Poster Presentation New Zealand Association of Plastic Surgeons Annual Scientific Meeting

Latissimus Dorsi Free Flap Reconstruction for Infective Mediastininitis and Ascending Aortic Graft Patch-Case Report and Review of the Literature (468)

Justin Yousef 1 , Andrew Cheng 2 , Rafael Acosta 1 , Bo Zhang 2
  1. Department of Plastic and Reconstructive Surgery, Barwon Health, Geelong, VIC, Australia
  2. Department of Cardiothoracic Surgery, Barwon Health, Geelong, VIC, Australia

Introduction

Sternal wound dehiscence (SWD) following ascending aorta grafting is rare and serious, with mortality ranging from 25 to 42% (1). Current treatment consists of aggressive antibiotic therapy; graft resection and replacement; debridement; and negative-pressure wound therapy (2, 3). Omental wrapping is also used to reduce the recurrence of infected grafts (4, 5). We present the case of an aortic graft infection and sternal dehiscence which was successfully treated with a latissimus dorsi myocutaneous free flap (LDMFF)

 

Case Report

A 64-year-old-female underwent coronary artery bypass and aortic grafting for coronary artery disease and ascending aortic aneurysm. She developed SWD and infective mediastinitis with staphylococcus aureus cultured. Antibiotics were commenced. Pus/infected tissue was no longer evident after multiple debridements and VAC dressing changes. Due to surgical risk, the aortic graft was not replaced. To both reconstruct the sternum and decrease infection risk around the graft, a LDMFF was used. The thoracodorsal pedicle was end-end anastomosed to the left facial artery and the vein to facial vein. Part of the muscle flap was placed on either side of the aortic graft for biological coverage. The postoperative course was uneventful with inflammatory markers decreasing, no infective signs, early drain removal, and discharge on a course of antibiotics.

 

Discussion

SWD with infected aortic grafts are rare but highly morbid (5). One option for  treatment is preservation of the graft as removal is technically difficult and requires a long period of cardiac arrest (3). Omental wrapping reduces subsequent graft infections (1), however a solution for sternal reconstruction and graft infection eradication remains controversial (2). The LDMFF has many applications (6). In our case, both SWD and graft infection were solved with the use of a single myocutaneous free flap, which has not been previously described. The LDMFF may be an option for the treatment of infected aortic grafts and SWD.

  1. 1. von Aspern K, Etz CD, Mohr FW, Battellini RR. Two-Stage Procedure for Infected Aortic Graft Pseudoaneurysm: 10-Year Follow Up after Omental Prosthesis Wrapping. Aorta. 2015;3(4):140-4.
  2. 2. Ennker IC. Treatment of mediastinitis following cardiac surgery-still in discussion. HSR proceedings in intensive care & cardiovascular anesthesia. 2013;5(2):120-1.
  3. 3. Takano T, Terasaki T, Wada Y, Seto T, Fukui D, Amano J. Treatment of prosthetic graft infection after thoracic aorta replacement. Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 2014;20(4):304-9.
  4. 4. Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2013;43(6):1177-82.
  5. 5. Parissis H, Al-Alao B, Soo A, Orr D, Young V. Risk analysis and outcome of mediastinal wound and deep mediastinal wound infections with specific emphasis to omental transposition. Journal of cardiothoracic surgery. 2011;6:111.
  6. 6. Kim JT, Kim SW, Youn S, Kim YH. What Is the Ideal Free Flap for Soft Tissue Reconstruction? A Ten-Year Experience of Microsurgical Reconstruction Using 334 Latissimus Dorsi Flaps From a Universal Donor Site. Annals of plastic surgery. 2015;75(1):49-54