RESUMEN
OBJECTIVE: Our purpose was to evaluate our results with CPAs in patients with infected grafts or primary arterial infection with emphasis on long-term durability of these grafts. METHODS: To evaluate the long-term durability of CPAs, clinical outcomes were analyzed following their use for either graft or primary arterial infections at a single institution over a 9-y period (2000-2009). The 30-d mortality rate, 90-d mortality rate, and the cause of early mortality were determined in each case. Among those surviving 90 d, the grafts were evaluated for subsequent failure. RESULTS: From 2000 through 2009, 51 patients with either infected prosthetic grafts (35) or primary arterial infections (15) received CPAs. One patient had infection of a previously placed thoracic allograft. Forty-three graft infections involved either the thoracic or abdominal aorta. Eleven patients presented with fulminant sepsis with systemic inflammatory response syndrome (SIRS), seven of whom died postoperatively. Eight patients presented with aorto-enteric, esophageal, or bronchial fistulae with infected prosthetic grafts. The 30-d mortality rate was 25.5% (11 deaths) seven of which occurred in patients with SIRS. The 90-d mortality rate was 41.4%. There were 10 graft failures, seven occurring in patients with aorto-enteric or bronchial fistulae all of whom had recurrent hemorrhage. The other three graft failures were due to anastomotic hemorrhage in the early postoperative period. Among those surviving 90 d, the mean follow-up was 46.4 mo (range 1-112 mo). No aneurysmal degeneration of the CPAs was noted. Only one subsequent allograft graft failure was noted among those surviving more than 90 d. CONCLUSIONS: CPAs are a suitable option in dealing with cardiovascular infections. Patients with enteric or bronchial fistulae are a difficult group to treat perhaps because of ongoing contamination of the allograft. The operative mortalities are largely determined by patient comorbidities (SIRS). Subsequent degeneration or infection of the CPAs is rare.
Asunto(s)
Criopreservación , Rechazo de Injerto/microbiología , Rechazo de Injerto/cirugía , Enfermedades Vasculares/microbiología , Enfermedades Vasculares/cirugía , Injerto Vascular/métodos , Adulto , Anciano , Anciano de 80 o más Años , Aorta Abdominal/trasplante , Aorta Torácica/trasplante , Arterias Carótidas/trasplante , Femenino , Arteria Femoral/trasplante , Fístula/microbiología , Fístula/mortalidad , Fístula/cirugía , Rechazo de Injerto/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Sepsis/microbiología , Sepsis/mortalidad , Sepsis/cirugía , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Enfermedades Vasculares/mortalidad , Injerto Vascular/efectos adversosRESUMEN
One of the most feared complications following vascular reconstruction is infection due to the attendant risks of limb loss, sepsis, or death. The reported incidence of infection following infrainguinal prosthetic graft infection is 2.5% with associated mortality rates and amputation rates of 18% and 41%, respectively. There are several options in treating infected prosthetic infrainguinal bypass grafts. Some authors have advocated complete removal of the infected graft with concomitant in situ revascularization using autogenous tissue or extra-anatomic bypass using either autogenous or prosthetic material, depending upon the clinical circumstances. Other authors have advocated attempting graft preservation to decrease the risk of amputation. Infected, thrombosed grafts are generally treated with graft excision alone with care taken to preserve collateral flow. The treatment options may also be influenced by the type of infection, as infections caused by gram-negative bacteria are thought to be more virulent than those associated with gram-positive bacteria. We recently treated a patient with an 18-month history of an exposed prosthetic graft in the groin, which was infected by Proteus mirabilis. Despite the extended period of graft exposure and despite gram-negative bacteria being the causative organism, the patient reported only intermittent drainage of pus from the groin. The management of this unusual infection forms the basis of this report.
Asunto(s)
Implantación de Prótesis Vascular/efectos adversos , Prótesis Vascular/efectos adversos , Arteria Femoral/cirugía , Enfermedades Vasculares Periféricas/cirugía , Arteria Poplítea/cirugía , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Antibacterianos/uso terapéutico , Implantación de Prótesis Vascular/instrumentación , Enfermedad Crónica , Remoción de Dispositivos , Femenino , Arteria Femoral/trasplante , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/microbiología , Proteus mirabilis/aislamiento & purificación , Reoperación , Colgajos Quirúrgicos , Tomografía Computarizada por Rayos X , Trasplante Homólogo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Patients who use the palms of their hands as a hammer may cause irreversible damage to the radial or ulnar arteries. Damage to the intima may lead to arterial thrombosis, whereas damage to the media may cause aneurysm formation with embolization to the digital arteries, causing symptoms of ischemia. These patients may have symptoms of Raynaud syndrome, or they may have ischemic ulcerations of their fingers. Hypothenar hammer syndrome with involvement of the ulnar artery is much more frequently encountered than thenar hammer syndrome, which is caused by damage to the radial artery. We report a patient with symptomatic occlusion of both the radial and ulnar arteries secondary to repetitive trauma to the palm of his hand. In our review of the literature, we found two reports involving a total of four patients with similar findings. Both conservative and surgical treatments have been used successfully. Avoidance of the precipitating activities is important in long-term management of these patients.
Asunto(s)
Aneurisma/etiología , Arteriopatías Oclusivas/etiología , Trastornos de Traumas Acumulados/complicaciones , Traumatismos de la Mano/complicaciones , Enfermedades Profesionales/complicaciones , Arteria Radial/lesiones , Arteria Cubital/lesiones , Adulto , Aneurisma/patología , Aneurisma/cirugía , Arteriopatías Oclusivas/patología , Arteriopatías Oclusivas/cirugía , Trastornos de Traumas Acumulados/patología , Trastornos de Traumas Acumulados/cirugía , Traumatismos de la Mano/patología , Traumatismos de la Mano/cirugía , Humanos , Masculino , Enfermedades Profesionales/patología , Enfermedades Profesionales/cirugía , Arteria Radial/patología , Arteria Radial/cirugía , Vena Safena/trasplante , Síndrome , Resultado del Tratamiento , Arteria Cubital/patología , Arteria Cubital/cirugía , Ultrasonografía Doppler en ColorRESUMEN
Infected aneurysms are rare and may present with rupture or sepsis. Surgical treatment is often required to prevent catastrophic sequelae. Bacterial endocarditis is one of the classic causes of infected aneurysm. We present a case of a 6.1-cm infected splenic artery aneurysm secondary to endocarditis. Surgical treatment consisted of aortic and mitral valve replacements, splenic artery aneurysm resection, and splenectomy. We reviewed five other reported infected splenic artery aneurysms in which documented ruptured had occurred in three patients. Because the rate of rupture in these patients appears to be quite high, infected splenic artery aneurysms require prompt treatment.
Asunto(s)
Absceso/etiología , Aneurisma Infectado/etiología , Endocarditis Bacteriana/complicaciones , Arteria Esplénica , Enfermedades del Bazo/etiología , Infecciones Estreptocócicas/complicaciones , Estreptococos Viridans , Absceso/microbiología , Aneurisma Infectado/microbiología , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Bazo/microbiologíaRESUMEN
A case of a symptomatic 5.1-cm left subclavian venous aneurysm, which was treated with surgical excision, is presented. Most venous aneurysms in the head and neck region involve the internal or external jugular veins and are asymptomatic. Aneurysms involving the subclavian or axillary veins are rare. The natural history of these aneurysms is benign with no reported instances of rupture or thromboembolic events. Operative treatment is most often undertaken for cosmetic reasons or for the development of symptoms.
Asunto(s)
Aneurisma/cirugía , Vena Subclavia , Anciano , Aneurisma/diagnóstico por imagen , Femenino , Humanos , Vena Subclavia/diagnóstico por imagen , Vena Subclavia/cirugía , Tomografía Computarizada por Rayos X , Maniobra de Valsalva , Procedimientos Quirúrgicos VascularesRESUMEN
The natural history of infected aneurysms or arterial infections is characterized by rapid expansion leading to rupture, pseudoaneurysm formation, and sepsis. Treatment options include in situ grafting either with prosthetic or autogenous grafts or with cryopreserved allografts (CPAs), resection of the aneurysm with remote bypass grafting, and ligation. The purpose of this study was to review our recent experience with these infections and to present long-term follow-up with in situ CPAs. From January 2000 through June 2005, we treated nine patients with infected aneurysms and one patient with an infection without aneurysm formation. The infection involved the infrarenal abdominal aorta in six patients and the femoral artery in three patients. One patient had an infected splenic artery aneurysm. Aortic rupture occurred in five of the six patients with infected aortas. Two of the three patients with infected femoral aneurysms presented with recurrent hemorrhage. Of the six patients with aortic infections, five were treated with in situ CPAs. One patient was treated with aortic resection and axillofemoral grafting. Two patients with femoral aneurysms were treated with in situ CPAs, and the third patient underwent aneurysm resection and prosthetic grafting through the obturator foramen. The patient with the splenic aneurysm underwent combined valve replacement, aneurysm resection, and splenectomy. Three of the six patients with aortic infections died postoperatively, all of whom were septic at presentation. The cause of death in these three patients was multiple organ failure in two and overwhelming sepsis in one. The three survivors are alive and well with up to 5-year follow-up. The three patients with infected femoral aneurysms are alive and well with follow-up extending to 44 months. The patient with the splenic aneurysm is doing well. No recurrent infections have been noted among the survivors. The CPAs have remained structurally intact in all. The mortality rate among patients with abdominal aortic infections remains high and is likely related to their preoperative septic state. In situ grafting with CPAs appears to be a reasonable treatment option for arterial infections. CPAs appear to maintain their structural integrity and to be resistant to recurrent infection.
Asunto(s)
Aneurisma Infectado/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Arteria Femoral/cirugía , Arteria Esplénica/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Anciano de 80 o más Años , Aneurisma Infectado/diagnóstico por imagen , Aneurisma Infectado/microbiología , Aneurisma Infectado/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/microbiología , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/microbiología , Rotura de la Aorta/mortalidad , Aortografía , Vasos Sanguíneos/trasplante , Criopreservación , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/microbiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Arteria Esplénica/diagnóstico por imagen , Arteria Esplénica/microbiología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: The carotid artery is frequently patched after carotid endarterectomy (CEA) to minimize the risks of early postoperative thrombosis and late recurrent stenosis. The small intestinal submucosa (SIS) patch is a biologic vascular patch derived from porcine small intestine. It is composed primarily of cell-free collagen and other extracellular matrix constituents that act as a scaffold for host cell deposition. METHODS: In May 2001, we began an investigational trial of SIS patches in 76 patients undergoing patch angioplasty of the carotid artery after CEA. RESULTS: No adverse events related to the patches were observed in the first 69 patients implanted with an SIS patch. However, in late 2002, seven patients were found to have asymptomatic pseudoaneurysms (PSA) by duplex imaging < or =10 weeks after their CEAs. The trial was immediately suspended. The PSAs were treated by surgical resection with vein grafting in two patients and placement of covered endoluminal stents in four patients. One patient is being followed as the PSA is small and has remained stable. Histopathologic examination of the SIS patch explanted from one of the surgically treated patients demonstrated the presence of actin-positive myofibroblasts or smooth muscle cells. Extensive mechanical testing of the SIS material from the two material lots associated with PSAs demonstrated thinner and more variable physical characteristics compared with control device lots. CONCLUSIONS: Biologic patches that undergo active remodeling in the carotid artery require greater thickness than was anticipated to decrease wall stress and suture hole elongation. Patches exceeding this minimum thickness will be required to ensure the safety of new SIS patch designs for vascular operations.
Asunto(s)
Aneurisma Falso/etiología , Angioplastia/efectos adversos , Bioprótesis/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Arterias Carótidas , Endarterectomía Carotidea , Mucosa Intestinal/trasplante , Complicaciones Posoperatorias/etiología , Aneurisma Falso/diagnóstico , Angiografía , Angioplastia/métodos , Biopsia , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/patología , Estenosis Carotídea/cirugía , Estudios de Seguimiento , Humanos , Intestino Delgado , Complicaciones Posoperatorias/diagnóstico , Estudios Retrospectivos , Prevención Secundaria , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
This report describes our results with covered endoluminal stents in the management of 4 patients with carotid artery pseudoaneurysms (PSAs) following carotid endarterectomy (CEA). Two patients had symptomatic embolization of thrombus from the PSA's into branches of the middle cerebral arteries (MCA) during deployment of the stents. Endoluminal stents were deployed uneventfully in the other two. At 12 month follow-up, one patient had an occlusion of the stent. While endoluminal therapy of carotid PSAs in an effective method to exclude PSAs, embolization of thrombus is a potential hazard. The long-term patency of covered stents in the carotid artery is unknown.