Endovascular Treatment of Mycotic Aneurysms of the Thoracic and Abdominal Aorta: The Need for Level I Evidence

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patients presented with painful, rapidly growing aneurysms associated with fever, leukocytosis and positive blood cultures. The traditional principles of surgical treatment for mycotic aneurysms include the debridement of all infected tissue, broad-spectrum antibiotic cover, the use of muscle flaps to cover the infected field, and either extra-anatomic or in situ revascularisation with synthetic grafts or homografts. In a series of 33 patients using extra-anatomic and in situ revascularisation, the operative mortality was 36%. 1 This and other papers suggest that traditional open surgical repair is associated with significant problems in patients with mycotic aneurysms. The use of antibiotic impregnated or antibiotic coated grafts seems to be a logical approach if a graft needs to be placed in an infected tissue bed. Unfortunately, the results of prophylactic antibiotic soaked grafts in three randomised trials of grafts not used for infected aneurysms failed to show any benefit. 2‐5 Rifampicinimpregnated grafts showed a trend towards a beneficial effect, but the difference was not statistically significant in reducing post-operative infection. In addition, the pathophysiology of the infected aorta and the methods of prophylaxis may be more complicated than first thought. For example, graft infection may not be due to implantation of pathogenic bacteria and may have more to do with the milieu of an immunocompromised patient, poor tissues, and inappropriate antibiotic therapy. Changing the surface characteristics of the graft material to repel microbes is one solution that has not yet been taken up by the graft