Infected aortic aneurysms: clinical outcome and risk factor analysis

PURPOSE: Infected aortic aneurysms are difficult to treat, and are associated with significant mortality. Hospital survival is poor in patients with severe aortic infection, Salmonella species infection, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location. We reviewed the clinical outcome in 46 patients with primary infected aortic aneurysms and identified clinical variables associated with prognosis. METHODS: Data were collected by means of retrospective chart review. Univariate and multivariate logistic regression models were used for risk factor analysis. RESULTS: Between August 1995 and March 2003, 48 patients with primary infected aortic aneurysms were treated at our hospitals. Two patients with negative culture results were excluded. Of the remaining 46 patients, 35 patients had aortic aneurysms infected with Salmonella species and 11 patients had aortic aneurysms infected with microorganisms other than Salmonella species. There were 20 suprarenal infections and 26 infrarenal infections. Surgical debridement and in situ graft replacement were performed in 35 patients, with an early mortality rate of 11%. The incidence of late prosthetic graft infection was 10%. The 90-day mortality rate in patients operated on was 0% for elective operation and 36% for nonelective operation (P =.006, Fisher exact test). Independent predictors of aneurysm-related death were advanced age, non-Salmonella infection, and no operation. CONCLUSION: With timely surgical intervention and prolonged antibiotic treatment, in situ graft replacement provides an excellent outcome in patients with primary infected aortic aneurysms and elective operation. Mortality is still high in patients undergoing urgent operation. Advanced age, non-Salmonella infection, and no operation are major determinants of mortality.     

Surgical pathology of infected aortic aneurysm and its clinical correlation

Pathology of infected aortic aneurysm and its clinical correlation have rarely been reported. Between 1995 and 2005, 48 patients with infected aortic aneurysm underwent in situ graft replacement. Twenty-five patients had a suprarenal and 23 patients had an infrarenal infection. The most common responsible pathogen was nontyphoid Salmonella in 32 patients (67%). During operation, gross pus was present in 26 patients (54%). On pathological examination, aortic atherosclerosis was present in all cases, acute suppurative inflammation was present in 31 patients (65%), and bacterial clumps were present in five patients (10%). Positive culture of the aneurysm wall was present in 14 patients (29%). There were 10 patients with prosthetic graft infection (21%) and 12 patients with aneurysm-related death (25%). Although statistically insignificant, local purulent infection with positive culture of the aneurysm wall, gross pus during operation, or acute suppurative inflammation on pathology tended to be associated with high risk of prosthetic graft infection and aneurysm-related death. In conclusion, infected aortic aneurysm occurred in patients with aortic atherosclerosis. On pathology, acute suppurative inflammation was present in the majority of cases but bacterial clumps were not commonly present. Local purulent infection tended to be associated with high risk of prosthetic graft infection and aneurysm-related death.     

Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta

BACKGROUND: To review the outcome of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta treated in a major teaching hospital. METHODS: Between December 1994 and January 2003, 13 infected aortic aneurysms and pseudoaneurysms (5 thoracic, 4 paravisceral, 4 infrarenal) in 10 consecutive patients were treated surgically. Aortic debridement with in situ reconstruction is our standard practice. Endovascular repair was offered to suitable patients with thoracic aortic involvement. RESULTS: There were six men and four women with a mean age of 63 years. The commonest pathogen was Salmonella species, accounting for 50% of the cases. Aortic debridement with in situ revascularization was performed for six patients with visceral reconstruction in four of them. One patient with aortic bifurcation involvement and gross purulent infection had ligation and debridement followed by right axillobifemoral bypass. Four infected thoracic aortic pseudoaneurysms in three other patients underwent endovascular repair. There was no hospital death, limb loss, renal failure, or intestinal ischemia. There were two late deaths from sepsis and pneumonia at 3 months and 77 months after operation. Eight patients were alive after a mean follow-up of 36 months and no late graft infection was evident. CONCLUSIONS: Surgical treatment for infected aortic aneurysms with in situ reconstruction is associated with favorable outcome and good long-term result. Endovascular repair has a potential role.     

Infected aneurysm of the thoracic aorta

BACKGROUND: Infected aneurysm of the thoracic aorta is rare and can be fatal without surgical treatment. We review our experience with 32 patients during a 12-year period. METHODS: Retrospective chart review. RESULTS: Between 1995 and 2007, 32 patients (24 men, 8 women) with infected aneurysms of thoracic aorta were treated at our hospital. Their median age was 74 years (range, 50-88 years). Of the 28 pathogens isolated, the most common responsible microorganism was nontyphoid Salmonella in 16 (57%), followed by Staphylococcus aureus in four (14%) and Mycobacterium tuberculosis in three (11%). The site of infection was the aortic arch in 13 patients, proximal descending thoracic aorta in 10, and distal descending thoracic aorta in 9. Seven patients had medical treatment alone, and 25 patients underwent in situ graft replacement. The hospital mortality rate of medical treatment alone was 57%, and the hospital mortality rate of in situ grafting was 12%. Of the 22 operated-on survivors, there were 11 late deaths, four of which were aneurysm-related. The aneurysm-related mortality rate in operated-on patients was 28%. Of 16 patients with infection caused by nontyphoid Salmonella, 13 patients underwent in situ grafting, with a hospital mortality rate of 8% and aneurysm-related mortality rate of 31%. CONCLUSIONS: Infected aneurysm of the thoracic aorta was uncommon. The clinical results of in situ grafting were improving. Nontyphoid Salmonella was the most common responsible microorganism, and the prognosis of infection caused by Salmonella was not dismal. Outcomes of other management strategies, such as endovascular stenting, need to be compared with these results.     

Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases

OBJECTIVE: A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition, threatening life, organs, and limbs. With regard to the aortic segment involved, repair by either in situ replacement or extra-anatomic reconstruction can be quite challenging. Even when surgery has been successful, the prognosis is described as very poor because of the weakened health status of the patient who has developed this type of aneurysm. The aim of our study was to find out whether any progress could be achieved in a single center over a long time period (18 years) through use of surgical techniques and antiseptic adjuncts. MATERIAL AND METHODS: From January 1983 to December 1999, a total of 2520 patients with aneurysms of the thoracic and abdominal aorta and iliac arteries underwent surgery for aortic or iliac replacement at our institution. During that period, 33 (1.31%) of these patients (mean age, 64.3 years) were treated for mycotic aneurysms of the lower descending and thoracoabdominal (n = 13), suprarenal (n = 4), and infrarenal (n = 10) aorta and iliac arteries (n = 6). Twenty (61%) of these 33 patients had histories of various septic diseases; in the other 13 (39%), the etiology remained uncertain. Preoperative signs of infection, such as leukocytosis and elevated C-reactive protein, were found in 79% of the patients, and fever was apparent in 48%; 76% of the patients complained of pain. At the time of surgery, eight (24%) mycotic aneurysms were already ruptured, and 20 (61%) had penetrated into the periaortic tissues, forming a contained rupture. Five (15%) aneurysms were completely intact. The predominant microorganisms found in the aneurysm sac were Staphylococcus aureus and Salmonella species. Careful debridement of all infected tissue was essential. In the infrarenal aortic and iliac vascular bed, in situ reconstruction was performed only in cases of anticipated "low-grade" infection. Alternative revascularization with extra-anatomic procedures (axillobifemoral or femorofemoral crossover bypass graft) was carried out in eight of 16 cases. All four suprarenal and all 13 mycotic aneurysms of the thoracoabdominal aortic segment were repaired in situ. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics. RESULTS: In-hospital mortality was 36% (n = 12). Because of the smallness and heterogeneity of the sample, we could not demonstrate significant evidence for any influence of aneurysm location or type of reconstruction on patients' outcome. However, survival was clearly influenced by the status of rupture. During long-term follow-up (mean, 30 months; range, 1-139 months), 10 patients (48%) died-one (4.8%) probably as a consequence of the mycotic aneurysm, the others for unrelated reasons. Eleven patients (52%) are alive and well today, with no signs of persistent or recurrent infection. CONCLUSIONS: A mycotic aneurysm of the aortic iliac region remains a life-threatening condition, especially if the aneurysm has already ruptured by the time of surgery. Although the content of the aneurysm sac is considered septic, as was proved by positive cultures in 85% of our patients, in situ reconstruction is feasible and, surprisingly, was not more closely related to higher morbidity and mortality in our series than ligation and extra-anatomic reconstruction, although most of the aneurysms repaired in situ were located at the suprarenal and thoracoabdominal aorta. We assume that our operative mortality rate of 36%, which relates to a rupture rate of 85%, could be substantially lowered if the diagnosis of mycotic aneurysm were established before rupture.     

Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts

PURPOSE: Prosthetic graft infection is an uncommon but life-threatening complication of descending thoracic/thoracoabdominal aortic aneurysmectomy. The purpose of this study was to assess the value of in situ arterial allografts in the management of this complication. METHODS: From 1992 to 2000 we treated 11 consecutive patients with prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy by replacing the prosthetic graft with an in situ arterial allograft. There were 10 men and one woman with a mean age of 50.8 years (range, 32-73 years). The primary aortic disease was degenerative aneurysm in 6 patients, chronic type B dissection in 2 patients, inflammatory aneurysm in 1 patient, Marfan's disease in 1 patient, and Beh?et's disease in 1 patient. Replacement involved only the descending thoracic aorta in three patients and more or less extensive segments of the thoracoabdominal aorta in eight patients. Signs of severe infection were present in all patients, and false anastomotic aneurysms were noted in six patients. Aortoenteric fistula occurred in three patients and aortobronchial fistula in two patients. The causative organisms were identified in nine patients. The mean interval between the primary surgery and reoperation was 33.4 +/- 27.5 months. Reoperation was performed under emergency conditions because of hemorrhage in three patients. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in seven patients. Allograft replacement of the aorta was associated with reimplantation of intercostal and/or visceral arteries in all patients. RESULTS: One patient died intraoperatively of heart failure during emergency surgery. Two patients died of persistent infection during the postoperative period at 19 and 58 days. Mean follow-up was 34 +/- 19 months. One patient died during the late follow-up period after surgery of the infrarenal aorta. Another patient underwent surgery for stenoses of one branch of a bifurcated allograft and a renal bypass graft to a solitary kidney. CONCLUSIONS: The use of in situ arterial allografts is a significant advance in the management of prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy provided that reoperation is performed early.     

Arterial Infections in the New Millenium: An Old Problem Revisited

The natural history of infected aneurysms or arterial infections is characterized by rapid expansion leading to rupture, pseudoaneurysm formation, and sepsis. Treatment options include in situ grafting either with prosthetic or autogenous grafts or with cryopreserved allografts (CPAs), resection of the aneurysm with remote bypass grafting, and ligation. The purpose of this study was to review our recent experience with these infections and to present long-term follow-up with in situ CPAs. From January 2000 through June 2005, we treated nine patients with infected aneurysms and one patient with an infection without aneurysm formation. The infection involved the infrarenal abdominal aorta in six patients and the femoral artery in three patients. One patient had an infected splenic artery aneurysm. Aortic rupture occurred in five of the six patients with infected aortas. Two of the three patients with infected femoral aneurysms presented with recurrent hemorrhage. Of the six patients with aortic infections, five were treated with in situ CPAs. One patient was treated with aortic resection and axillofemoral grafting. Two patients with femoral aneurysms were treated with in situ CPAs, and the third patient underwent aneurysm resection and prosthetic grafting through the obturator foramen. The patient with the splenic aneurysm underwent combined valve replacement, aneurysm resection, and splenectomy. Three of the six patients with aortic infections died postoperatively, all of whom were septic at presentation. The cause of death in these three patients was multiple organ failure in two and overwhelming sepsis in one. The three survivors are alive and well with up to 5-year follow-up. The three patients with infected femoral aneurysms are alive and well with follow-up extending to 44 months. The patient with the splenic aneurysm is doing well. No recurrent infections have been noted among the survivors. The CPAs have remained structurally intact in all. The mortality rate among patients with abdominal aortic infections remains high and is likely related to their preoperative septic state. In situ grafting with CPAs appears to be a reasonable treatment option for arterial infections. CPAs appear to maintain their structural integrity and to be resistant to recurrent infection.     

A ten-year experience with bacterial aortitis

Twenty-one patients with bacterial aortitis were treated in four institutions over a 10-year period. Clues to the diagnosis were a pulsatile mass; fever; positive blood culture; CT scan revealing aortic nodularity, an aneurysm of irregular configuration, or air in the aortic wall; and angiography revealing a lobulated aneurysm. The most commonly identified organisms were Salmonella and Staphylococcus. Excision with in situ repair was performed in nine patients; 11 patients underwent extraanatomic bypass grafting with aortic ligation. In situ graft repair was performed when the infected aorta could be removed entirely or when the thoracic or suprarenal aorta was involved. Axillofemoral bypass grafting was used when infection was extensive. There were eight disease-related deaths. No graft infections were encountered in patients who survived.     

Alternative technique for endovascular treatment of an abdominal aortic aneurysm with a severely angulated neck

An 86-year-old female was incidentally discovered with an asymptomatic 5.3 cm infrarenal aortic aneurysm. Preoperative imaging demonstrated the aortic neck to have severe suprarenal and infrarenal angulation. The patient was deemed unfit for open aortic repair due to multiple medical comorbidities. Endovascular treatment was performed with a modified Zenith bifurcated graft using a Zenith TX2 endograft as a proximal aortic cuff. There were no perioperative complications, and postoperative imaging demonstrated aneurysm exclusion with no migration or major endoleaks. The patient died of unrelated causes at 21 months. The use of a thoracic endograft as a proximal cuff is an alternative technique in the endovascular treatment of abdominal aortic aneurysms with a severely angulated neck.     

Psoas abscess in patients with an infected aortic aneurysm

BACKGROUND: Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. Infected aortic aneurysms could be complicated by psoas abscess. METHODS: A retrospective chart review was conducted to examine the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with an infected aortic aneurysm. RESULTS: Between 1996 and 2007, 40 patients (32 men) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). In 38 patients a blood or tissue culture had a positive result. The most common responsible pathogen was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One patient underwent endovascular repair but died. In-situ graft replacement was done in 32 patients. Persistent or recurrent infection occurred in seven (22%) of 32 operated on patients. The mortality rate was 86%, and the overall aneurysm-related mortality rate of in situ graft replacement was 22% (7/32). In eight (20%) of the 40 patients, aortic infection was complicated by psoas abscess. Infection complicated by psoas abscess was present in seven of 32 operated patients. It was associated with higher incidence of emergency operation, hospital mortality, prosthetic graft infection, and aneurysm-related mortality than infection without abscess. CONCLUSION: Psoas abscess was common in patients with infected infrarenal aortic aneurysm. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.     

Management of pararenal aneurysms of the abdominal aorta

The operative treatment of 77 patients with atherosclerotic aneurysms of the pararenal aorta (54 juxtarenal and 23 suprarenal) is analyzed. Repair of these complex lesions is formidable because of difficult exposure, renal ischemia and myocardial strain as a result of proximal aortic occlusion, and associated renal atherosclerosis with secondary renal functional impairment. Nineteen (25%) patients were normotensive with normal renal function. Sixteen patients (21%) had hypertension alone and 42 (54%) were hypertensive with abnormal renal function. There were multiple renal arteries in 22% of patients. Aortic reconstruction involved infrarenal graft in 27 patients (35%), infrarenal graft plus pararenal aortic endarterectomy (TEA) in 26 (34%), and infra- and pararenal aortic graft in 24 (31%). Twenty-two patients (30%) had normal renal arteries and therefore no renal reconstruction. Of the 55 patients who required combined aortic and renal artery repair, 24 required renal artery repair because of involvement of the renal arteries by the aneurysm and 31 because of atherosclerotic renal artery disease. TEA was the most common technique of renal artery repair (54 of 93 arteries, 58%), followed by reimplantation (18 arteries) and prosthetic graft (13). The perioperative mortality rate was 1.3%. The perioperative morbidity rate was 28% and consisted principally of renal insufficiency (23%). This was usually transient (44%) and (89%) mild. Renal morbidity was adversely affected by renal ischemia status, severity of renal artery disease and extent of renal revascularization. Following reconstruction, hypertension was cured or improved in 77% of patients and abnormal renal function was cured or improved in 46% and stabilized in an additional 39% of patients. These results show that combined aortic aneurysm repair and renal artery reconstruction can be performed with minimal mortality and an acceptable morbidity. Aggressive intraoperative monitoring is necessary to minimize myocardial complications. Careful attention must be paid to the technical details of the reconstruction, especially in minimizing renal ischemia, to reduce the subsequent incidence of renal function deterioration.     

Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections

BACKGROUND: In situ treatment of artery/graft infection has distinct advantages compared to vessel excision and extra-anatomic bypass procedures. Based on animal studies of a rifampin-soaked, gelatin-impregnated polyester graft that demonstrated prolonged in vivo antibacterial activity, this antibiotic-bonded graft was used selectively in patients for in situ treatment of low-grade Gram-positive prosthetic graft infections or primary aortic infections not amenable to excision and ex situ bypass. METHODS: In a 5-year period (1995-1999), 27 patients with prosthetic graft infection (aortofemoral, n = 18, femorofemoral, n = 3; axillofemoral, n = 1) or primary aortic infection (mycotic aneurysm, n = 3; infected AAA, n = 2) underwent excision of the infected vessel and in situ replacement with a rifampin soaked (45-60 mg/ml for 15 min) gelatin-impregnated polyester graft. All prosthetic graft infections were low grade in nature, caused Gram-positive bacteria (Staphylococcus epidermidis, 16; Staphylococcus aureus, 5; Streptococcus, 1), and were treated electively. Patients with mycotic aortic aneurysm presented with sepsis and underwent urgent or emergent surgery. RESULTS: Two (8%) patients died-1 as a result of a ruptured Salmonella mycotic aortic aneurysm and the other from methicillin-resistant S. aureus infection following deep vein replacement of an in situ replaced femorofemoral graft. No amputations or late deaths as the result of vascular infection occurred in the 25 surviving patients. Two patients developed recurrent infection caused by a rifampin-resistant S. epidermidis in a replaced aortofemoral graft limb and were successfully treated with graft excision and in situ autogenous vein replacement. Eighteen patients remain alive and clinically free of infection after a mean follow-up interval of 17 months. CONCLUSIONS: In situ replacement treatment using a rifampin-bonded prosthetic graft for low-grade staphylococcal arterial infection was safe, durable, and associated with eradication of clinical signs of infection. Failure of this therapy was the result of virulent and antibiotic-resistant bacterial strains.     

Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.

OBJECTIVE: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. RESULTS: Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). CONCLUSION: Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.     

Treatment of aortic and peripheral prosthetic graft infections with bovine pericardium

ObjectiveGraft infections are rare but serious complications of vascular operations. The aim of this study was to evaluate the results of in situ reconstruction with bovine pericardium in infected aortic and peripheral vessel fields.MethodsA retrospective cohort study was conducted with a focus on the treatment of infected grafts with bovine pericardium. We retrospectively reviewed 19 consecutive patients with prosthetic graft infections and in situ repair with bovine pericardium. All operations were done between March 2015 and January 2018. No other materials were used. Excision of the infected graft, radical débridement of the infected tissue, and in situ reconstruction with bovine pericardium were applied in all patients. Short-term outcomes including primary patency, freedom of reinfection, mortality, and complication rates were analyzed.ResultsBovine pericardium was used in 19 patients (84% male) with a median age of 70 years (range, 56-84 years) to reconstruct the descending aorta (n = 1), abdominal aorta (n = 5), iliac artery (n = 4), and femoral artery (n = 9). Graft infections were observed in all patients (one thoracic endovascular aneurysm repair, three infrarenal endovascular aneurysm repairs, two open aortic repairs, four iliac-femoral reconstructions, and nine femoral reconstructions including two closure device infections after coronary angiography). Ten patients (53%) had a complication perioperatively and postoperatively. The 30-day mortality was 10.5%; the total mortality rate after 1 year was 32%. There was no reinfection after bovine reconstruction observed in our cohort. Graft occlusions were detected in two cases during follow-up (median, 6 months; range, 1-47 months).ConclusionsBovine pericardium reconstruction shows a good short-term outcome after aortic or peripheral graft infections. It is associated with good patency, low reinfection rate, and acceptably low early mortality rate. It can be a good therapeutic option in prosthetic graft infections when in situ repair with a prosthetic (even soaked) or autologous vein or homograft is not recommended or is not possible.     

Ruptured Abdominal Aortic Aneurysms due to <Emphasis Type="Italic">Salmonella</Emphasis>, not of <Emphasis Type="Italic">typhi</Emphasis> Species

Ruptured aortic aneurysms due to Salmonella not of typhi species are rare and associated with high morbidity and mortality. We present three patients with Salmonella-infected ruptured aortic aneurysms successfully treated with an in situ prosthetic bypass graft. One patient had a saccular aneurysm at the infrarenal aorta and two patients had fusiform aneurysms at the aortic bifurcation. All the patients were treated with wide debridement of the infected aortic tissue followed by in situ graft replacement and long-term systemic antibiotic therapy. The method of revascularization, in situ bypass or extraanatomic bypass, remains controversial. On the basis of our clinical experience and recent literature focusing on more than 10 cases, in situ bypass reconstruction may be a feasible surgical technique for Salmonella-infected ruptured aortic aneurysm.     

Exclusion-bypass for aneurysms of the descending thoracic and thoracoabdominal aorta

From October 1973 to April 1985, 81 patients with aneurysms of the descending thoracic or thoracoabdominal aorta underwent surgery. Eight (10%) of these patients were treated by exclusion-bypass. The aneurysm was located in the descending aorta alone in five cases, and in the descending thoracic and thoracoabdominal aorta in three cases. In all cases, the proximal anastomosis of the bypass was performed on the ascending aorta. The site of the distal anastomosis was the supraceliac aorta in two cases, the infrarenal aorta in three cases and the iliac arteries in three other cases. Exclusion was bipolar, at each end of the aneurysm, in six cases, and unipolar, ie. proximal interruption only, in two cases. Two patients died during the first postoperative month, one of rupture of the distal portion of the aortic arch, the second, after onset of secondary paraplegia. There were no other spinal, cardiac or cerebral complications. One patient died three months postoperatively of intercurrent pulmonary infection. The five other surviving patients whose mean follow-up period is 48.1±25 months, are alive and enjoying good health. Resection and grafting as advocated by Crawford, is the usual treatment proposed for aneurysms of the descending thoracic and thoracoabdominal aorta. Exclusionbypass may however be preferred in the following cases: elderly patients with compromised respiratory status, aneurysms of the descending thoracic aorta, either voluminous, of infectious origin or associated with aneurysm of the infrarenal abdominal aorta.     

Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Combined resection of the thoracic esophagus and thoracic descending aorta

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Combined resection of the thoracic esophagus and thoracic descending aorta.

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.