Ascending Aortic Arch Prosthetic Graft Infection with Mediastinitis: Successful Salvage with Vacuum Assisted Closure and Anterior Lateral Thigh Free Flap

Abstract

Background: Mediastinitis is devastating complication of median sternotomy incisions. The condition is compounded by an associated infection of the prosthetic aortic graft. We described a case where vacuum assisted closure (VAC) device was used for the preservation of the prosthetic graft and an anterolateral thigh (ALT) musculocutaneous free flap was used successfully for reconstruction. Aim and Objectives: Introduce the concept that VAC can be used successfully for the preservation of prosthetic grafts and a free flap simplifies the reconstruction of large complex sternal defects. Materials and methods: We describe a case of a 51-year-old man with acute aortic dissection, who had undergone prosthetic graft replacement of the ascending aorta. He presented two months later with purulent discharge from the sternotomy wound. Surgery revealed necrosis of the steranl bone as well as frank pus around the prosthetic graft. Multiple debridements were performed. Vacuum assisted closure was used successfully in the preservation of the prosthetic graft and also as a bridge prior to definitive reconstruction. Vacuum assisted closure was exchanged four times with an interval of 3-4 days. The resultant large degect was reconstructed with an anterolateral thigh musculocutaneous free flap. The muscular portion of the flap was used as a tamponade for the mediastinal space and to envelope the exposed prosthetic graft, with the fasciocutaneous portion of flap used for wound closure. Results: The flap survived completely. The prosthetic graft was well preserved. An acceptable cosmetic result was achieved. Conclusion: VAC can be used successfully for the preservation of prosthetic grafts. Free flap reconstruction is an optional method in the reconstruction of large complex defects involving the sternum and the medistinum.