P187. Latissimus Dorsi Muscle Flap Coverage for Open Surgical Repair of an Infected TEVAR.
McGovern Medical School at UTHealth
Houston, TX
United States - Contact Me
Avanced Aortic Surgery Fellow at Memorial Hermann Hospital, Houston.
I currently live in Houston, where I am completing a two- year Fellowship in advanced aortic surgery. I am greatly engaged in open surgery for aortic aneurysms and dissections, as well as in modern vascular surgery, with large interest in vascular innovations, latest technology in vascular and aortic endovascular surgery, and greatly interested in medical and academic education, as well as surgical simulation.
I previously joined La Fe University Hospital in 2014 as a junior physician in angiology and vascular surgery, within the department of vascular surgery.
Prior to La Fe, I was the first Spanish junior vascular surgeon to complete a senior clinical Fellowship in aortic surgery at St. Mary’s Hospital, Imperial College of London, during an 18- month period,
and one of the first Spanish surgeons to become an official fellow of the European board of vascular and endovascular surgery (FEBVS).
Prior to this experience, I completed my residency in vascular surgery at Gregorio Marañón University hospital in Madrid, during a five- year period.
During my tenure in Madrid, I helped the hospital with the medical and residents training program, and participated in several national and international simulation courses, workshops, and meetings.
I am a graduate of the University of Alcala in Madrid, where I majored my bachelor in medicine.
Description
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.
Authors
Lucas Ribe (1), Yuki Ikeno (1), Rana Afifi (2), Akiko Tanaka (3), Alexander Mills (4), Gustavo Oderich (1), Anthony Estrera (3)
Institutions
(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