Six of the Best, Vascular 25

Abstract

Aims: Mycotic aortic aneurysms present a surgical challenge. We reviewed our management of both ruptured and nonruptured, abdominal and thoracoabdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs. Methods: Data regarding presenting symptoms, investigations, operative techniques and outcome were prospectively collected on 15 consecutive patients treated at a single centre from 1991 to 2001 inclusive. Results: There were 11 men and 4 women, with a median age of 70 years (range: 24–79). The median duration of symptoms was 26 days (range: 1–1810). All but one patient were symptomatic. Nine had back pain, five were pyrexial, six had a raised white cell count, six were anaemic, four were septic and six had a contained leak on admission. Blood or tissue cultures isolated Salmonella (n = 3), staphylococci (n = 3), streptococci (n = 1), coliforms (n = 1), Treponema pallidum (n = 1), while in six patients no organisms were identified. Preoperative CT identified four infra-renal, four juxta-renal, three (Crawford thoracoabdominal) type IV, three type III and one type II aortic aneurysms. Thirteen were repaired with in situ prostheses following extensive local debridement and two required axillo-femoral prosthetic grafts. There were four early deaths, two (type IV) relating to blood loss, one secondary to myocardial event (type IV) and one secondary to multiorgan failure (juxta-renal). All surviving patients have been followed up for a median duration of 38 months (range: 1/2–112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection. Conclusions: In the absence of uncontrolled sepsis, in situ repair of mycotic aortic aneurysms using prosthetic grafts achieves durable results with only one late infection.