Clamshell Thoracosternotomy for Single-Stage Repair of a Rare Aortic Graft Infection Involving Ascending, Arch, and Descending Aortic Pathologies.

Single-stage repair of infected aortic grafts through a clamshell incision (bilateral thoracotomy with transverse sternotomy) is rarely undertaken, even when this approach could offer better exposure. We describe the use and considerations of a clamshell approach in the context of a rare prosthetic graft infection involving ascending, arch, and descending aortic segments. A 59-year-old man underwent aortic valve plus ascending aorta and total arch replacement for acute type A dissection. Eleven months later, he presented with a contained rupture at the distal anastomosis of his aortic arch graft. A thoracic endovascular aortic repair was performed extending into the descending aorta. However, within a few weeks, the patient developed fever and persistent distal anastomotic pseudoaneurysms, suggesting graft infection (without an obvious culprit organism). Replacement of the entire aortic arch, ascending, and descending aorta, preserving the aortic valve, was ultimately performed via a clamshell incision, requiring total circulatory arrest (eight minutes) and antegrade cerebral perfusion (28 minutes). Postoperatively, the patient was ventilated for 2.7 days and was discharged home on postoperative day 26 with empirical antibiotic therapy. The culprit organism was later identified as Parvimonas micra (P. micra) following extensive microbiological analysis (16S ribosomal deoxyribonucleic acid sequencing). The patient presented with hemoptysis and recurrent signs of infection on aortic imaging at approximately three months following his final operation. After discussion with the patient and family, nonoperative management was determined as the most appropriate path forward. This case illustrates the technical feasibility of this approach to address graft material present in the ascending, arch, and descending aorta. While the outcome was not ideal for this patient, our approach made this very extensive removal of graft material possible; such a procedure would not have been feasible with a midline sternotomy and would have required a multi-stage repair. Further, P. micra was an unexpected culprit, difficult to detect and detected late; this underscores the potentially growing importance of considering unexpected culprits and using advanced sequencing in culture-negative graft infections.