Planned Y-shaped Muscle Wrapping for Salvaging Aortic Graft Infection: Latissimus Dorsi and Reverse Serratus Anterior Muscles

Abstract

Aorta-related infections are life threatening. Aggressive replacement surgery using artificial aortic grafts should be performed using well-vascularized tissue wrapping to avoid reinfection. An omental flap is the first choice; however, a history of abdominal surgery necessitates other methods. In a cadaveric study in 2021, we verified the distal tight attachment area between the latissimus dorsi (LD) muscle and serratus anterior (SA) muscle to apply a Y-shaped combined flap consisting of the LD and reverse SA. We used this procedure to treat a 79-year-old man who underwent stent-graft insertion in the descending thoracic aorta. Descending aortic graft replacement was performed with a left anterior lateral thoracotomy. Then, we elevated the LD and SA combined flap by "posterior-to-anterior elevation" based on the previous cadaveric study. After blocking blood flow from the SA branch with a microvascular clip, blood flow from the LD branch of the thoracodorsal artery to the distal part of the SA muscle across the distal attachment area was evaluated using indocyanine green fluorescence. Fluorescence had spread throughout the distal part of the SA muscle. Postoperative computed tomography and the clinical course indicated successful regulation of infection. We established a novel surgical technique for the complete muscle wrapping of the descending thoracic aorta, including the aortic arch. The accumulation of further cases is needed to determine whether the blood flow of the distal connection area from the LD to the SA has individual variations; however, we hope this technique improves the mortality and morbidity associated with aorta-related infections.

Fig. 1.

Intraoperative findings. A, Intraoperative ICG fluorescence test. View before the ICG test. Yellow dotted line, SA muscle; blue dotted line, LD muscle; white arrow, clamping of the thoracodorsal artery and vein. B, Early phase of the ICG test. The distal tight attachment area between the LD and SA showed a direct arterial network.

Fig. 2.

A Y-shaped muscle flap constructed with the combined LD muscle and reverse SA muscle. Arrowheads represent the following: yellow, reverse SA muscle flap; blue, LD muscle flap.

Fig. 3.

At 2 weeks postoperatively, contrast CT showed muscular coverage of the entire aortic graft. Dotted lines represent the following: yellow, reverse SA muscle flap; blue, LD muscle flap; red, left thoracodorsal artery entering from the partially resected fourth rib to the chest cavity.