Clinical Use of the Seromuscular Jejunal Patch for Protection of the Infected Aortic Stump Dhiraj All. Shah, MD, Albany, New York Dale Buchbinder, MD, Albany, New York, Robert P. Leather, MD, Albany, New York John Corson, MD, Albany, New York Allastair M. Karmody, MD, Albany, New York Pathologic involvement of aortic prosthetic grafts with elements of the gastrointestinal tract retains pride of place as one of the most difficult of all problems in the realm of vascular surgery. When unrecognized or inadequately treated, the inevitable results are those of graft and aortic sepsis, graft- enteric fistulas and erosion, hemorrhage, generalized septicemia, and death. The only method of man- agement of this dreadful complication that has pro- vided uniform and reasonable success has consisted of complete excision of the graft, secure closure of the proximal aortic stump, and extraanatomic bypass to assure survival of the lower limbs. However, many workers [I ,2] including ourselves, have reported that if sepsis of the aortic stump continues postopera- tively, it will eventually result in the fatal process of dissolution and exsanguinating hemorrhage. In our earlier report, after careful application of the afore- mentioned principles of management, this lethal event nevertheless accounted for 4 of the 6 deaths in the postoperative period. Protection of the proximal aortic stump from sepsis remains, therefore, one of the most important and unsolved therapeutic di- lemmas within this already difficult clinical problem area. The difficulties involved in secure closure of the proximal aorta after removal of a graft have already been reported but are worth repeating. There is usually little aortic tissue left distal to the renal ar- teries, and retention of even tenuous tissue for sub- From the Department of Surgery. Vascular Surgery Section. Albany Medical College and the Veterans Administration Medical Center. Albany. New York. Requests for repints should be adbessed to Allastair M. Karrrwdy. MD. Department of Surgery, Albany Medical College. Albany. New York 12208. Presented at the 1 lth Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, March 23-27, 1983. sequent provision of a hemostatic closure generally takes precedence over theoretically “desirable” de- bridement of the infected aortic wall. This difficulty becomes particularly pronounced when the graft is originally inserted close to the renal arteries due to aortic aneurysm or occlusive disease. Under such poor circumstances, the infected aortic wall is com- monly included in the closure. The principles of surgical management of this predicament should incorporate the protection of these vital suture lines by reinforcement with healthy tissue. In other anatomatic areas, somatic muscle has been found to be of superior quality in this respect, but this entity is singularly hard to come by in the abdominal cavity. The psoas muscle, which is the closest, has been used, but it is difficult to sufficiently mobilize it to cover the stump. Reliance has therefore been centered on the “policeman” of the abdomen, that is, the omentum, for stump protection [3]. Many of these patients lack the quantity, if not the quality, of this otherwise excellent tissue. In addition, the omentum has withdrawn from the area of the stump closure in our experience. zyxwvutsrqponmlkjihgfedcbaZYXWVU Experimental study: In an attempt to solve this pressing problem, we have shown in a canine model that healthy, well-vascularized muscular tissue de- rived from a mucosa-free segment of jejunum can effectively protect the aortic stump which remained infected after removal of deliberately contaminated prosthetic grafts [4]. In this experiment, the mucosa was removed from a piece of jejunum on an intact vascular pedicle to form a seromuscular jejunal patch. The patch was used to cover the infected aortic stump following its debridement and closure with a fine monofilament suture. A diagram of this experiment is shown in 198 The Am&can Journal of Surgery