In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-impregnated Dacron grafts: A preliminary case report

Treatment of mycotic aortic aneurysm by excision and extraanatomic bypass is difficult to apply when the infectious process involves the visceral arteries. On the basis of experimental studies in our laboratory that demonstrated prolonged antistaphylococcal activity of rifampin-bonded, gelatin-impregnated Dacron grafts after implantation in the arterial circulation, this conduit was successfully used for in situ replacement of a native aortic infection in two patients. Both patients had fever, leukocytosis, abdominal or back pain, and a computed tomographic scan that demonstrated contained rupture of a mycotic aneurysm. Preoperative computed tomography guided aspiration and culture of periaortic fluid from one patient grew Staphylococcus aureus. Treatment consisted of prolonged (6 weeks) culture-specific parenteral antibiotic therapy, excision of involved aorta, oxychlorosene irrigation of the aortic bed, and restoration of aortic continuity by in situ prosthetic replacement. A preliminary right axillobifemoral bypass was performed in the patient who had an infection involving the suprarenal and infrarenal aorta. In both patients intraoperative culture of aorta wall recovered S. aureus. Patients were discharged at 20 and 21 days. Clinical follow-up and computed tomographic imaging of the replacement graft beyond 10 months after surgery demonstrated no signs of residual aortic infection. In the absence of gross pus and frank sepsis, the use of an antibiotic-bonded prosthetic graft with antistaphylococcal activity should be considered in patients who have arterial infections caused by S. aureus when excision and ex situ bypass are not feasible. (J Vasc Surg 1996;24:472-6.)     

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.     

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.     

Mycotic aneurysm of the suprarenal abdominal aorta.

We report on the successful treatment of a patient with a mycotic aneurysm of the suprarenal aorta. The aorta was resected and reconstructed using an in-situ polytetrafluoroethylene graft with a side arm branch to the left renal artery. The use of polytetrafluoroethylene graft for aortic reconstruction after suprarenal mycotic aneurysm resection has not been previously reported. The etiology, bacteriology, diagnosis, and principles of management of mycotic aneurysms of the suprarenal aorta are discussed.     

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.     

Cryopreserved Arterial Allografts for In situ Reconstruction of Infected Arterial Vessels

OBJECTIVE: To review our experience of using cryopreserved allografts for in situ reconstruction in the presence of infection involving the aorta, iliac or femoral arteries. DESIGN: Retrospective clinical study. METHODS: From 3/2000 to 8/2003 all patients with mycotic aneurysms or secondary infection following earlier prosthetic replacement were treated with cryopreserved human allografts. Forty-two patients, 39 (93%) with a prosthetic graft infection and 3 (7%) with a mycotic aneurysm of the abdominal aorta were treated. Six (14%) had aorto-enteric fistulas, 5 (12%) had ruptured aneurysms, and 2 also had vertebral destruction. The median follow-up time was 20 months (range 1-42 months). RESULTS: Thirty-day mortality was 14%. Three patients died due to multi-organ failure, two patients died from hypovolaemic shock due to allograft rupture and one from rupture of the native aorta. The overall mortality was 24% (four additional patients). Graft patency was 100% at 30 days and 97% at follow up in the survivors. The mean actuarial survival time was 32 months (95% CI=27-37 months). CONCLUSIONS: Cryopreserved allografts for the in situ reconstruction of infected arteries or grafts have acceptable intermediate results.     

Surgical treatment for primary infected aneurysm of the descending thoracic aorta,abdominal aorta,and iliac arteries

OBJECTIVE AND METHOD: In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. RESULTS: From October 1996 to October 2001, 19 patients with infected aortic aneurysm were treated with surgery, nine with suprarenal infections (four proximal descending thoracic aortic aneurysms, two distal descending thoracic aortic aneurysms, and three suprarenal abdominal aortic aneurysms) and 10 with infrarenal infections (eight infrarenal abdominal aortic aneurysms and two iliac artery aneurysms). All had a positive blood or tissue culture; 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%). Nine of 10 infrarenal infections were caused by Salmonella organisms. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. There was no perioperative intestinal ischemia or perioperative limb loss. Acute renal failure occurred in two patients with suprarenal infection. Late deaths have occurred in three patients with one early graft infection (5%) resulting in the only one in-hospital death at 4 months. Sixteen patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). There have been no late aortic or graft infections. During the same period, there were five unoperated patients, four of whom died of shock during hospitalization. CONCLUSIONS: Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. The incidence of prosthetic graft infection was low, even in patients with infections due to Salmonella species and with in situ graft replacement.     

Use of the superior pedicled rectus abdominis flap to cover infected aortic grafts.

Replacement of aortic aneurysms by a prosthetic graft is a common procedure in vascular surgery. Although success is generally achieved, infection or fistula may occur. Prosthetic graft infection has been reported in between one and six percent in most large series and is one of the most dreaded complications of abdominal aorta surgery. Dissatisfaction with extraanatomic procedures has led to the development of techniques of in situ replacement by allogenic material. However, adequate debridement and coverage of the aortic graft is necessary. To our knowledge, this is the first report of the use of a rectus abdominis muscle flap to cover an aortic allograft when other reconstructive options were impossible.     

Implantation of antibiotic-releasing carriers and in situ reconstruction for treatment of mycotic aneurysm.

Four patients with mycotic aneurysm of the extracranial carotid artery, the innominate artery, the ascending aorta, and the infrarenal aorta were treated with local implantation of antibiotic-releasing carriers after resection of the aneurysm, excision of all infected tissue, and in situ reconstruction by prosthetic graft replacement in two patients and patch plasty in two patients. The patient with a mycotic aneurysm of the ascending aorta was operated on again 1 month after the first operation because of a second mycotic aneurysm located on the aortic arch. No early or late signs of recurrent infection were seen on clinical and laboratory postoperative follow-up done between 9 and 16 months or on duplex scan or computed tomography done at these times. Implantation of antibiotic-releasing carriers after débridement of all infected tissue and in situ reconstruction for treatment of mycotic aneurysm was performed successfully in four patients with this life-threatening condition.     

Patch closure of aortic annulus mycotic aneurysms

Twenty-three patients with bacterial endocarditis and mycotic aneurysms of the aortic annulus were treated between 1978 and 1985. There were 18 men and 5 women ranging from 24 to 72 years old. All patients had congestive heart failure and positive blood cultures as a complication of the endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. The aneurysm complicated late prosthetic valve endocarditis in 7 patients and native valve endocarditis in 16. The most common infecting organisms were streptococci (12 patients) and staphylococci (7 patients). The noncoronary sinus was the most frequent site for aneurysm formation. Following debridement of the abscess cavity, the orifice of the aneurysm was closed with a patch of Dacron in 20 patients and autologous pericardium in 3. A prosthetic valve (18 bioprosthetic and 5 mechanical) was secured to the noninfected portion of the native annulus and to the patch at the level of annulus. There were 3 deaths, 1 perioperative and 2 late, each without evidence of residual infection or aortic insufficiency. There are 20 late survivors (87%). After a mean follow-up of 1 year, all patients are in NYHA Functional Class I. Patch closure of mycotic aneurysms involving the aortic annulus permits aggressive debridement of the abscess cavity and affords closure of the orifice without tension. The prosthetic valve can be seated at the level of the native annulus, thus avoiding complicated reconstructive procedures of the aortic root and coronary arteries. This technique is an effective alternative in selected cases of mycotic aneurysms involving the aortic annulus.     

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.     

Abdominal aortic aneurysm infected with Campylobacter fetus subspecies fetus

We report a survivor of Campylobacter fetus septicemia from an infected abdominal aortic aneurysm who was successfully treated with an anatomic graft reconstruction and antibiotics. According to a survey of the English-language medical literature this was the fourth such patient successfully treated. C. fetus sepsis associated with an abdominal aortic aneurysm was first reported in 1971. The first patient to survive reconstruction of an aortic tube graft aneurysm infected with C. fetus was reported in 1983. Because the natural history of an aneurysm infected by C. fetus appears to be rapid progression to rupture, patients should be operated on promptly. All patients reported in the literature who were operated on before rupture survived. Survival was independent of the type of reconstruction. When the aneurysm ruptured all patients died. Whereas extraanatomic bypass is generally considered the procedure of choice for an infected abdominal aneurysm, the aneurysms of our patient and three other patients cited in the literature were reconstructed with anatomically placed prosthetic grafts. In the absence of other contraindications such as a grossly evident purulent infection, an abdominal aortic aneurysm infected by C. fetus may represent a subset of infected aneurysms that can be treated successfully with an anatomically placed prosthetic graft and antibiotics.     

Aortic transection and diverting bypass as treatment of repetitive recurrent abdominal aortic false aneurysm rupture in a patient with Behcet's disease

Abdominal aortic false aneurysms in patients with Behcet's disease have been reported frequently and repaired successfully by various procedures; however, anastomotic false aneurysms have often been reported to occur after the operation. In this article, we report a case of four-time repetitive, recurrent suprarenal abdominal aortic false aneurysm ruptures that lasted for 7 years. The location of this aneurysm was not easy to repair not only by open surgical procedures but by endovascular stent because the aortic defect was too close to the visceral arterial branches. The last operation consisted of primary repair of aortic defect, transection of abdominal aorta at the level of supraceliac aorta with end closure, and a thoracic aorta to abdominal aorta bypass with Dacron graft. An 8-year follow-up revealed no more abdominal aortic aneurysm recurrence.     

Extra-anatomic revascularization and aortic exclusion for mycotic aneurysms of the infrarenal aorta and iliac arteries in an Asian population

OBJECTIVES: To study the clinical presentation, management and eventual outcome of patients with mycotic abdominal aortic aneurysms managed with aortic exclusion and extra-anatomic reconstruction. DESIGN: A retrospective chart review of 18 cases treated at a single institution. METHODS: Medical records of 18 patients admitted to our institution from October 1997 to July 2006 with a diagnosis of mycotic abdominal aortic aneurysms were reviewed. In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered. Seventeen patients had surgical debridement, aneurysm exclusion, and extra-anatomic reconstruction. The antibiotics were continued in the postoperative period for 6 weeks. RESULTS: Immunosuppression was present in 72%, with diabetes mellitus present in 56%. Salmonella sp was the causative organism in 72% of cases. Most patients presented late, with a 67% incidence of contained rupture. Seventy-two percent needed early or emergency surgery with less than 1 week of preoperative antibiotics. Disease-specific mortality was 39% (7/18). There was 1 late death during the mean follow-up period of 34 +/- 26 months. One patient with an infrarenal aneurysm arising relatively close (neck, 2 cm) to the renal arteries died on table when proximal ligatures cut through the friable aortic wall, resulting in uncontrollable exsanguination. One third of patients on long-term graft surveillance developed mild to moderate stenosis at the anastomotic site. CONCLUSIONS: Empirical antibiotics must be started early, aiming to achieve 1 week of antibiotics prior to surgery. In the Asian population, 3 characteristics are apparent: (1) most patients are immunocompromised; (2) patients present late in the course of disease; and (3) Salmonella is usually responsible. Extra-anatomic bypass may provide a safe option for revascularization of mycotic aneurysms of the iliac arteries and infrarenal aorta.     

Mycotic aneurysms--A retrospective analysis]

12 patients (10 males and 2 females, average age 53 years) were operated upon in our hospital between 1994 and 1999 for mycotic aneurysms. The aneurysms were located in 7 patients in the aorto-iliac segment, 5 patients were treated for peripheral or visceral aneurysms. Two of these patients suffered from multiple aneurysms. When peripheral arteries were affected, a pulsatile tumour was felt. Most of these tumours developed in a relatively short period of time and sometimes a perivascular inflammation occurred. This was not the case when central arteries were attacked. A septic process or an infection, for example salmonella-enteritis, often preceded shortly the development of a mycotic aneurysm. In the case of an aneurysm of the aorto-iliac section we consider an in situ reconstruction with alloplastic material in combination with a perivascular debridement, lavage and omentum majus plastic as the treatment of choice. In peripheral arteries reconstruction should be performed with autologous vessels. Depending on the local findings, a perivascular debridement should also be performed in these cases. The reconstruction always should be combined with a calculated antibiotic therapy. Two of our patients died perioperatively. During follow up, 8 patients showed patent reconstructions and no signs of infection. The urgency of surgery depends on the level of inflammation and the existence of any secondary complications.     

Source of elastin-degrading enzymes in mycotic aortic aneurysms: bacteria or host inflammatory response?

Elastolytic matrix metalloproteinases play a central role in the development of chronic atherosclerotic aortic aneurysms, but mycotic aortic aneurysms are a distinct and unusual form of aneurysm disease caused by bacterial infection. Mycotic aortic aneurysms follow a more rapid and unpredictable course than chronic aneurysm disease and they exhibit a predilection for the suprarenal aorta, further implying unique pathophysiologic mechanisms. The purpose of this study was to examine the nature and source of elastin-degrading enzymes in mycotic aortic aneurysm. Bacterial isolates and aortic tissues were obtained from four consecutive patients undergoing surgical repair of suprarenal mycotic aortic aneurysm. Using an in vitro 3H-labeled elastin degradation assay, elastin-degrading enzyme activity was only observed in the bacteria-conditioned medium from an isolate of Pseudomonas aeruginosa. Elastin-degrading enzyme activity in the aortic tissue homogenate of this patient was abolished by the serine protease inhibitor, phenylmethylsulfonyl fluoride, but it was not suppressed by the metalloproteinase inhibitor, ethylenediamine tetraacetic acid (EDTA). In contrast, elastin-degrading enzyme activity in the bacterial-conditioned medium was decreased by about half by both phenylmethylsulfonyl fluoride and EDTA. Elastin substrate zymography revealed two phenylmethylsulfonyl fluoride-inhibitable elastin-degrading enzyme activities in the aortic tissue homogenate that corresponded to human neutrophil elastase (approximately 30 kDa) and its stable complex with alpha 1-proteinase inhibitor (approximately 80 kDa), but no activity attributable to Pseudomonas elastase, a 33-kDa metal-dependent enzyme. Human neutrophil elastase was readily detected throughout mycotic aortic aneurysm tissues by immunohistochemistry, but elastolytic metalloproteinases were only occasionally observed. The results of this study suggest that the elastin-degrading enzyme produced in mycotic aortic aneurysm are largely serine proteases of host neutrophil origin, rather than elastases produced by the infecting microorganisms or the macrophage-derived metalloproteinases typically observed in atherosclerotic aneurysm disease. Further studies will be needed to extend these findings to a larger number of patients with mycotic aortic aneurysm and those caused by additional microorganisms.     

Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection

BACKGROUND: Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this. METHODS: Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients. RESULTS: Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4-33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance. CONCLUSION: Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.     

Novel visceral reconstruction for paravisceral aortic aneurysm complicated with aortoiliac occlusion

Visceral ischemia is a serious factor in the postoperative morbidity and mortality of suprarenal aortic reconstruction. We report a case of a patient who underwent surgical repair for a paravisceral aortic aneurysm complicated with aortoiliac occlusion, using a novel visceral reconstruction. Prior to proximal anastomosis of the aorta, we reconstructed visceral arteries by bypass grafting to the superior mesenteric artery and right renal artery (RA), using a straight 12-mm prosthetic graft originating from the intact descending aorta. During the visceral reconstruction, selective cold crystalloid perfusion of the RA was performed. We then underwent the proximal anastomosis of the aorta just below the celiac trunk using a Y-shaped prosthetic graft 18×10?mm in diameter, in keeping the adequate visceral perfusion. Finally, a femoro-femoral bypass was performed with an 8-mm Gore-Tex Vascular Graft, and the left limb of the Y-shaped graft was sewn onto the side of this prosthetic graft. Postoperative computed tomography (CT) identified the successful repair of the aneurysm without any complications. Our novel visceral reconstruction could allow the surgeon to provide a physiological perfusion of visceral organs and prevent the potential visceral ischemia, during suprarenal aortic reconstruction.     

Rupture of an extended mycotic aneurysm of the descending thoracic aorta in a multiple myeloma patient undergoing anti-myeloma therapy

Infectious complications in patients with multiple myeloma remain the main cause of mortality because of disease-related immunodeficiency. A mycotic aortic aneurysm caused by Burkhoderia cepacia, which has been recognized as nosocomial pathogen in immunocompromised populations, is very rare and only few cases have been reported in the literature. We describe an unusual case of a ruptured mycotic aneurysm of the descending thoracic aorta with a DeBakey IIIb aortic dissection caused by Burkhoderia cepacia in a patient with active multiple myeloma during chemotherapy with anti-myeloma agents. Successful treatment of this mycotic aneurysm included appropriate antibiotic therapy and replacement of the aortic arch and the descending aorta for the extensive debridement of all infected aortas. This was followed by the wrapping of a prosthetic graft with a well-vascularized tissue flap of the greater omentum and of the latissimus dorsi muscle.     

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.