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