PURPOSE: In surgeries of the aortic arch, mediastinal wound needs to be extended to expose branches of aortic arch. When the tracheostomy is indicated postoperatively, the consequence of sternal wound infection and graft infection is anticipated. The safety of percutaneous dilational tracheostomy (PDT) is investigated.
METHODS: The perioperative data in consecutive 32 patients (21 male, 51–89 [median 76] year-old) for whom PDT was indicated after graft replacement of aortic arch were reviewed. All aortic surgeries were performed through hemi-collar incision and the selective cerebral perfusion under deep hypothermia was applied for cerebral protection. The total arch replacement with three-branch graft were performed in 26 patients and the hemiarch replacement were performed in 6 patients. The indications of PDT were respiratory disorders in 17 patients (respiratory insufficiency: 10, COLD: 4, pneumonia: 2, epiglottic cyst: 1), disturbance of consciousness in 12, and cardiac instability in 3. The intervals from the aortic surgeries to PDT were 7–70 days (7–14 days: 12, 15–21 days: 9, >21 days: 11).
RESULTS: Twenty patients (63%) weaned from respirator support 2 to 26 days after the PDT(2–3 days: 5, 4–7 days: 5, 8–14 days: 4, >14 days: 6). Eleven patients (34%) died during the hospitalization mostly due to multiple organ failure. Sternal wound infection was observed in three patients and all causatives were MRSA. In the first patient, the direct connection between the PDT site and the sternal wound resulted in mediastinitis. In the second patient, the sternal wound opened due to aseptic fat necrosis 4 days after the PDT and worsened to osteomyelitis in relation with MRSA pneumonia. In the third patient, re-fixation of the sternum was performed one week after the aortic surgery and PDT was performed 5 weeks later. The MRSA mediastinitis was complicated 7 weeks after PDT.
CONCLUSION: PDT can be indicated safely in patients who underwent the aortic arch replacement through the hemi-collar incision.
CLINICAL IMPLICATIONS: However, if the sternal wound problem, eg. sternal instability or fat necrosis, is complicated, its safety is not promising.
DISCLOSURE: Hitoshi Matsuda, No Financial Disclosure Information; No Product/Research Disclosure Information