Omentoplasty For the Treatment of Early Graft Infection After Valve-Sparing Aortic Root Replacement

Even though infection of thoracic aortic grafts is rarely seen, management of these cases still remains a real challenge in current clinical practice. The treatment of complete removal of the infected graft and radical debridement has been accepted as the gold standard. Reoperation has been shown to be a high mortality situation (1). In situ graft-sparing surgical therapy with aggressive debridement has been proposed as a promising alternative to conventional treatment in patients with thoracic graft infection. Umminger et al (2) showed that conservative or graft sparing policy with debridement and mediastinal irrigation was a comparable approach to reoperation with graft reimplantation if performed less than one month after surgery in the treatment of thoracic graft infection. On the other hand, patients with anastomotic pseudoaneurysms, graft-enteric fistulas, and the graft infection due to invasive gram-negative organisms, such as Pseudomonas or Salmonella species are not suitable for a graft sparing approach.

The greater omentum is a double layer of peritoneum that hangs down like an apron from the greater curvature of the stomach, and it ascends to the transverse colon before reaching to the posterior abdominal wall. The greater omentum is a mobile structure and its length shows variation. Omentoplasty via wrapping the greater omentum around the infected graft is an adjunctive procedure in graft sparing approaches in the treatment of thoracic graft infections (3). As the omentum has a vast majority of blood vessels and lymphatics, the omentum seems to be the best material to fulfill the perigraft space and it, thus, facilitates the elimination of microorganisms on the prosthetic material. In this paper, the authors present the successful treatment of early graft infection after valve-sparing root replacement in a 54-year-old man using aggressive debridement of the perigraft infectious tissue, omentoplasty, and continuous mediastinal antibiotic irrigation.

References

1. Corvera JS, Blitzer D, Copeland H, Murphy D, Hess PJ Jr, Pillai ST, et al. Repair of thoracic and thoracoabdominal mycotic aneurysms and infected aortic grafts using allograft. Ann Thorac Surg. 2018;106:1129-1135.
2. Umminger J, Krueger H, Beckmann E, Kaufeld T, Fleissner F, Haverich A, et al. Management of early graft infections in the ascending aorta and aortic arch: a comparison between graft replacement and graft preservation techniques. Eur J Cardiothorac Surg. 2016;50: 660-667.
3. Ogino H, Ueda Y, Sugita T, Matsuyama K, Matsubayashi K, Nomoto T, et al. Treatment for abdominal aortic graft infection: irrigation with electrolyzed strong aqueous acid, in-situ grafting, and omentoplasty. Thorac Cardiovasc Surg. 2000;48:43-44.

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