Staged Omental Wrapping for Perigraft Fluid Collection after Total Aortic Arch Replacement: A Case Report

Perigraft fluid collection after aortic graft replacement is often self-limiting; however, progressive enlargement or the development of symptoms warrants careful evaluation. The differential diagnosis includes hematoma, abscess, seroma, and lymphatic leakage. However, differentiating among these conditions can be challenging based solely on clinical symptoms and imaging findings.

A 51-year-old man underwent total aortic arch replacement (TAR) for chronic Stanford type A aortic dissection. Nine months later, he developed rapidly progressive swelling and erythema over the upper portion of the median sternotomy incision. Contrast-enhanced CT revealed a low-attenuation fluid collection surrounding the prosthetic graft and extending into the subcutaneous mass. Although there was no evidence of active extravasation, anastomotic disruption, or gas formation suggestive of graft infection, exploratory resternotomy was performed under cardiopulmonary bypass (CPB) standby because a redo TAR might have become necessary if either anastomotic disruption or gross graft infection had been identified intraoperatively. Intraoperative inspection revealed no evidence of active bleeding. However, graft infection could not be definitively excluded because yellowish-brown turbid fluid was drained from the subcutaneous mass and around the prosthetic graft. Fluid samples were obtained for microbiological culture, and the perigraft space was thoroughly irrigated. Based on the intraoperative findings, fluid characteristics, and negative microbiological culture results, a sterile inflammatory perigraft fluid collection was considered the most likely diagnosis. Omental wrapping was subsequently performed as a second-stage procedure to manage the large residual space and prevent graft infection. No recurrence was observed during 12 months of follow-up.

Perigraft fluid collection after aortic graft replacement has a broad differential diagnosis. When active bleeding or graft infection cannot be confidently excluded, an exploratory resternotomy under CPB standby may be a practical option for direct evaluation and management. Omental wrapping may be a simple and effective option for preventing recurrence and graft infection.