RESUMO
Aortic pseudoaneurysm is a rare but life-threatening complication after graft replacement. One of the main challenges of surgery is the appropriate and safe method of re-entering the chest cavity. Therefore, it is necessary to consider a strategy which includes cardiopulmonary bypass. The patient was a 64-year-old man who had undergone hemi-arch replacement for pseudoaneurysm of the native thoracic aorta 17 years previously. The exact surgical details of the previous operation were unknown. He experienced progressive chest pain for 1 month, and noticed a parasternal pulsatile mass. An enhanced computed tomographic scan revealed a pseudoaneurysm originating from the thoracic aortic artificial graft itself, which had eroded the left parasternum and which would possibly rupture out of the skin. Preoperative examinations suggested a high risk of bleeding if redo sternotomy was performed. Therefore, we decided to perform open surgical repair with a cardiopulmonary bypass with cannulation through the femoral artery and vein before resternotomy. In addition, we performed a transthoracic left ventricular venting and selective cerebral perfusion using bilateral axillary arteries, which enabled core cooling in case of uncontrollable hemorrhage. He successfully underwent redo graft replacement of the thoracic aorta, and his postoperative course was uneventful.
RESUMO
We encountered 15 cases of surgical site infection (SSI) by Methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) among 153 patients who underwent a cardiovascular operation in 2000. SSIs consisted of 5 mediastinal infections, 9 surface wound infections and 1 artificial graft infection after an abdominal aortic surgery. All infected cases had been operated on between June and December 2000. Eighty-three cases, which underwent cardiovascular operations during this period, were divided into SSI or no-SSI groups and their clinical data were analyzed. The data included age, gender, preoperative diabetes, urgency, preoperative usage of a device like Swan-Ganz catheter or IABP, preoperative albumin level, preoperative physical state by ASA score, National Nosocominal Infections Surveillance index, duration of operation, usage of a cardiopulmonary bypass, duration of bypass, type of operation, and number of distal anastomoses in CABG operations. Multivariate analysis showed gender (male), diabetes, and emergency operation as independent risk factors for the incidence of SSI by MRSA. One patient, who suffered a mediastinal infection after CABG, had confirmed as demonstrating the colonization of MRSA in sputum preoperatively. Microbiological screening of medical staff showed 2 of the 6 surgical doctors and 3 of the 25 ward nurses exhibited colonization with MRSA. DNA analysis of MRSA, harvested from 5 infected patients, indicated at least 2 strains of MRSA and 1 of the 2 strains was identical to the MRSA that was detected in a doctor. We applied prophylactic measures with reference to the guideline for prevention of surgical site infection announced by CDC in 1999, which included the following: routine work-up of MRSA-colonization, and treatment of all MRSA colonized patients and those undergoing emergency operations with Mupirocin. Preoperative patients were isolated from MRSA-infected or colonized patients. MRSA-colonized surgical personnel were treated with Mupirocin ointment. Cephazoline was administered shortly before and after the operation as a prophylactic antibiotic. Vancomycin was added to Cephazoline in patients with a history of MRSA-colonization or infection. Through hand washing before and after daily contact with patients was emphasised to all medical staff. SSI surveillance conducted by an infection control team was implemented. After the introduction of the prophylactic measurements, one MRSA-SSI was observed among 113 cases who underwent a cardiovascular operation between January and September 2001.
RESUMO
We report 2 cases of successful treatment by percutaneous catheter drainage and irrigation for methycillin-resistant <i>Staphylococcus aureus</i> (MRSA) prosthetic graft infection after abdominal aortic aneurysm (AAA) repair. Case 1 was a 71-year-old man in whom MRSA graft infection was diagnosed on the basis of high fever and CT-guided taps of the perigraft fluid 11 days after AAA repair, and a percutaneous catheter was inserted into the perigraft space by the CT-guided method. Case 2 was a 77-year-old man in whom MRSA graft infection was diagnosed because of high fever and purulent discharge from the wound of retroperitoneal drainage 5 days after AAA repair. A percutaneous catheter was placed into the retroperitoneal space via an extraperitoneal route. In both cases, intermittent irrigation by 0.5% Povidone-iodine solution and saline was performed as well as systemic and local antibiotic administration. The graft infection was well controlled and both patients were discharged after 4 months. Percutaneous catheter drainage and irrigation can be one of the choices for critically ill patients with graft infection after AAA repair.
RESUMO
The early and mid-term survival after thoracic aortic surgery and the influence of age on operative mortality were examined in 93 consecutive patients from August 1994 to June 1999, together with assessment of postoperative quality of life (QOL). The mean age was 63.8±11.6 years old (range 26 to 84 years) and 65 patients were male. Aneurysms were atherosclerotic in 43 patients and aortic dissection was present in 50. Forty-eight (52%) required emergency operation. Operative procedures consisted of ascending aorta or hemiarch replacement in 23 patients, Bentall's operation was performed in 4, total arch replacement in 31, distal arch replacement in 9, descending aorta replacement in 13, replacement of the thoracoabdominal aorta in 6, and patch repair in 7. These patients were divided into two groups: the under 70 group (Y group, <i>n</i>=61) and the 70 or older group (O group, <i>n</i>=32). Current QOL of the survivors was assessed using the Asanoi method with a mailed questionnaire. There were 13 early deaths (14%). There were 10 late deaths (5.6%/P-Y (Patients-Years)). The actuarial survival rate of the Y group was significantly higher than that of the O group (<i>p</i>=0.0412). Perioperative stroke was seen in 11% of the Y group and 16% of the O group. These patients had a high mortality rate (Y group 43%, O group 100%) during early and long term follow-up periods. The postoperative NYHA category and exercise ability of the O group were better than those of the Y group. We obtained satisfactory answers concerning the results of operation in the majority of current survivors. Patients aged 70 years and older could undergo thoracic aortic surgery with reasonable risk. QOL following operation was satisfactory except in patients with merged perioperative stroke.