Improved outcome in thoracoabdominal aortic aneurysm repair: the role of cerebrospinal fluid drainage.

INTRODUCTION: To evaluate the protective effect and the optimum duration of cerebrospinal fluid drainage (CSFD) during and after thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: From April 2001 to October 2003, we retrospectively compared 17 (n = 17) consecutive patients who have been electively operated on by Martin Grabenwoger for left heart bypass and selective perfusion of the visceral and renal organs. RESULTS: The first 7 patients had CSFD for 72 hours; the duration of CSFD was increased to 100 hours in the remaining 10 patients. Median drained cerebrospinal fluid (CSF) volume was 680 milliliters in the 72-hour group versus 1441 milliliters in the 100-hour group. A characteristic increase in CSF volume was noted between POD No. 2 and POD No. 4 indicating persistent spinal cord edema. Univariate and multivariate analysis demonstrated that CSFD for 100 hours is a significant predictor for decreased incidence of late onset paraplegia (p < 0.001). The overall incidence of postoperative neurological deficit was 17.6% (3 of 17). There was one patient (6%) who developed permanent paraplegia and two patients (12%) with transient paraplegia. These patients sustained late-onset paraplegia 72 hours after surgery for removal of a CSFD device. Complete motor function could be restored after re-insertion of a CSFD device. In one patient, permanent paraplegia was evident after awakening from anesthesia. Because of technical difficulties, only two intercostal arteries could be re-implanted, which was obviously not sufficient to restore spinal cord perfusion. In contrast, no neurological deficit occurred in patients in whom a CSFD instrument was left for 100 hours. CONCLUSION: The extended duration of CSFD may lower the risk of late-onset paraplegia and could improve outcome in patients undergoing thoracoabdominal aortic surgery.

Primary or delayed closure for the treatment of poststernotomy wound infections?

OBJECTIVE: The methods of primary versus delayed wound closure for the treatment of sternal wound infections after cardiac surgery were retrospectively compared. METHODS: From January 2001 to March 2003, 132 patients (median age 66 years, male to female ratio 88:44) with sternal wound infection after cardiac surgery were treated at our department. After thorough debridement, 35 patients received preconditioning of the wound before implementation of definitive therapy; the remainder (97 patients) were treated with immediate closure. RESULTS: From the 35 patients with preconditioning, 19 patients proceeded to delayed primary closure, whereas the remaining 14 patients were referred to plastic reconstruction with a pectoralis muscle flap. Primary success rate in this group was 100%. In the immediate primary closure group, 33 patients experienced 1 or more therapy failures, resulting in a recurrence rate of 39%. Fifteen patients received a pectoralis muscle flap as definite treatment modality. CONCLUSIONS: Immediate primary closure is associated with a high rate of local infection recurrence. Surgical debridement and conditioning of the wound until resolution of infections with delayed primary closure or plastic reconstruction is suggested as the more appropriate treatment modality, with promising results.

The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest.

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.

The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery.

BACKGROUND: The VAC system (vacuum-assisted wound closure) is a noninvasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure by controlled suction to the wound surface. The method was introduced into clinical practice in 1996. Since then, numerous studies proved the effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation. METHODS: Eleven patients (5 men, 6 women) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting = 5, aortic valve replacement = 5, ascending aortic replacement = 1) were fitted with the VAC system by the time of initial surgical debridement. RESULTS: Complete healing was achieved in all patients. The VAC system was removed after a mean of 9.3 days (range 4 to 15 days), when systemic signs of infection resolved and quantitative cultures were negative. In 6 patients (54.5%), the VAC system was used as a bridge to reconstructive surgery with a pectoralis muscle flap, and in the remaining 5 patients (45.5%), primary wound closure could be achieved. Intensive care unit stay ranged from 1 to 4 days (median 1 day). Duration of hospital stay varied from 13 to 45 days (median 30 days). In-hospital mortality was 0%, and 30-day survival was 100%. CONCLUSIONS: The VAC system can be considered as an effective and safe adjunct to conventional and established treatment modalities for the therapy of sternal wound infections after cardiac surgery.