A Gupta

Akihiro Yoshimoto

H Kubota

H Yamamoto

Hidehito Endo

Hiroshi Kubota

Hiroshi Tsuchiya

Kenichi Sudo

M Czerny

Mio Noma

Mitsuru Matsukura

P Vogt

Yu Takahashi

Yusuke Inaba

Journal of Cardiothoracic Surgery

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Kubota et al. Journal of Cardiothoracic Surgery 2012, 7:45http://www.cardiothoracicsurgery.org/content/7/1/45CASE REPORT Open AccessEquine pericardial roll graft replacement ofinfected pseudoaneurysm of the aortic archHiroshi Kubota*, Hidehito Endo, Mio Noma, Hiroshi Tsuchiya, Akihiro Yoshimoto, Mitsuru Matsukura, Yu Takahashi,Yusuke Inaba and Kenichi SudoAbstractResection of the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexyis the standard procedure for treating infected aortic aneurysms, but the question of which graft material is optimalis still a matter of controversy. We recently treated a patient with an infected thoracic aortic aneurysm. Theaneurysm was located in the proximal aortic arch. Because the patients had previously undergone abdominalsurgery, the aortic arch were replaced in situ with a branched equine pericardial roll grafts. The patient is alive andwell 23 months after the operation.Keywords: Equine pericardium, Biomaterial, Infection, Aortic aneurysm, SurgeryBackgroundA 79-year-old male came to our hospital with a chiefcomplaint of fever of unknown origin and low backpain. His leukocyte count was 9300/μl, and his serumC-reactive protein level was elevated to 19.8 mg/dl.After three weeks of intravenous antibiotic therapy inanother department with Cefotiam 3 g/day, the labora-tory data indicating inflammation had become normal. Be-cause computed tomography revealed an abdominal aorticaneurysm measuring 69 mm in diameter and a small pseu-doaneurysm in the proximal aortic arch, the patient was re-ferred to our department. In view of the risk of rupture ofthe abdominal aortic aneurysm, Y-graft replacement wasperformed first. The abdominal aneurysm was atheroscler-otic, but there was no evidence of infection. Postoperativecomputed tomography showed rapid enlargement of thepseudoaneurysm of the proximal aortic arch (Figure 1-A).He was diagnosed as an infected thoracic aortic aneurysm.The aortic arch replacement was performed.MethodsPreparing a three branched equine pericardial sheetA branched equine pericardial sheet was made on an-other sterile operative table simultaneously to the op-* Correspondence: kub@ks.kyorin-u.ac.jpDepartment of Cardiovascular Surgery, Kyorin University, 6-20-2, Shinkawa,Mitaka, Tokyo, 181-8611, Japan© 2012 Kubota et al.; licensee BioMed CentralCommons Attribution License (http://creativecreproduction in any medium, provided the oreration. A 10 cm× 10 cm equine pericardial sheet(XGA-400; Edwards Lifesciences, Irvine, CA, USA) wasprepared. Three holes in a row were made. A 10-mmhole each was created for the left subclavian artery andleft common carotid artery, and a 15-mm hole for thebrachiocephalic artery. The holes were made 5 mmapart, and the last hole was made 20 mm from the edgeof the sheet. Three rectangular pericardial sheets werecut from another pericardial sheet. Each of them wassutured to the circumference of a hole and formed intoa cylinder by continuous suturing with 5–0 polypropylene.To determine the appropriate length of the graft to avoidthe kinking of the branches, these sutures to roll up thebranches were stopped 20 mm from origin of the branchand the remnants were left open (Figure 2).Operative procedureThe operation was performed on February 13, 2010. Thepericardium was opened through a median sternotomyand revealed a moderate amount of muddy reddishbrown pericardial effusion with pus laver. When thepatient’s tympanic membrane temperature had decreasedto 20 degrees centigrade, the aortic arch was openedunder circulatory arrest. A saccular pseudoaneurysm wasidentified in the proximal aortic arch, opposite the orificeof the brachiocephalic artery, and a reddish brownthrombus was found inside the aneurysm (Figure 1-B).The aorta was transected between the left subclavianLtd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.Figure 1 A, B. Preoperative computed tomography scan and intraoperative photograph. The aneurysm was located in the proximalportion of the aortic arch. It was visible opposite the orifice of the brachiocephalic artery.Kubota et al. Journal of Cardiothoracic Surgery 2012, 7:45 Page 2 of 5http://www.cardiothoracicsurgery.org/content/7/1/45artery and the left common carotid artery. A side of thebranched equine pericardial sheet was anastomosed witha 4–0 polypropylene continuous suture (Figure 3-A).When the corners of the pericardium met, the samethread was used continuously to form the sheet cylindric-ally. Because the diameter of the transected aorta was30 mm, 10 cm x 10 cm pericardial sheets were used as is.The third distal branch was cut to obtain adequate lengthand anastomosed to the left common carotid artery. TheFigure 2 Three-branched pericardial sheet. Three holes, having a diamewere made 5 mm apart, and the last hole was made 20 mm from the edgpericardial sheet, and each of them was sutured to the circumference of asuturing with 5–0 polypropylene.second middle branch was not used to reconstruct a ves-sel because native subclavian artery could be preserved,but it was used as an inflow root of the cardiopulmonarybypass. The main roll graft was clamped, antegrade per-fusion was restored from the middle branch (Figure 3-B).While warming, the first proximal branch was anasto-mosed to the brachiocephalic artery. After completingthe proximal anastomosis, the aorta was de-clamped(Figure 3-C). The aortic cross clamp time was 120 min,ter of 10 mm, 10 mm, and 15 mm, respectively, were made. The holese of the sheet. Three rectangular sheets were cut from anotherhole in the pericardial sheet and formed into a cylinder by continuousFigure 3 Operative procedure. A. The aorta was transected between the left subclavian artery and the left common carotid artery. A branchedequine pericardial sheet was anastomosed to the transected aorta. B. The sides of the pericardial sheet were sutured continuously to form acylinder. The third distal branch was cut to obtain adequate length and anastomosed to the left common carotid artery. The second middlebranch was used as an inflow root of the cardiopulmonary bypass. The main roll graft was clamped, and antegrade perfusion was restored.C. The first proximal branch was anastomosed to the brachiocephalic artery. Finally, the proximal anastomosis was performed.Kubota et al. Journal of Cardiothoracic Surgery 2012, 7:45 Page 3 of 5http://www.cardiothoracicsurgery.org/content/7/1/45and the circulatory arrest time was 60 min. The intermit-tent pressure-augmented retrograde cerebral perfusionwas used as additional brain protection during deephypothermic circulatory arrest, and biological glue con-taining vancomycin was sprayed on the grafts and anas-tomoses [1].Written informed consent was obtained from the pa-tient for publication of this report and any accompany-ing images.ResultsIntraoperative microscopic examination of the thrombusin the pseudoaneurysm revealed a large number of leu-kocytes. The pericardial effusion also contained a largenumber of leukocytes.Culture results from blood and intraoperative speci-men were negative. The patients recovered from surgerywell and had no neurological deficits. Treatment with anantiplatelet drug was started. Considering the effective-ness of the initial treatment with wide spectrum antibio-tics, we targeted as the second series of the antibiotictherapy, not to the MRSA but common microorganism.Dibekacin sulfate (50 mg/day) and cefazolin sodium(4 g/day) were administered intravenously for one week.Continuously, Biapenem (600 mg/day) and clindamycin(600 mg/day) were administered for three weeks andterminated because of systemic drug eruption. Thepatient’s leukocyte count and C- reactive protein levelgradually decreased to within the normal range. As of24 months after surgery, the patient is well without recur-rence of any evidence of the infection. Postoperative com-puted tomography demonstrated well functioning rollgrafts without stenosis, dilatation, or thrombus formation(Figure 4).DiscussionDacron grafts, rifampicin-soaked Dacron grafts, andhomografts are the choices to cure infected aorticaneurysm [2-4]. Although cryopreserved homografts areexcellent material to treat infected aortas, it is difficultto be in time for urgent operation. Yamamoto et al.described successful in situ replacement of the thoracicdescending aorta with an equine pericardial roll graft foran aortobronchial fistula caused by the infection due toα–streptococcus [5]. Omentopexy was not performed intheir patient, because omental mobilization was consid-ered impossible due to a past history of laparotomy foran esophageal hiatal hernia. In our case, we also did notuse the omentum because abdominal adhesions wereexpected and the lesion was thought to be too distant towrap the graft. Yamamoto et al. also described two casesof successful in situ replacement with an equine pericar-dial roll graft to treat a ruptured infected abdominal aor-tic aneurysms [6]. In presented case, no pathogen wasFigure 4 Postoperative 3-dimension computed tomography. There is no stenosis or dilatation of the branches.Kubota et al. Journal of Cardiothoracic Surgery 2012, 7:45 Page 4 of 5http://www.cardiothoracicsurgery.org/content/7/1/45detected. It may have been due to the long preoperativeperiod of intravenous antibiotic therapy. The type ofpathogen also affects the prognosis. A case who showedthe colonized and damaged inner layer of the equinepericardial roll graft by methicillin-resistant Staphylococcusaureus was reported [7].Czerny et al. reported excellent result of the bovinepericardial tube graft to treat prosthetic graft or endovas-cular graft infection in 15 patients. They concluded thattreatment of graft infections after operation or endovas-cular treatment of thoracic, thoracoabdominal, and ab-dominal aortic diseases by complete removal of theinfected prosthetic material and extensive debridementas well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segmentsprovides excellent results with regard to durability andfreedom from reinfection and reoperation [8]. They alsomention that this new concept is an additional alterna-tive to cryopreserved homografts that extends the arma-mentarium for treating patients with highly complexconditions. Considering these excellent result of self-made xenopericardial tube graft as “rescue” procedure,we propose a question that why not use the xenopericar-dial tube graft for “initial” treatment.However, As far as we investigated, we could not findany reports of aortic arch reconstruction with a self-made branched equine pericardial roll graft. A pericardialsheet is soft but firm and easy to suture. It was made tobe cylindrical not preoperatively but intraoperatively toobtain a good operative field. The diameter of the rollgraft was easy to match to the transected aorta. Becausethe side length of the pericardium was 10 cm, an eachmargin to sew up was calculated as 10–3 π/2 = 0.3 cm.The graft dilatation, stenosis, mural thrombus formation,and recurrence of the infection are concerns during long-term follow up. Enhanced computed tomography may bethe most suitable examination for follow-up. The needfor treatment with antiplatelet agents is a matter of con-troversy. We propose that, patients who have undergonesurgical reconstruction of the arch vessels, be treatedwith an anticoagulant or antiplatelet drug to preventstrokes and graft stenosis due to mural thrombi.Kubota et al. Journal of Cardiothoracic Surgery 2012, 7:45 Page 5 of 5http://www.cardiothoracicsurgery.org/content/7/1/45ConclusionBecause this technique is simple and less invasive thanthe standard procedure, it may have the potential toserve as one of the choices of treatment for infectedaneurysms of the thoracic aorta. By accumulating clinicalcases, when its long-term durability will be confirmed, itmay demonstrate the advantages of xenopericardialbranched graft as one of the choices of treatment forinfected aortic aneurysms.Competing interestThe authors declare that they have no competing interests.Authors’ contributionsHK, HE, MN, HT conceives of the study, and participated in its design andcoordination. AY, MM, YT, YI and SK participated in the sequence alignment.All authors read and approved the final manuscript.Received: 04 January 2012 Accepted: 17 April 2012Published: 14 May 2012References1. Kubota H, Takamoto S, Yoshino H, Kitahori K, Kawata M, Tonari K, Endo H,Tsuchiya H, Inaba Y, Takahashi Y, Sudo K: Clinical application ofintermittent pressure-augmented retrograde cerebral perfusion. AnnThorac Surg 2010, 90:1340–1343.2. Vogt P, von Segesser L, Goffin Y, Pasic M, Turina M: Cryopreserved arterialhomografts for in situ reconstruction of mycotic aneurysms andprosthetic graft infection. Eur J Cardio-thorac Surg. 1995, 9:502–506.3. Vogt P, Pasic M, von Segesser L, Carrel T, Turina M: Cryopreserved aortichomograft for mycotic aneurysms. J Thorac Cardiovasc Surg 1995,109:589–591.4. Gupta A, Bandyk D, Johnson B: Insitu repair of mycotic abdominal aorticaneurysms with rifampicin-bonded gelatin-impregnated Dacron grafts.J Vasc Surg 1996, 24:472–476.5. Yamamoto H, Yamamoto F, Ishibashi K, et al: In situ replacement of thethoracic aorta using an equine pericardial roll graft for an aortobronchialfistula due to aortic rupture. Gen Thorac Cardiovasc Surg 2009, 57:413–417.6. Yamamoto H, Yamamoto F, Ishibashi K, et al: In situ replacement withequine pericardial roll grafts for ruptured infected aneurysms of theabdominal aorta. J Vasc Surg 2009, 49:1041–1045.7. Yamamoto H, Yamamoto F, Tanaka F, et al: Vulnerability of an equinepericardial roll graft to gram-positive cocci after graft replacement for aruptured infected abdominal aorta. Interact Cardiovasc Thorac Surg 2011,12:866–868.8. Czerny M, Allen R, Opfermann P, et al: Self-made pericardial tube graft: anew surgical concept for treatment of graft infections after thoracic andabdominal aortic procedures. Ann Thorac Surg 2011, 92:1657–1662.doi:10.1186/1749-8090-7-45Cite this article as: Kubota et al.: Equine pericardial roll graftreplacement of infected pseudoaneurysm of the aortic arch. Journal ofCardiothoracic Surgery 2012 7:45.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch

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Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch

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