Role of Extra-anatomic Ascending to Descending Bypass in Complex Thoracic Aortic Pathology

Complex pathology of the distal arch and proximal descending thoracic aorta is usually approached by stent endografting or in situ graft replacement. Oftentimes, these options are not feasible due to unfavorable anatomy, multiple previous procedures, active infection, or presence of concomitant cardiac disease. Thoracic aortic extra-anatomic bypass, as part of an open surgical strategy, is a useful and often the only curative option left for the treatment in these patients. Herein, we describe two cases that illustrate the utility of extra-anatomic thoracic aortic bypass for complex aortic disease.

A Case of In Situ Phage Therapy against Staphylococcus aureus in a Bone Allograft Polymicrobial Biofilm Infection: Outcomes and Phage-Antibiotic Interactions

Phage therapy (PT) shows promising potential in managing biofilm infections, which include refractory orthopedic infections. We report the case of a 13-year-old girl who developed chronic polymicrobial biofilm infection of a pelvic bone allograft after Ewing’s sarcoma resection surgery. Chronic infection by Clostridium hathewayi, Proteus mirabilis and Finegoldia magna was worsened by methicillin-susceptible Staphylococcus aureus exhibiting an inducible Macrolides-Lincosamides-Streptogramin B resistance phenotype (iMLSB). After failure of conventional conservative treatment, combination of in situ anti-S. aureus PT with surgical debridement and intravenous antibiotic therapy led to marked clinical and microbiological improvement, yet failed to prevent a recurrence of infection on the midterm. This eventually led to surgical graft replacement. Multiple factors can explain this midterm failure, among which incomplete coverage of the polymicrobial infection by PT. Indeed, no phage therapy against C. hathewayi, P. mirabilis or F. magna could be administered. Phage-antibiotic interactions were investigated using OmniLog® technology. Our results suggest that phage-antibiotic interactions should not be considered “unconditionally synergistic”, and should be assessed on a case-by-case basis. Specific pharmacodynamics of phages and antibiotics might explain these differences. More than two years after final graft replacement, the patient remains cured of her sarcoma and no further infections occurred.

Impella insertion for residual aortic dissection

Acute aortic dissection with coronary malperfusion is a life-threatening disease, resulting in demanding postoperative management. We report a successful insertion of percutaneous heart pump Impella through the intact true lumen in a patient with residual aortic dissection after the graft replacement and its recovery from the post-cardiotomy cardiogenic shock.

False aortic aneurysm due to proximal and distal tears after aortic replacement

A 68-year-old woman who had been well for 2 years after ascending aortic graft replacement experienced sudden chest pain. Computed tomography showed a large false aortic aneurysm around the prosthesis. However, the patient was hemodynamically stable and did not have anemia. Emergency surgery under hypothermic circulatory arrest revealed tears at both the proximal and distal anastomotic sites and blood circulating from the proximal (exit) to the distal (entry) tears underneath the pericardium. To our knowledge, the present case represents a previously unreported pathology that will be of great interest to cardiologists and cardiac surgeons.