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ARTICLE IN PRESS

doi:10.1510/icvts.2008.176727

Interactive CardioVascular and Thoracic Surgery xxx (xxx) xxx–xxx


www.icvts.org
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2 Brief communication - Vascular thoracic 3

4 An effective vacuum-assisted closure treatment for mediastinitis


with aortic arch replacement

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7 Yoshikatsu Saiki*, Shunsuke Kawamoto, Sadahiro Sai, Koichi Tabayashi
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9 Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aoba-ku, Sendai 980-8574, Japan
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11 Received 10 February 2008; received in revised form 6 May 2008; accepted 7 May 2008
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21 Abstract
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23 Little experience exists with the vacuum-assisted closure (VAC) therapy in the high-risk group of patients with perigraft abscess containing
24 a large amount of prosthetic vascular grafts. We report our experience in the VAC therapy for patients with mediastinitis after aortic arch
25 replacement. Between February 2003 and December 2006, five patients with a mean age of 72.2 years developed postoperative mediastinitis
26 after aortic arch replacement, and were treated with the VAC system. In all the patients the mediastinal fluid and tissue examinations
turned out to be negative for microbiological cultures, and successful closure of the midline incision was achieved with concomitant
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omental transfer after a mean duration of 22.6 days of VAC treatment. Four of the five patients survived to discharge and have been free
29 from recurrent sign of mediastinal or graft infection at long-term follow-up. Our study indicates that the VAC treatment may reduce early
30 mortality of life-threatening deep sternal wound infection complicated by a prior aortic arch replacement and become a preferred
31 therapeutic option for the patients to whom another replacement is too risky.
32  2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
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34 Keywords: Mediastinal infection; Aortic arch; Postoperative care
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36 64
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38 1. Introduction 2. Patients and method

39 Early mortality among the patients who had aortic arch Between February 2003 and December 2006, five patients 65
40 replacement that resulted in mediastinitis is high w1x. with aortic arch replacement who developed mediastinitis 66
41 Common treatments for them include surgical debride- were treated with the VAC system. The patients’ demo- 67
42 ment, drainage, irrigation, and replacement of the pros- graphy and history are summarized in Table 1. In terms of 68
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43 thetic graft with an omental or a pectoral muscle flap. The the predisposing factors to mediastinitis, all the five except 69
44 graft, a foreign object, makes the infection management a for patient no. 4 were septuagenarians. Early postoperative 70
challenge. A safe effective treatment for their mediastinitis course in patient no. 1 was complicated with pneumonia
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45 71
46 has been sought. and sepsis. Patient no. 2 underwent re-do aortic root 72
47 The vacuum-assisted wound closure (VAC) system, com- replacement for prosthetic valve endocarditis with aortic 73
48 monly adopted for the treatment of pressure ulcers and annular abscess. Patient no. 3 had undergone multiple 74
49 other chronic wounds w2x, is a relatively new non-invasive mediastinal exposure for delayed mediastinal bleeding due 75
50 treatment that promotes granulation. It was previously to coagulopathy associated with thoraco-abdominal aortic 76
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51 described for the treatment of osteomyelitis and originally aneurysm. Bacterial translocation was suspected in patients 77
52 applied to mediastinal infection by Durandy et al. as early no. 4 and 5 when mediastinitis was diagnosed. Patient no. 78
53 as in 1984 w3x. Its application has been steadily expanding 4 had developed brain abscess with methicillin-sensitive 79
54 and constitutes presently the treatment of choice in many Staphylococcus aureus. Her CT-scan revealed mediastinitis 80
55 institutes for post-sternotomy mediastinitis. However, its with perigraft abscess (Fig. 1a,b). 81
56 application to mediastinitis of patients who had aortic arch
57 replacement is not yet widely known. The standard protocol 2.1. Installation of the VAC system 82
58 for such mediastinitis at our facility has been a complete
59 replacement of the infected graft with a homograft or The VAC system components: 84
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60 xenograft. This option, however, is of great burden and
• polyurethane foam (Hydrosite , Smith & Nephew Inc., 85
61 unsuitable for severely infected patients.
Florida, FL), 87
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62 The authors attempted to manage mediastinitis where a
• non-collapsible chest tube (BLAKE Drains , Ethicon Inc., 89
63 large amount of graft is used with the VAC system.
192 San Anglo, TX), 91
193 *Corresponding author. Tel.: q81-22-717-7222; fax: q81-22-717-7227. • vacuum pump (HAMA Servo drain, Hama Medical Indus- 93
194 E-mail address: ysaiki@mail.tains.tohoku.ac.jp (Y. Saiki). trial Co. Ltd., Tokyo) 95
 2008 Published by European Association for Cardio-Thoracic Surgery

icvts 176727 Mp 1 Tuesday May 20 2008 06:48 AM 13,47,51


ARTICLE IN PRESS
2 Y. Saiki et al. / Interactive CardioVascular and Thoracic Surgery xx (2008) xxx–xxx
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Table 1
4 Summary
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6 Case Age Sex Prior surgeries Period before Organism VAC Mediastinal Long-term
VAC* therapy culture** follow-up
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13 1 77 M TAR 5 days Enterobacter cloacae 11 days – 59 months
14 2 76 F Hemi-Arch, Root, Re-root 1 month MRSA, Klebsiella 26 days – Died on VAC Day 27***
15 3 78 M TAR, BCAR 3 months MRSA 55 days – 16 months
16 4 52 F TAR, Root 48 months MSSA 12 days – 33 months
17 5 78 M TAR, CABG 72 months Candida parapsilosis 9 days – 45 months
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19 *The period between the aortic arch replacement and the VAC treatment.

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20 **Post-VAC mediastinal culture before chest closure.
21 ***Died on Day 27 of renal failure and sepsis induced DIC. The chest was once closed.
22 TAR, total aortic arch replacement; Hemi-arch, proximal hemi-aortic arch replacement; Root, aortic root replacement; BCAR, brachiocephalic artery replace-
23 ment; CABG, coronary artery bypass grafting; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive Staphylococcus aureus.
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99 • LAP sponge (Kawamoto Co. Ltd., Osaka). wound was then covered with a 3M Ioban 2 antimicrobial
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101 • 3MTM IobanTM 2 antimicrobial incise drape (3M Health incise drape. The mediastinum and the prosthetic grafts 113
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103 Care Inc., St. Paul, MN). were observed everyday while the patient was sedated. 114
Pyoktanin was applied for gram-positive micrococci, amply 115
104 When a CT-scan confirmed mediastinitis, mediastinum of around the prosthetic grafts w4x (Fig. 1e). 116
105 each patient was explored under general anesthesia in the
operating room. Precise debridement and wound excision
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107 were followed by copious irrigation with warm saline. The
ed 2.2. Timing of sternal closure 117
108 deep sternal wound was then dressed with the VAC system
When mediastinal tissue or gauze cultures became nega- 118
109 that provided continuous pressure of y99 mmHg. A BLAKE
tive on multiple consecutive tests, the chest was closed 119
110 Drain was placed in the middle of the incision and the
transferring omentum or major pectoral muscle (Fig. 1c, 120
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111 incision perimeter was covered with LAP sponges. The
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3. Results 122
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Mediastinitis was healed in all five patients (see Table 1). 123
Four patients survived to discharge and have been free 124
from recurrent infections of the lesion. Patient no. 3 died 125
from rupture of the thoracoabdominal aortic aneurysm 126
16 months after chest closure. But his postmortem graft 127
examination showed no signs of infection (Fig. 1f). 128
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4. Discussion 129
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Despite the condition of the five patients in this study 130


being too severe for the standard protocol, VAC therapy 131
was effective in such high-risk patients in managing medi- 132
astinal infection even with the presence of the prosthesis. 133
The effectiveness of the VAC system on microcirculation
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and promotion of tissue granulation was also confirmed. 135
Removal of exudate from the mediastinal cavity and of 136
the vascular graft surface also contributed to the successful 137
infection management. Slime protects bacteria from anti- 138
biotics w5x. Extracellular glycocalyx slime is known as a 139
virulence factor of many pathogenic bacteria, especially in 140
the presence of biomaterial. Cytokines, radicals and nitro- 141
gen species secreted from blood monocytes and macro- 142
28 Fig. 1. Computed tomography (CT) demonstrated perigraft abscess at the
phages that are stimulated by cleavage products of gram 143
29 aortic arch (a) and the ascending aorta level (b) in patient number 4. Follow-
30 up CT-scan examined at 4 months after the VAC therapy showed no recurrent positive bacteria, cause oxido-inflammatory damage w6x. 144
31 signs of perigraft abscess being replaced with the omentum (c, d). External Strong vacuum of the VAC was effective for elimination of 145
32 appearance of the mediastinum at re-exploration in patient number 3 is slime ameliorating virulent local infection. 146
33 shown in Fig. (e). The prosthetic graft for the aortic arch replacement infect- The negative pressure of the VAC system, much higher 147
34 ed with methicillin-resistant Staphylococcus aureus was treated with pyok-
35 tanin, a triphenylmethane dye, and appeared to be dry after the treatment.
than that of a conventional drain, caused no adverse events 148
36 Postmorten examination after 16 months confirmed no residual or recurrent such as anastomotic rupture and bleeding. The VAC imposed 149
37 infection around the prosthetic graft surrounded by the omentum (f). no pressure difference between prosthetic graft and the 150
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Y. Saiki et al. / Interactive CardioVascular and Thoracic Surgery xx (2008) xxx–xxx 3
151 168
native aorta, and no suture lines were pulled apart. The References
152 VAC had no impact on hemodynamics and respiratory func-
153 tion either. w1x Coselli JS, Koksoy C, LeMaire SA. Management of thoracic aortic graft 169
infections. Ann Thorac Surg 1999;67:1990–1993. 170
154 The VAC therapy can, by and large, eliminate the need w2x Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum- 171
155 for omentopexy or pectral muscle transfer in some media- assisted closure: a new method for wound control and treatment: 172
156 stinal infections, since a strong negative pressure per se animal studies and basic foundation. Ann Plast Surg 1997;38:553–562. 173
157 can enhance neovascularization in the mediastinal tissue. w3x Durandy Y, Batisse A, Bourel P, Dibie A, Lemoine G, Lecompte Y. 174
Mediastinal infection after cardiac operation: a simple closed tech- 175
158 However, the presence of a large amount of prosthetic nique. J Thorac Cardiovasc Surg 1989;97:282–285. 176
material limits the granulation around the prosthetic grafts.

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159 w4x Higashi S, Miyamoto T, Hashizume K. Experience with pyoktanin lavage 177
160 We believe that supplemental treatment using an omental for mediastinitis and prosthetic graft infection following thoracic aortic 178

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161 or a pectral muscle flap is essential in the management of surgery (in Japanese). Kyobu Geka 2002;55:379–382. 179
w5x Ferguson DA Jr, Veringa EM, Mayberry WR, Overbeek BP, Lambe DW Jr, 180
162 graft infection. Verhoef J. Bacteroides and Staphylococcus glycocalyx: chemical analy- 181
163 The VAC therapy augmented by pyoktanin and omentopexy sis, and the effects on chemiluminescence and chemotaxis of human 182
164 as well as pectral muscle transfer was effective to treat polymorphonuclear leucocytes. Microbios 1992;69:53–65. 183
w6x Ersoz G, Aytacoglu BN, Sucu N, Tamer L, Bayindir I, Kose N, Kaya A, 184
165 mediastinitis that developed after aortic arch replacement.

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Dikmengil M. Comparison and evaluation of experimental mediastinitis 185
166 The successful VAC therapy may eliminate the need for models: precolonized foreign body implants and bacterial suspension 186
167 high-risk replacement of prosthetic graft. inoculation seems promising. BMC Infect Dis 2006;6:76–82. 187
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