Reoperation with xenologous pericardial tubes for aortic graft infection presenting as a contained aortic rupture

P0281 

Abstract Submission 

Laura Rings (1), Achim Haeussler (2), Mathias van Hemelrijck (2), Hector Rodriguez Cetina Biefer (2), Omer Dzemali (2), Petar Risteski (2)

(1) Department of Cardiac Surgery, City Hospital of Zurich – Site Triemli, Zurich, Switzerland, (2) Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland

Laura Rings    -  Contact Me
Department of Cardiac Surgery, City Hospital of Zurich – Site Triemli

Achim Haeussler    -  Contact Me
Department of Cardiac Surgery, University Hospital Zurich

Mathias Van Hemelrijck    -  Contact Me
Department of Cardiac Surgery, University Hospital Zurich

Hector Rodriguez Cetina Biefer    -  Contact Me
Department of Cardiac Surgery, University Hospital Zurich

Omer Dzemali    -  Contact Me
Department of Cardiac Surgery, University Hospital Zurich

Petar Risteski    -  Contact Me
Department of Cardiac Surgery, University Hospital Zurich

Laura Rings    -  Contact Me
Zurich Data Scientists GmbH

Objective: Ruptured thoracic aortic aneurysms and reoperation on the proximal thoracic aorta remain a surgical challenge. Time to the operating room, surgical strategy, and cerebral protection play is essential for patients' survival. Additionally, an ascending aortic graft rupture, contained below the posterior sternal plate, complicates not only the reentry in the thorax but also endangers the organ protection. In this case report, we would like to present our surgical strategy during the reoperation of a thoracic-contained ruptured aneurysm after acute aortic dissection.

Methods: A 32-yo male patient presented in 2022 with an acute aortic dissection type A. He was urgently treated with a mechanical aortic valve replacement, replacement of the non-coronary sinus, ascending aorta, and aortic arch with a dacron prosthesis. Furthermore, the innominate and proximal 8 cm of his left common carotid artery were replaced with separate polyester grafts. 18 months later, he presented with fever, shivering, and sweating at the emergency department. Blood cultures and echocardiography remained negative for endocarditis, but a fluorodeoxyglucose-positron emissions tomography (FDG-PET) scan showed abnormal uptake in the aortic graft and contained graft rupture. Reoperation was carefully planned with bilateral cannulation of the carotid arteries and venous cannulation through the right femoral vein. Simultaneously and on the back table, two 14x9 cm xenologous pericardium blocks were used to construct two pericardial tubes. The patient was cooled to 26° C. During re-sternotomy, the contained rupture converted into an open rupture, which was controlled manually by one surgeon while the other surgeon kept preparing the scar tissue. After cardioplegic arrest, cerebral perfusion was initiated, and all prosthesis material, sutures, and felt were removed. The aortic arch showed necrotic and dissected tissue, which was resected. A xenologic self-made pericardial tube was anastomosed as a neo-aortic arch, clamped, and systemic perfusion started. After that, mobilization of the coronary ostia, implantation of a new mechanical aortic prosthesis and re-implantation of the coronary ostia into the pericardial tube graft. After reperfusion, the patient was weaned from the bypass properly and transferred to the ICU after the surgery. Extracorporeal circulation times were 341 min, Aortic clamp time 213 min, antegrade cerebral perfusion 41 min, and visceral ischemia time 41 min.

Results: The patient was extubated in the evening hours of the operation day and transferred to the ward on the second postoperative day. A postoperative initial LBBB could no longer be detected during the postoperative period. Postoperative echocardiography showed sufficient valve function without elevated gradients and an LVEF of 47 %. All intraoperative microbiological samples remained negative. He remained on antibiotic therapy with Ceftriaxon and Doxycyclin. The patient suffered from aphonia postoperative due to laryngeal nerve palsy with bilateral vocal fold paralysis.

Conclusions: Graft infection is a disastrous complication after aortic repair, with reported morbidity and mortality rates exceeding 35%. Surgeons confronted with the dare of exploring these aneurysms are facing the probability of numerous unwanted events during surgery. Experts' recommendations include radical explantation of the infected graft, extensive debridement followed by aortic reco

Aortic Arch