Aortic graft infection (AGI) is a lethal, complex complication affecting 1–3% of patients, likely higher due to underreporting among those deemed unsuitable for surgical treatment. Historically, AGI treatment outcomes have been poor, with mortality ranging from 25–75%, and little improvement has been achieved to date. Surgical treatment typically involves resecting and debriding all infected material, followed by reconstructing affected areas. However, the aggressive nature of these techniques limits patient eligibility.

This study reports their experience using the omentum as a vascularized flap for AGI treatment. From 2005 to 2023, 31 AGI patients were retrospectively analyzed following omental transposition. Included cases involved infections of the aortic root graft, ascending aorta, and aortic arch, as well as hybrid prostheses or full arch replacements with frozen elephant trunks, excluding infected endovascular prostheses. Two patient groups were analyzed: curative intent (n = 9), where aggressive treatment involved graft replacement and mediastinal debridement followed by omental transposition; and palliative intent (n = 22), where the AGI could not be replaced, and only mediastinal cleaning with omental interposition was performed.

With a median follow-up of nearly 2 years, in-hospital and one-year mortality was 0% in the curative cohort, whereas the palliative cohort saw mortality rates of 23% (n = 5) and 41% (n = 9), respectively. No reinfections occurred within 3 years in the curative group. In the palliative group, 3-year survival was 52%, with a 59% infection-free rate (n = 13).

The authors conclude that omental transposition for AGI may be a viable palliative option for high-risk patients who are unsuitable for aggressive surgery. However, mortality remains elevated. For patients with curative intent, this procedure could serve as an effective adjunct treatment and should be considered in conjunction with extensive debridement.

COMMENTARY:

The omentum has been utilized in various surgical contexts for over 130 years. It is a voluminous, highly vascular, and pedicled tissue capable of absorbing fluids, resisting infection, sealing inflammation, and covering tissue defects. Deriving from the mesogastrium as a double layer of peritoneum, its vascular network supports lymph-rich in macrophages, thus earning it the title of the ideal biological drain. Experimental studies in the 1960s with canine models demonstrated its utility, where infected aortic grafts covered with omentum showed a remarkable survival rate. In cardiac surgery, its use has been limited to case series, with this study of 31 patients representing the largest published series. The potential advantages of the omentum over other vascularized pedicles include its reach to any intrathoracic region, the volume and flexibility to cover irregular spaces, and as a source of endothelial growth factors promoting angiogenesis in ischemic territories.

Omental use may require assistance from an experienced general surgeon for extraction and handling. The objective is to achieve contact across the graft’s entire surface, covering suture and fibrous areas. Complications include pedicle necrosis due to vascular torsion, diaphragmatic hernia, gastrointestinal issues, or infection spread to the peritoneal cavity.

Concerning limitations, this is a single-center, retrospective study, and while it is the largest series to date, it still involves a limited patient sample. No control group without omental transposition was available for comparison in either the curative or palliative cohort, complicating outcome assessment. Individualized treatment and technical variability further challenge comparability.

In conclusion, while the need to “make a heart of stone” may not always be necessary, knowledge of such techniques and the willingness to apply them can make a crucial difference in returning our patients from the brink of the Styx. After all, as Voltaire reminded us, we are not only responsible for what we do, but also for what we fail to do.

REFERENCE:

Pitts L, Pasic M, Wert L, Nersesian G, Kaemmel J, Buz S, et al. Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch. Eur J Cardiothorac Surg. 2024 Jun 3;65(6):ezae225. doi: 10.1093/ejcts/ezae225.