. Throughout the hospitalization, the patient received treatment from the infectious disease team, involving intravenous daptomycin, micafungin, and meropenem. Tissue cultures obtained during surgery revealed Clostridium species. Discharge occurred on the 18th postoperative day with a prescription for long-term ampicillin/sulbactam. A postoperative CT scan indicated no aneurysmal dilatation or recurrence of infection.

Conclusions:

Open surgery with Latissimus muscle- flap coverage is an achievable option for infected TEVAR repair.

Descending/Thoracoabdominal Aorta