Pedicled Vastus Lateralis and Tensor Fascia Lata Flap for Aortic Graft Salvage

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A 70-year-old man with retroperitoneal liposarcoma statis post-neoadjuvant radiation, radical resection, and abdominal aortic reconstruction presented with recurrent retroperitoneal abscess and entero-enteric and entero-cutaneous fistulae consistent with a contaminated abdomen. Following failed conservative management with intravenous antibiotics and percutaneous drainage, he was taken for surgical graft salvage with flap coverage (Figure 1). Various reconstructive options were considered. Local retroperitoneal flaps were in the radiated field. An omental flap was used in index operation and was necrotic. The nephrectomy scar precluded a rectus flap and, given the degree of muscle wasting, a rectus femoris flap was deemed too small. Given the size of the defect, a combined vastus lateralis and tensor fascia lata flap was chosen. The vastus lateralis and tensor fascia lata were identified (Figure 2). The flap was dissected free and the arc of rotation confirmed (Figure 3). Finally, the flap was tunneled through the rectus sheath and inset without tension in the retroperitoneum over the aortic graft (Figure 4). The patient had a prolonged hospital course, but no complications were noted relating to the vastus lateralis flap or aortic graft. He was discharged to a nursing facility 2 months postoperatively and, at his final visit 1 year postoperative, there was no evidence of aortic graft compromise or infection.

Figure 1. Exposed aortic graft in the retroperitoneum with necrotic omentum.

Figure 2. Suprafascial dissection of vastus lateralis and tensor fascia lata.

Figure 3. Pedicled vastus lateralis/tensor fascia lata flap arc of rotation.

Figure 4. Tension-free flap inset over aortic graft in the retroperitoneum.

Graft infection complicates 4% of all aortic reconstructions.¹ Independent risk factors for graft infection comprise both patient and surgical factors, including diabetes, immunosuppression, malnutrition, groin access, open wound at time of procedure, emergency procedure, and need for early reoperation in the early postoperative period.¹ Infection typically arises from direct inoculation of the graft or peri-graft space. The most common causative organism is coagulase-negative Staphylococcus spp.^1,2 Aortic graft infection has a high morbidity and may result in sepsis, aneurysm formation, thrombosis, and distal embolization. If untreated, graft infection causes erosion between the graft and the surrounding bowel, urinary tract, or skin, and may lead to potentially catastrophic aortic fistulae in 1% to 2% of patients undergoing aortic reconstruction.

Standard treatment of exposed grafts involves extended parental antibiotic therapy and resection of the exposed segment with extra-anatomic bypass. The use of muscle flaps for graft salvage has evolved from its origins in the 1980s to become more common today.³ Muscle flaps provide a well-vascularized tissue bed to eliminate dead space, enhance local tissue oxygenation, and deliver intravenous antibiotics and immune cells. Muscle-flap graft salvage has been shown to reduce bacterial counts, increase salvage rates, and accelerate healing time. Recent studies advocate for attempted vascularized tissue salvage without graft excision if no fistula is present.⁴ Timing is key, with earlier time to coverage associated with increased graft salvage.^3,4  

Several factors are considered when it comes to flap selection including the location, size of the defect, structures involved, and presence of contamination. Pedicled flaps are advantageous in that they require a shorter operating time and decrease the time for tissue resorption.⁵ First-line local flaps include retroperitoneal flaps with psoas muscle and intra-abdominal omental flaps. Regional flaps such as rectus abdominis or reversed latissimus dorsi may then be considered. Next, more distal pedicled flaps may be considered, including the rectus femoris, vastus lateralis, or tensor fascia lata. Conversion of pedicled flap to free-tissue transfer, or direct free-tissue transfer is always an option in the case of insufficient reach or lack of available pedicled flaps. In this case, a rectus flap was not possible because of the previous nephrectomy scar, which compromised the potential vascularity and reach of a rectus flap. A rectus femoris was deemed too small given the degree of muscle wasting the patient had undergone. A pedicled vastus lateralis-tensor fascia lata graft was chosen to cover the graft and prevent a potentially catastrophic aorto-enteric fistula. 

The vastus lateralis and its overlying anterolateral thigh skin island has been a workhorse pedicled flap for defects from the upper third of the thigh to the epigastrum.⁶ The pedicled vastus lateralis flap may comfortably cover defects below the umbilicus; however, for defects above, additional maneuvers must be used.⁶ Maneuvers that may increase reach of the flap to the maximum cranial reachable distance include dissecting the descending lateral circumflex pedicle to its origin, raising the vastus lateralis and tensor fascia lata as a composite unit to incorporate the horizontal branch of the descending lateral circumflex, passing the flap deep to the rectus femoris and sartorius, ligating the branch to the rectus femoris if originating from the descending lateral circumflex artery (type 2 pattern), and, if raised as a myocutaneous flap, shifting the skin.⁶ Finally, the hip may be flexed up 30° to 60° to reach up to the epigastrium; however, the patient must maintain this flexed position for several days to reduce tension on the pedicle and allow for healing before the hip is extended.⁷