Mycotic aneurysm of the suprarenal aorta secondary toStreptococcus pneumoniae: An unusual pathogen

Mycotic aneurysms of the suprarenal aorta are rare lesions, accounting for less than 1% of aortic reconstructions for aneurysmal disease. The bacteriology of these lesions differs from the infrarenal aneurysms and primarily consists of Gramnegative organisms. We report an unusual case of an 87-year-old man successfully treated for a ruptured mycotic suprarenal aortic aneurysm caused byStreptococcus pneumoniae. We have not seen a previously reported case where this pathogen has been associated with a suprarenal mycotic aneurysm. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of these aneurysms is summarized.     

The management of traumatic aortic tear in the multiply-injured patient

Patients with traumatic aortic tears and severe life-threatening associated injuries require early and expeditious evaluation and treatment in order to improve survival. Diagnostic and treatment priorities, however, are not clearly established in this subset of patients. The purpose of this retrospective analysis was to help identify successful diagnostic and treatment priorities in this group of patients. Between 1979–1989 the medical records of all patients sustaining blunt chest trauma resulting in a traumatic aortic tear were reviewed. There were 11 patients with multiple injuries and this diagnosis was treated at Boston University Medical Center. Five patients had diagnostic peritoneal lavage or an exploratory laparotomy prior to a thoracotomy. Four patients had only a thoracotomy. Two patients in this series had a thoracotomy prior to treatment of suspected intraabdominal injuries. One of these two patients died. Our overall survival rate was 82%. This series suggests that the management sequence in patients with coexistent injuries should include treatment of severe associated injuries prior to treatment of the aortic injury and that initial treatment of traumatic aortic tears is appropriate if there is no evidence of severe life-threatening trauma.     

Prevention of vascular graft infection by rifampin bonding to a gelatin-sealed dacron graft

This study examines the efficacy of rifampin bonding to a gelatin-sealed knitted Dacron graft to prevent perioperative bacteremic vascular graft infection. Antibiotic bonding was obtained by soaking grafts for 15 minutes in a 1 mg/ml saline solution of rifampin at 37°C. Nineteen dogs had thoracoabdominal aortic bypass: seven (group I) received a rifampin treated graft; six (group II) received an untreated gelatin-coated graft; and six (group III) received an uncoated Dacron graft. Two days later bacteremic challenge was produced by rapid intravenous injection of 5×10 ⁵ colony forming units of methicillin resistantStaphylococcus aureus.Grafts were harvested five days after this challenge and cut into 10 fragments, each submitted to bacterial counts. Results were expressed as CFU/cm ² of graft material. In group I, no graft was infected, whereas all grafts in groups II and III were infected (p<0.05). Median bacterial counts from the infected fragments (median±SD) were similar in groups II (2.5×10⁵ CFU/cm²) and III (4×10⁴ CFU/cm²). Blood cultures at time of sacrifice were negative in all dogs in group I and positive in five of six dogs in groups II and III. Cultures of liver, spleen, kidney, and lung specimens were always negative in group I and positive in 22 of 24 specimens in group II and 23 of 24 specimens in group III. Soaking a gelatin-sealed Dacron graft in rifampin solution evidently prevents early bacteremic graft infection and secondary foci of infection in this model.Presented at the Annual Meeting of the French Vascular Surgery Society, Nancy, France, May 18–19, 1990.     

Acute aortic occlusion secondary to aspergillus endocarditis in an intravenous drug abuser

A 55-year-old black man, an intravenous substance abuser who had an acute arterial embolus to the distal aorta originating from his mitral valve, was noted on pathologic examination of the clot to have aspergillosis emboli. The infective endocarditis also resulted in emboli to the brain with subsequent death.     

A modified approach to transcrural celiac plexus block

OBJECTIVES: Transcrural celiac block using the needle "walking off" the L1 vertebra technique may cause complications. We used patient-specific computed tomography (CT) images as a roadmap to perform the block under fluoroscopy. We present 1 case to describe the technique. CASE REPORT: The patient is a 63-year-old woman with refractory pain from pancreatic cancer. Her CT showed the celiac trunk at the upper L1 vertebra and 2 cm left to the midline. Needle trajectories were drawn on that film. The line representing the classic "walking off" the bone technique on the left side crossed the aorta. Two lines targeting the base of the celiac trunk were modified, thereby avoiding both the L1 vertebra and the surrounding organs. The following were measured: the distance from the midline to the left needle entry (2.5 cm), the angle for the left needle insertion (90 degrees), the distance (6 cm) and the angle (65 degrees) for the right needle entry, and the distance from the anterior margin of the L1 to the celiac trunk (2.6 cm). During the procedure, 2 needles were placed according to these measurements in a plane superior to the transverse process of the L1. No bony contact or needle redirection was made. Both needles reached 3 cm anterior to the anterior margin of the L1. X-ray contrast crossed the midline and silhouetted the target vasculature. Five milliliters of 0.2% ropivacaine followed by 10 mL of 6% phenol were injected on each side. The patient's pain level improved to 0 to 1/10 on a visual analog scale. CONCLUSIONS: The modified technique avoided painful needle contact on the bone, reduced needle redirections, and decreased the possibility of vital organ puncture.     

Cross-femoral bypass graft for combined iliac arterial venous injury

We report on the treatment of a patient who sustained combined arterial and venous injury to the left iliac vessels as a result of a gunshot wound. Repair was accomplished as a staged procedure following lifesaving ligation of both artery and vein, using extraanatomic, cross-femoral polytetrafluoroethylene (arterial) and saphenous vein (venous) bypass techniques, followed by prophylactic caval filter placement. Principles of management with respect to combined arterial venous vascular injury are discussed, with special reference to controversies surrounding repair of major venous injury.     

Replacement of the abdominal aorta with an aortic homograft in a patient with an aortic dissection

The use of aortic and femoral homografts in early vascular surgery has been abandoned for the more successful and abundant synthetic substitutes. With the recent introduction of cryopreservation, homograft use has again met with improved success. A 40-year-old man who had a DeBakey Type I aortic dissection initially underwent replacement of the aortic root with a pulmonary homograft. Subsequently, in the presence of an intraabdominal infectious process, progressive mesenteric and lower limb ischemia was treated by replacing the abdominal aorta with an aortic homograft. Thirty-six months postoperative the patient has a functioning gastrointestinal tract and no vascular insufficiency of the lower extremities and no evidence of degeneration of the homograft. Further laboratory studies should be undertaken using the newer and improved cyropreserved homograft in the presence of, or potential for, an intraabdominal infectious process. Presented at the 42nd Annual Meeting of the Southwestern Surgical Congress, LaQuinta, California, April 22–25, 1990.     

Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful secondary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3–48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

True aneurysmal disease in the hand and upper extremity

Ten patients with true aneurysmal disease of the hand and forearm vessels were treated at our institution between 1981 and 1990. Pseudoaneurysms resulting from penetrating trauma or mycotic aneurysms were specifically excluded. Eight patients were male, two were female; mean patient age was 38 years (range 26 to 72 years). A history of repetitive occupational or recreational trauma was elicited in five patients. All patients presented with painful masses or neurologic symptoms due to nerve compression. Ischemic changes were evident in five patients due to thrombosis or distal embolization. Arteriography and transcutaneous Doppler ultrasound aided in documentation of flow characteristics and planning for operative intervention. Three patients underwent excision and ligation once collateral flow was demonstrated to be adequate and reconstruction was not felt to be feasible. Seven patients underwent resection with vein graft reconstruction. Immediate postoperative and interval patency rates were 100%. No digital amputations were required even in those patients presenting with severe distal ischemia.     

Mechanisms of ceftriaxone prophylaxis against late bacteremic vascular graft infection caused byStaphylococcus aureus in a dog model

Possible mechanisms of the prophylactic effect of ceftriaxone against late bacteremic vascular graft infection in dogs were investigated. Dogs bearing an expanded polytetrafluoroethylene graft implanted as thoracoabdominal aortic bypass for one month were exposed to transient bacteremia produced by intravenous injection of 2.6±1.8 × 10⁸ colony forming unitsStaphylococcus aureus 209P-R. To assess the effect of the antibiotic on bacteria already adherent onto the grafts, we compared the results from six untreated dogs used as controls and six dogs receiving ceftriaxone (0.5 g, intramuscularly) 90 minutes after the bacteremic challenge. The grafts were removed one week after the bacteremic challenge and cut into 10 to 15 fragments, each submitted to viable bacterial counts. The number of grafts and the number of fragments yielding bacterial growth were the same in the two groups. However, the median density of bacteria was lower (p< 0.01) in the dogs given ceftriaxone, 64 colony forming units/cm (range: 3–8,700), than in the control dogs, 585 colony forming units/cm (range: 12–64,000), suggesting that ceftriaxone had an effect on the postadherence phase of the development of infection. To assess the effect of ceftriaxone on the adherence phase we compared the results from seven untreated dogs and seven dogs receiving ceftriaxone (0.5 g intramuscularly) 90 minutes before the bacteremic challenge. The grafts were removed two hours after the bacteremic challenge. Though all the seven grafts were colonized in each group, the number of fragments yielding bacterial growth was lower (p<0.05) in the dogs given ceftriaxone (59/70) than in the control dogs (90/91). Several mechanisms may be responsible for successful antibiotic prophylaxis of graft infection, involving both early events and postadherence effects. Part of this work was presented at 27th Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract n 513, October 4–7, 1987, New York, New York.     

Surgical treatment of primary aortoduodenal fistula

Primary aortoduodenal fistula is a rare and potentially fatal condition. Awareness of its existence, precise diagnostic evaluation,and early surgical intervention are essential for the survival of the patient. Although early experience indicated that interruption of the fistula, repair of the enteric defect, oversewing of the aorta and extraanatomic bypass was the procedure of choice, in situ aortic replacement with a prosthetic graft seems to be a viable option. This article includes a case report of a primary aortoduodenal fistula and review of the literature.     

Acute pancreatitis following aortic aneurysm repair: Report of three cases

This paper reports three cases of acute pancreatitis that occurred after repair of an abdominal aortic aneurysm. The aneurysms were ruptured in two patients and asymptomatic in one. No patient had biliary disease or history of pancreatitis or alcohol abuse. Two of the patients required operation for drainage and debridement; one died. The etiology and diagnosis are discussed.     

Chylous ascites following abdominal aortic surgery

Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided. Presented at the Ninth Annual Meeting of the Southern California Vascular Surgical Society, Newport Beach, California, September 22, 1990.     

Transfemoral intraluminal graft implantation for abdominal aortic aneurysms

This study reports on animal experimentation and initial clinical trials exploring the feasibility of exclusion of an abdominal aortic aneurysm by placement of an intraluminal, stent-anchored, Dacron prosthetic graft using retrograde cannulation of the common femoral artery under local or regional anesthesia. Experiments showed that when a balloon-expandable stent was sutured to the partially overlapping ends of a tubular, knitted Dacron graft, friction seals were created which fixed the ends of the graft to the vessel wall. This excludes the aneurysm from circulation and allows normal flow through the graft lumen. Initial treatment in five patients with serious co-morbidities is described. Each patient had an individually tailored balloon diameter and diameter and length of their Dacron graft. Standard stents were used and the diameter of the stent-graft was determined by sonography, computed tomography, and arteriography. In three of them a cephalic stent was used without a distal stent. In two other patients both ends of the Dacron tubular stent were attached to stents using a one-third stent overlap. In these latter two, once the proximal neck of the aneurysm was reached, the sheath was withdrawn and the cephalic balloon inflated with a saline/contrast solution. The catheter was gently removed caudally towards the arterial entry site in the groin to keep tension on the graft, and the second balloon inflated so as to deploy the second stent. Four of the five patients had heparin reversal at the end of the procedure. We are encouraged by this early experience, but believe that further developments and more clinical trials are needed before this technique becomes widely used.     

Aortoiliac surgery and kidney transplantation

Between January 1980 and December 1989, we performed 407 renal transplantations. Twelve of these patients (3%) underwent aortoiliac reconstruction before (Group I, two patients), concomitant to (Group II, five patients) or after (Group III, five patients) renal transplantation. The aortoiliac lesions treated included four aneurysms and seven occlusions of the abdominal aorta and one postarteriography dissection of the iliac artery. A prosthetic graft was inserted in nine cases (75%). Endarterectomy was performed in the three other cases (25%). Four of five patients in Group III were operated on without any particular protection for the transplant. There were no postoperative deaths in Groups I and III. In Group II, one patient died of infection secondary to a urinary tract fistula. Early and late vascular morbidity (renal artery stenosis, occlusion of aortoiliac reconstruction, anastomotic false aneurysm) occurred with equal frequency in the three groups. Renal transplantation in patients having already undergone aortoiliac surgery and, conversely, aortoiliac reconstruction in the renal transplant patient, are possible without any particular technical precautions with minimal mortality and kidney morbidity. Simultaneous renal transplantation and aortoiliac reconstruction carries a significant risk of infection and a two-stage procedure should be considered in this situation.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.