Cryopreserved aortic homograft for mycotic aneurysm

Abstract

Mycotic aneurysm is a life-threatening pathologic entity with high morbidity and mortality. The optimal surgical management is a subject of controversy. 1Pasic M Carrel T Vogt M von Segesser L Turina M Treatment of mycotic aneurysm of the aorta and its branches: the location determines the operative technique.Eur J Vasc Surg. 1992; 6: 419-423Abstract Full Text PDF PubMed Scopus (42) Google Scholar We report in situ replacement of mycotic aneurysm of the aorta with cryopreserved aortic homografts. A 67-year-old man underwent an elective operation for a mycotic aneurysm of the infrarenal abdominal aorta (Fig 1). The aneurysm was resected and the infrarenal aorta was replaced with a cryopreserved aortic homograft tube (Fig. 2). Fig. 2A cryopreserved homograft has been implanted in the infrarenal position after excision of the entire infrarenal part of the abdominal aorta. Note that the intercostal arteries arising from the grafts had been ligated by clips (arrows).View Large Image Figure ViewerDownload (PPT)Preoperative blood cultures and cultures from the aneurysm both grew Streptococcus pneumoniae. Penicillin G, given intravenously before the operation, was continued after the operation for 4 weeks, followed by cephalosporin given by mouth for another 2 weeks. The second patient was a 59-year-old man with a mycotic aneurysm of the descending thoracic aorta caused by Streptococcus pneumoniae (Fig 3). The diseased part of the descending thoracic aorta was replaced with a cryopreserved homograft (Fig. 4). Fig. 4Intraoperative view with the descending thoracic aorta replaced by a cryopreserved homograft. The homograft has been implanted in situ after extensive debridement of the diseased part of the descending thoracic aorta.View Large Image Figure ViewerDownload (PPT)Preoperative intravenous antibiotic therapy with clindamycin was continued after the operation for another 4 weeks. After resection of the mycotic aneurysm and the adjacent parts of the aorta, both patients received cryopreserved homografts harvested from the descending thoracic aorta of donors during harvesting of the heart for transplantation (Fig 5). The intercostal arteries arising from the grafts were ligated by clips (see Fig. 2), and then the grafts were implanted with end-to-end anastomoses in the usual manner with continuous polypropylene suture. The postoperative courses of both patients were uneventful. The patients received the appropriate antibiotic therapy for 4 to 6 weeks after the operation. The two patients have remained free of complications 12 and 6 months, respectively, after the operation. The standard operation for the treatment of patients with mycotic aneurysm consists of arterial ligation, aneurysm excision, and extraanatomic bypass grafting. 2Taylor Jr, LM Deitz DM McConnell DB Porter JM Treatment of infected abdominal aneurysm by extraanatomic bypass, aneurysm excision, and drainage.Am J Surg. 1988; 155: 655-658Abstract Full Text PDF PubMed Scopus (79) Google Scholar This procedure is associated with late complications and, in certain situations, is difficult or technically impossible to do, necessitating in situ reconstruction. 3Chan FY Crawford SE Coselli JS Safi HJ Williams Jr, TW In situ prosthetic graft replacement for mycotic aneurysm of the aorta.Ann Thorac Surg. 1989; 47: 193-203Abstract Full Text PDF PubMed Scopus (277) Google Scholar, 4Pasic M Carrel T von Segesser L Turina M In situ repair of mycotic aneurysm of the ascending aorta.J THORAC CARDIOVASC SURG. 1993; 105: 321-326PubMed Google Scholar However, in situ prosthetic graft replacement increases the risk of recurrent infection. 3Chan FY Crawford SE Coselli JS Safi HJ Williams Jr, TW In situ prosthetic graft replacement for mycotic aneurysm of the aorta.Ann Thorac Surg. 1989; 47: 193-203Abstract Full Text PDF PubMed Scopus (277) Google Scholar The usefulness of homograft cryopreserved tissue has already been proved in cardiac surgery. 5Kirklin JK Smith D Novick W et al.Long-term function of cryopreserved aortic homografts: a ten-year study.J THORAC CARDIOVASC SURG. 1993; 106: 154-166PubMed Google Scholar When used for infective processes of the aortic valve, homograft tissue reduces the postoperative infection rate and improves survival. 6Doty DB Michielon G Wang N-D Cain AS Millar RC Replacement of the aortic valve with cryopreserved aortic allograft.Ann Thorac Surg. 1993; 56: 228-236Abstract Full Text PDF PubMed Scopus (30) Google Scholar The use of a cryopreserved aortic homograft conduit for treatment of mycotic aortic aneurysm might reduce the rate of late postoperative infections and improve survival of this high-risk group of patients. Therefore, we strongly suggest harvesting of the entire aorta with its branches for further cryopreservation during the harvesting of other organs from a donor. If stored in a tissue bank, the homograft might be used for emergency operations because mycotic aneurysms are usually ruptured when diagnosed.