A male patient, 70 years of age, was evaluated for an infected thoracic endovascular aneurysm repair (TEVAR). After presenting with persistent fever, a positron emission tomography scan found an infected aortic stent graft. The patient underwent open repair with explantation of the infected TEVAR, extensive periaortic debridement, graft replacement with a Dacron graft, and complete coverage with a latissimus dorsi muscle flap. Tissue culture reveale

Afifi, Rana O

Bernal, Lucas Ribé

Estrera, Anthony L

English

DigitalCommons@The Texas Medical Center

From tMediCorrespVascuSt, StThe edidisclomanu2468-4 2024Surgecreathttps://Open repair with latissimus muscle flap coverage fortreatment of infected thoracic endovascular aneurysmrepairLucas Ribé Bernal, MD, Rana O. Afifi, MD, and Anthony L. Estrera, MD, Houston, TXABSTRACTA male patient, 70 years of age, was evaluated for an infected thoracic endovascular aneurysm repair (TEVAR). Afterpresenting with persistent fever, a positron emission tomography scan found an infected aortic stent graft. The patientunderwent open repair with explantation of the infected TEVAR, extensive periaortic debridement, graft replacementwith a Dacron graft, and complete coverage with a latissimus dorsi muscle flap. Tissue culture revealed Clostridium spp.He was discharged home with long-term ampicillin and sulbactam. A postoperative computed tomography scanshowed no recurrence of infection. Open surgery with latissimus muscle flap coverage is an achievable option forinfected TEVAR. (J Vasc Surg Cases Innov Tech 2024;10:101434.)Keywords: Infected aortic flap; Latissimus dorsi muscle flap; TEVAR; Thoracic endovascular aneurysm repairThoracic endovascular aneurysm repair (TEVAR) hasbecome the preferred approach for the treatment ofmost cases of thoracic aortic aneurysms. Since the firstthoracic stent graft was used in 1994 for the treatmentof a descending thoracic aortic aneurysm, the use ofTEVAR has increased exponentially.1-3Complications after TEVAR include endoleak, accesssite complications, renal injury, stroke, spinal cordischemia, device migration, and aortoesophageal andaortobronchial fistulas.3-7 Although uncommon, infec-tion of the thoracic stent graft can occurdand can beassociated with high morbidity and mortality. Mid- andlong-term TEVAR infections represent a complex anddevastating complication.4,8,9 Management is complex.It includes conservative management with long-term an-tibiotics for patients who are not surgical candidates,endovascular treatment, which is usually used as abridging procedure, and explanation of the infectedgraft, with in situ or extra-anatomic bypass reconstruc-tion.4,10-12 When choosing graft explantation with in situreconstruction, adjunct procedures, such as the use ofan omentum flap or a muscle flap, are required todecrease the risk of reinfection.13,14We report the case of a patient with an infected TEVARwho underwent open repair with explanation of aninfected stent graft, in situ reconstruction, and latissimushe Department of Cardiothoracic and Vascular Surgery, McGoverncal School at UTHealth Houston.ondence: Anthony L. Estrera, MD, Department of Cardiothoracic andlar Surgery, McGovern Medical School at UTHealth Houston, 6400 Fannine 2850, Houston, TX 77030 (e-mail: Anthony.L.Estrera@uth.tmc.edu).tors and reviewers of this article have no relevant financial relationships tose per the Journal policy that requires reviewers to decline review of anyscript for which they may have a conflict of interest.287The Author(s). Published by Elsevier Inc. on behalf of Society for Vascularry. This is an open access article under the CC BY-NC-ND license (http://ivecommons.org/licenses/by-nc-nd/4.0/).doi.org/10.1016/j.jvscit.2024.101434dorsi muscle flap (LDMF) coverage. The patient providedwritten informed consent for the report of his case de-tails and imaging studies.CASE REPORTThe patient is male, 70 years of age, with a history of a Stanfordtype A aortic dissection with emergent open ascending repair inNovember 2013. He subsequently underwent total arch replace-ment with reconstruction of all three supra-aortic trunks, fol-lowed by TEVAR in 2015 at an outside institution.In June 2022, 6 months before his admission to our hospital, hebegan to experience chills, low-grade fever, and deep chestpain. Three weeks before our evaluation, he was admitted toan outside hospital for chest pain and altered mental status.He was diagnosed with infection of the descending thoracicaorta (DTA) stent graft. At the time, the patient was deemednot a candidate for surgical therapy. On admission, the labora-tory blood test results showed a hemoglobin level of 12 g/dL,creatinine of 1.3 mg/dL, and white blood cell count of 9  109/L.Computed tomography angiography with intravenouscontrast revealed gas surrounding the thoracic stent graft(Fig 1). A positron emission tomography scan revealed a 12-cmarea of 18F fluorodeoxyglucose avidity along the lateral edge ofthe DTA stent graft, with a standard uptake value of 19 (Fig 2).Echocardiography displayed an ejection fraction of 55% to60%. An antibiotic regimen with intravenous meropenem, dap-tomycin, and micafungin was implemented by the infectiousdisease team. A peripherally inserted central catheter line wasplaced for antibiotic administration.After a multidisciplinary team meeting, the patient consentedto undergo open surgical repair. The procedure was performedunder general anesthesia, through a left thoracotomy approach.The latissimus dorsi and trapezius muscles were dissected andmobilized for retraction. The latissimus flap was harvested, pre-serving its pedicle.Due to significant inflammation, it was decided that a prox-imal clamp could not be placed. For this reason, full cardiopul-monary bypass was used with deep hypothermic circulatory1Fig 1. Computed tomography angiography revealing gas (blue arrows) surrounding the infected thoracic stentgraft.Fig 2. Positron emission tomography scan in axial (A), frontal (B), and sagittal (C) planes displaying a 12-cmfluorodeoxyglucose avidity on the edges of the descending thoracic aorta (DTA) stent graft with a highstandard uptake value of 19.2 Bernal et al Journal of Vascular Surgery Cases, Innovations and TechniquesApril 2024arrest after systemic heparinization. The DTA and left commonfemoral vein were cannulated. Once adequate circulatory arrestwas achieved, the aneurysmal sac was entered sharply. Pus un-der pressure was observed and sent for cultures. The previouslyplaced TEVAR stent graft was removed, and the aortic wall andperiaortic tissue were debrided extensively. Repair was then per-formed using a rifampin-soaked 28-mm woven double velourDacron graft (Hemashield; Getinge) for an in situ interpositiongraft. The graft was presoaked in rifampicin before implantationat room temperature. It underwent immersion in a saline solu-tion containing 600 mg of rifampin (20 mg/mL) for a minimumof 30 minutes proceeding the graft implantation. The latissimusflap was brought into the chest space via the fourth intercostalspace laterally (Fig 3). This was used to wrap the entire descend-ing thoracic aortic graft and secured in place using multipleinterrupted 3-0 polypropylene sutures.Blood cultures and aortic tissue samples from surgery testedpositive for Clostridium spp. extubation was performed on post-operative day 6, with the patient discharged on postoperativeday 18. Antibiotics were administered intravenously for 6 weeks(3 g of ampicillin/sulbactam and 100,000 U/mL of nystatin), fol-lowed by oral amoxicillin 875 mg every 12 hours for 6 weeks. Life-long coverage with amoxicillin-clavulanate vs amoxicillin wasscheduled thereafter. A computed tomography scan 3 monthsafter surgery showed no aneurysmal dilatation or recurrence ofinfection (Fig 4).Fig 3. A,B, Latissimus dorsi muscle flap (LDMF) prepared before coverage of the woven graft. C, LDMF wrappedaround the new Dacron graft.Fig 4. Nonecontrast-enhanced computed tomography angiography revealing the latissimus dorsi muscle flap(LDMF) wrapped around the descending thoracic aorta (DTA; blue arrow).Journal of Vascular Surgery Cases, Innovations and Techniques Bernal et al 3Volume 10, Number 2DISCUSSIONThe results of our treatment with open repair of aninfected TEVAR, with the use of an adjunctive LDMF,highlights this alternative approach for successful treat-ment of complex thoracic aortic complications.Mycotic aortic aneurysms are a serious pathology, andan infected TEVAR represents at least a similar challenge,if not even more complex repair.15 Due to the highmorbidity and mortality associated and the demandingand highly experienced technique required, open surgi-cal repair can be a challenge.16,17Different series have reported a variable incidence ofstent graft infection, ranging from 0.2% to 6% after endo-prosthesis implantation.17-19 The morbidity and mortalityassociated with open repair of primary mycotic thoracicaortic aneurysms is elevated, ranging from 20% to40%.15-22 Thoracic stent graft infection in thoracic andthoracoabdominal aortic aneurysms is also associatedwith high complication rates, with reported mortalityrates >50% and as high as 100% for untreatedpatients.3,8,17,20,21,23Surgical techniques for thoracic aortic repair includethe use of deep or superficial femoral veins,prosthetic antibiotic-soaked grafts, cryopreserved arterialhomografts, Dacron grafts with biological tissuecoverage, adjunctive coverage with greater omentum, la-tissimus dorsi, or serratus anterior flaps for graft coverage,and extensive tissue debridement with vacuum-assistedclosure.15,22-24 Today, the standard of care for the treat-ment of TEVAR infections includes explantation of thestent graft, extensive periaortic tissue debridement, andextra-anatomic or in situ reconstruction of the aorta,which should be completed with tissue coverage, omen-tum or muscle flaps, and the use of fascia lata to rein-force the anastomosis.8,13,16 Although all these factorsare relevant, the importance of extensive debridementcannot be overemphasized.Although our primary approach to pedicled tissuecoverage remains the omentum, there are conditionsin which the omentum might not be a viable option.These include prior multiple operations without acces-sible omentum or poorly developed omentum due tosevere malnutrition and weight loss. The LDMF pro-vides another option. The benefits of the use of anLDMF include the ability to cover and wrap a lengthygraft, even in difficult access areas, such as the distalDTA, with the advantage of preserving the primarypedicles intact. Moreover, no motor functional loss is4 Bernal et al Journal of Vascular Surgery Cases, Innovations and TechniquesApril 2024generally observed in patients after the use of thisflap.13,25The use of a thoracic aortic LDMF might decrease thedead space surrounding the new graft and improve thedelivery of oxygen and antibiotics to the periaorticinfected area. Finally, the use of an LDMF might preventfurther infection, because it provides an extra vascular-ized supply to the tissues surrounding the replacedgraft.13,25,26 We have used this technique with good suc-cess to treat patients with aortic graft infection due toaortoesophageal fistula.27CONCLUSIONSAfter a review of the literature, to the best of our knowl-edge, this case report is the first English report of an openrepair of an infected thoracic stent graft with aorticreconstruction with an LDMF. We believe this techniqueis a feasible and safe technique in selected patients withinfected TEVAR.DISCLOSURESR.O.A. is a consultant for Medtronic and EndoRon Ltd.A.L.E. is a consultant for W.L. Gore & Associates, CryoLife,Edwards Lifesciences, and Terumo Aortic. L.R.B. has noconflicts of interest.REFERENCES1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP.Transluminal placement of endovascular stent-grafts for the treat-ment of descending thoracic aortic aneurysms. N Engl J Med.1994;331:1729e1734.2. Scali ST, Goodney PP, Walsh DB, et al. National trends and regionalvariation of open and endovascular repair of thoracic and thor-acoabdominal aneurysms in contemporary practice. J Vasc Surg.2011;53:1499e1505.3. Afifi RO, Sandhu HK, Leake SS, et al. Outcomes of patients with acutetype B (DeBakey III) aortic dissection: a 13-year, single-center expe-rience. Circulation. 2015;132:748e754.4. Chen SW, Lee KB, Napolitano MA, et al. Complications and man-agement of the thoracic endovascular aortic repair. Aorta (Stam-ford). 2020;8:49e58.5. Sattah AP, Secrist MH, Sarin S. Complications and perioperativemanagement of patients undergoing thoracic endovascular aorticrepair. J Intensive Care Med. 2018;33:394e406.6. Singh MJ, Makaroun MS. Thoracic and thoraco-abdominal aneu-rysms: endovascular treatment. In: Sidawy AN, Perler AB, eds. Ruth-erford’s vascular surgery and endovascular therapy. 9th ed. Elsevier;2019:1008e1024.7. Grabenwöger M, Alfonso F, Bachet J, et al. Thoracic endovascularaortic repair (TEVAR) for the treatment of aortic diseases: a positionstatement from the European association for CardioThoracic surgery(EACTS) and the European society of cardiology (ESC), in collabora-tion with the European association of percutaneous cardiovascularinterventions (EAPCI). Eur Heart J. 2012;33:1558e1563.8. Smeds MR, Duncan AA, Harlander-Locke MP, et al. Treatment andoutcomes of aortic endograft infection. J Vasc Surg. 2016;63:332e340.9. Schaefers JF, Donas KP, Panuccio G, et al. Outcomes of surgicalexplantation of infected aortic grafts after endovascular and openabdominal aneurysm repair. Eur J Vasc Endovasc Surg. 2019;57:130e136.10. O’Connor S, Andrew P, Batt M, Becquemin JP. A systematic reviewand meta-analysis of treatments for aortic graft infection. J VascSurg. 2006;44:38e45.11. Fatima J, Duncan AA, de Grandis E, et al. Treatment strategies andoutcomes in patients with infected aortic endografts. J Vasc Surg.2013;58:371e379.12. Lawrence PF. Conservative treatment of aortic graft infection. SeminVasc Surg. 2011;24:199e204.13. Taguchi S, Mori A, Suzuki R, Ishida O. Technique for using pedicledlatissimus dorsi muscle flaps to wrap prosthetic grafts in an infectedthoracic aorta. Ann Vasc Surg. 2013;27:1223e1227.14. Mitra A, Spears J, Perrotta V, McClurkin J, Mitra A. Salvage of infectedprosthetic grafts of the great vessels via muscle flap reconstruction.Chest. 2005;128:1040e1043.15. Ribé L, Requejo L, Ribes A, Miralles M. In: Shuhaiber J, ed. Mycoticaortic aneurysms. Intechopen; 2019.16. Miura S, Shichinohe R, Iba Y. Successful treatment of recurrentthoracic aortic prosthetic graft infection after omentopexy by freelatissimus dorsi and rectus abdominis muscle flap. Eur J CardioThorac Surg. 2022;62:ezac460.17. Kahlberg A, Grandi A, Loschi D, et al. A systematic review of infecteddescending thoracic aortic grafts and endografts. J Vasc Surg.2019;69:1941e1951.18. Li HL, Chan YC, Cheng SW. Current evidence on management ofaortic stent-graft infection: a systematic review and meta-analysis.Ann Vasc Surg. 2018;51:306e313.19. Murphy EH, Szeto WY, Herdrich BJ, et al. The management ofendograft infections following endovascular thoracic and abdominalaneurysm repair. J Vasc Surg. 2013;58:1179e1185.20. Chiesa R, Melissano G, Marone EM, Marrocco-Trischitta MM,Kahlberg A. Aorto-oesophageal and aortobronchial fistulae followingthoracic endovascular aortic repair: a national survey. Eur J VascEndovasc Surg. 2010;39:273e279.21. Estrera AL, Miller CC, Azizzadeh A, Safi HJ. Thoracic aortic aneurysms.Acta Chir Belg. 2006;106:307e316.22. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms:aggressive presentation, complicated early outcome, but durableresults. J Vasc Surg. 2001;34:900e908.23. Ribé L, Gibbs RG, Jenkins M, Wolfe JHN. In: Greenhalgh RM, ed.Visceral and arch hybrid aortic repair for thoracoabdominal aneu-rysms. Vascular and Endovascular Challenges Update. 2013:127e136,978-0-9570419-1-2.24. Corvera JS, Blitzer D, Copeland H, et al. Repair of thoracic andthoracoabdominal mycotic aneurysms and infected aortic graftsusing allograft. Ann Thorac Surg. 2018;106:1129e1135.25. Tsuge I, Saito S, Yamazaki K, et al. Latissimus dorsi muscle flap with adistally based serratus anterior extension for salvaging aortic graftinfection. Plast Reconstr Surg Glob Open. 2020;8:e2952.26. Frautschi RS, Bassiri Gharb B, Duong MM, et al. The cardioplasticapproach to the treatment of infected aortic grafts. Ann Plast Surg.2017;79:221e225.27. Afifi RO, Mushtaq HH, Sandhu HK, Khalil K, Safi HJ, Estrera AL. Suc-cessful multistaged surgical management of secondary aortoeso-phageal fistula with graft infection. Ann Thorac Surg. 2016;101:e203ee205.Submitted Nov 2, 2023; accepted Jan 8, 2024.

Open Repair With Latissimus Muscle Flap Coverage For Treatment of Infected Thoracic Endovascular Aneurysm Repair

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Open Repair With Latissimus Muscle Flap Coverage for Treatment of Infected Thoracic Endovascular Aneurysm Repair

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