A Novel Technique to Wrap, Not Merely Cover, the Omental Flap Around the Infected Graft

Prosthetic vascular graft infection is a severe complication associated with aortic and root replacement. In such situations, use of the omental flap conventional surgical treatment option. However, optimal technique using has not yet been fully established, especially in its application around an infected graft. Here, we present case which successfully controlled involving thoracic prosthetic ascending aorta by wrapping omentum discuss this novel technique. fatal complication, pedicled preferred management. there no consensus about involved addition, coverage alone may be sufficient owing to possibility dead space behind prosthesis. Surgeons need wrap graft; however, forceps pull dorsally risks injury fragile tissue. report A 43-year-old man presented our hospital congestive heart failure due mitral regurgitations. Computed tomography (CT) revealed aneurysm. Valve-sparing replacement valve repair concomitant were performed through median sternotomy. Initially, his postoperative course was good; site became infected, purulent exudate observed, temperature 39.7 °C developed. Wound blood cultures tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Subsequent CT accumulation fluid Four weeks after initial operation, he underwent débridement. Open drainage daily water irrigation subsequently. Two days débridement, massive bleeding unexpectedly occurred from chest wound without any trigger. With assistance cardiopulmonary bypass, tissue observed at base between left noncoronary cusps. We considered that likely have become MRSA. Therefore, urgent Bentall procedure small bovine pericardial patch. Our patient antibiotic therapy MRSA infection, washed every day 2 weeks. After confirmed improvement clinical signs closed 5 negative pressure therapy. The following performed. First, extended operation abdomen. diaphragm then incised create route reach mediastinum. detached stomach while retaining supply right gastroepiploic artery. This ensured both patent sufficiently long wrapped thorough rinsing saline, pulled up into mediastinum circumferentially. To pass limited graft, placed it sterile echo probe cover (P09250; Fuji Medical) so could smoothly guided being damaged (Figure 1). close coronary buttons fixed 5-0 polypropylene sutures. It also subcutaneous similar manner. Postoperative 2; Videos 1, 2). There recurrence mediastinitis.Figure 2Postoperative contrast-enhanced computed image showing (asterisk). (PA, pulmonary artery.)View Large Image Figure ViewerDownload Hi-res Download (PPT) often poor outcome sepsis hemorrhage patients significant comorbidities.1Botianu P.V. Current indications intrathoracic transposition omentum.J Cardiothorac Surg. 2019; 14: 103Crossref Scopus (8) Google Scholar When accompanied mediastinitis, life-threatening risk in-hospital death long-term survival.2Poon S.S. George J. Kumar P. Field M. explantation superior situ preservation?.Interact Cardiovasc Thorac 2022; 34: 291-296Crossref (2) incidence reported range 1% 2%, rates 25% 88%.3Andrade D. Vinck E.E. Torres L.N. Two-stage approach infection.Braz J 2020; 35: XII-XIVCrossref Omental option used treat mediastinal cardiovascular operation. because well vascularized, can fill or spaces.1Botianu Scholar,4Li Stadlbauer A. Floerchinger B. et al.Omental complex sternal wounds cardiac surgery.Thorac 2023; 71: 62-66Crossref (0) safe shown good outcomes relation management significantly reducing reinfection.5Hernandez J.A. Stranix J.T. Piwnica-Worms W. infection.Ann 109: 1845-1849Abstract Full Text PDF PubMed (10) comprehensively described, few reports providing as use, follows. midline transverse abdominal incision made enter peritoneum cavity. inspected adequacy volume, surface area, pedicle length. Next, elevated off colon mobilized on arcade. short gastric vessels are divided serially, permitting based preparation transposition, lengthened arch Barkow unwrap further. For flaps, vessel skeletonized but remains redundant. various defects, transposed either hole fascial defect wall.6Hultman C.S. Culbertson J.H. Jones G.E. al.Thoracic reconstruction omentum: indications, complications, results.Ann Plast 2001; 46: 242-249Crossref (90) despite descriptions harvest method, focused report, describe how Wrapping rather than simply covering preferable allows spaces, improve antibacterial outcomes. fragile, during trauma case, transparent possible remain intact traction forceps. reduced frictional resistance passed narrow created Moreover, straightforward place cover, positioned sustaining twisted process. comprises soft, air-rich molded like clay, air squeezed out flattened reduce volume friction. situations too bulky trimming effective. Other materials might if only one make smooth strong sustain applied when conclusion, simple effectively surgeons compromising reduction. viewed online version article [https://doi.org/10.1016/j.atssr.2023.07.006] http://www.annalsthoracicsurgery.org. authors funding sources disclose.