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Ann Thorac Surg 1996;61:1146-1152
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Using Aortic Allograft Material to Treat Mycotic Aneurysms of the Thoracic Aorta

Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany

Accepted for publication October 20, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Although mycotic aneurysms are rare in this age of antibiotics, they nevertheless represent life-threatening lesions of the aortic wall because of their high incidence of rupture and significantly high rate of recurrence.

Methods. Between March 1988 and August 1994, cryopreserved allograft material was used to treat 8 patients (mean age, 62.5 years; range, 47 to 80 years) with mycotic aneurysms of the thoracic aorta at our institution. Two patients had emergency operations; the other operations in 6 patients were elective. The aneurysms were located at the previous cannulation site of the aorta (n = 1) or at the donor/recipient aortic anastomosis (n = 1) in the patients who had heart transplantation, in the ascending aorta in 3 patients with aortic valve endocarditis, in the aortic arch in 2, and in the descending aorta in 1. The operative technique consisted of excision of the mycotic aneurysm followed by allograft patch reconstruction in 5 patients, an allograft composite graft replacement of the ascending aorta in 2 patients with endocarditis, and combined aortic allograft root replacement and allograft patch reconstruction of the ascending aorta in 1 patient.

Results. The underlying infections of the aorta were treated successfully in 6 patients. One heart transplant recipient had reoperation because of recurrent mycotic aneurysm after allograft patch reconstruction at the donor/recipient anastomosis. There was one early death involving a patient with Salmonellasp sepsis.

Conclusions. The use of aortic allograft material for repairing mycotic aortic aneurysms is a promising and effective operative concept for managing thoracic aortic infections.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
For editorial comment, see page 1053.

Replacement of the aorta with allograft material was introduced for clinical use in the early years of vascular surgery [1–3]. Although the clinical results were encouraging, several disadvantages were recognized, such as difficulties with procurement and preservation of human allografts or secondary dilation and calcification caused by allograft degeneration, as observed in a large number of patients. Since the early 1960s, aortic replacement with prosthetic material became the treatment of choice for diseases of the aortic wall. Nevertheless, cur-

For editorial comment, see page 1053.

rent operative procedures involving the use of prosthetic material for treating aortic infections, as reviewed by Robinson and Johansen [4], carry substantial early and late mortality rates as a result of recurrent infection. After achieving excellent long-term results with allograft replacement in managing active endocarditis [5], we decided to use allograft material to repair mycotic aortic aneurysms.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between March 1988 and September 1994, 8 patients were evaluated and underwent operative repair of mycotic aortic aneurysms at the German Heart Institute Berlin. Patients with aortic annulus abscess but without mycotic aortic aneurysm were not included in the study. There were 6 men and 2 women, ranging in age from 47 to 80 years (mean age, 62.5 years). Two patients underwent operations under emergency conditions, whereas the remainder were scheduled for elective operations.

Five patients had previously undergone cardiac operations (Table 1): 2 were heart transplant recipients, 1 of whom had experienced mediastinitis 2 weeks after transplantation; and 3 had had prosthetic valve endocarditis. One of them had undergone aortic valve replacement three times because of recurrent prosthetic valve infection. In the last operation, valve replacement was combined with in situ prosthetic graft replacement for a mycotic aneurysm of the ascending aorta. Another patient who had undergone aortic valve replacement, including composite replacement of the ascending aorta, at another institution presented with endocarditis of the aortic valve associated with a mycotic aneurysm of the ascending aorta. One patient had been treated with cortisone and methotrexate for several years for chronic polyarthritis (see Table 1). Diabetes mellitus was found in 2 patients. One patient exhibited no predisposing conditions.

Operations were performed through a median sternotomy in 7 patients. A thoracoabdominal approach was preferred in the case involving mycotic aneurysm of the descending aorta. If the aneurysm was located in the ascending or descending aorta, the operation was performed with cardiopulmonary bypass and moderate hypothermia. Patients with aneurysms in the aortic arch were given deep hypothermia of 15°C with a reduced flow of 0.5 L/min. Cardiopulmonary bypass through femoral cannulation was applied in 4 patients. In the other patients, cardiopulmonary bypass was instituted through cannulation of the ascending aorta and right atrial drainage.

Resection of the aneurysm and reconstruction that maintained continuity of the aorta were possible using an aortic allograft patch (Figs 1–3) in 3 patients (see Table 2). Two patients with aortic valve endocarditis were treated with an allograft as a composite graft (Figs 4–6), 1 additionally with combined aortic valve replacement with allograft and allograft patch reconstruction of the ascending aorta (Figs 7, 8). Aortic arch replacement with allograft material (Fig 9) was performed in the 2 patients whose aneurysms were located in the aortic arch (Fig 10).

View larger version (100K): [in this window] [in a new window]   Fig 1. . Allograft patch reconstruction of a mycotic aortic aneurysm at the previous cannulation site in a heart transplant recipient (patient 1). (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (123K): [in this window] [in a new window]   Fig 4. . Infected aortic valve and ascending aorta composite graft, paravalvular leaks, dehiscence of subaortic curtain, and mitral valve jet lesion in patient 3. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (117K): [in this window] [in a new window]   Fig 7. . Prosthetic valve endocarditis and infected ascending aortic prosthetic graft in patient 2. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (101K): [in this window] [in a new window]   Fig 8. . Allograft aortic root replacement and subtotal ascending aortic allograft patch replacement in patient 2. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (100K): [in this window] [in a new window]   Fig 9. . Partial aortic arch replacement with allograft in patients 6 and 7. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (156K): [in this window] [in a new window]   Fig 10. . Computed tomographic scan of a saccular mycotic aneurysm in the aortic arch in patient 6.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Underlying infection of the aorta was treated successfully in 6 patients. In 1 case in which a heart transplant recipient underwent allograft patch reconstruction involving resection of the mycotic aortic aneurysm at the donor/recipient anastomosis, recurrent aneurysm made it necessary to replace the ascending aorta with an aortic allograft conduit (Fig 11). The patient died of Candida sepsis 8 days after the last intervention. There was one early death involving a 70-year-old woman with Salmonella sp sepsis. Autopsy findings of both patients indicated that the aortic repair was intact, with no evidence of infection.

View larger version (101K): [in this window] [in a new window]   Fig 11. . Allograft ascending aorta replacement in patient 5. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (55K): [in this window] [in a new window]   Fig 12. . Chest roentgenogram in patient 1, 2 years after allograft patch reconstruction, looks normal and exhibits no signs of calcification.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Mycotic aortic aneurysms are rare, yet potentially life-threatening, lesions of the aortic wall. Kaufman and associates [9] reported mortality rates of 80% for such aneurysms (100% if the aneurysm was caused by S aureus and Escherichia coli). In cases involving S aureus infections, we observed a mortality rate of 25%. In recent years, there have been reports of patients being successfully treated by in situ reconstruction of mycotic aneurysms of the aorta using prosthetic material in selected cases [4, 10], particularly in those with minimally virulent infections and negative blood or perigraft cultures [11].

Pasic and co-workers [12] reported six in situ reconstructions of the thoracic aorta performed during a 21-year period at the University Hospital Zurich. Repeat operations were performed in 2 patients, in 1 to repair an acute rupture 1 cm distal to the previous repair of an aneurysm in the ascending aorta. Operative treatment in all of the patients involved in situ placement of the grafts after evacuation of clots and local debridement. No recurrent ruptures were observed at our institution when allograft material was used to treat mycotic aortic aneurysms. There was one early death in a patient with Salmonellasp sepsis who underwent operation for repair of an acute rupture of a mycotic aneurysm of the aortic arch. In a heart transplant recipient with a mycotic aneurysm at the donor/recipient anastomosis, the ascending aorta was ultimately replaced with an aortic allograft as a composite graft.

Kieffer and associates [13] reported the results of in situ fresh allograft replacement of infected infrarenal aortic prosthetic grafts in 43 patients. The mortality rate was 12% and the rate of recurrence was 2.3%. Moreover, there were no early or late amputations in the entire series, an outcome that was not reported for any of the conventional methods.

In this study, 3 cases of mycotic aortic aneurysms resulted from septic embolization from endocarditis. With the introduction of modern antibiotic therapy, the prevalence of endocarditis has decreased and the spectrum of causative organisms for mycotic aneurysm has changed markedly. As reported in various studies, the most common pathogens today are staphylococci, streptococci, and Salmonella sp [14, 15]. The microbiologic findings of this study are similar to those in the medical literature. We found that in 2 patients, mycotic aortic aneurysms developed at the cannulation site from a previous operation, which had been afflicted by mediastinitis. As reported previously, infections of the aortic wall may occur at potentially weakened areas, such as suture lines or cannulation sites, where intimal and endothelial ischemia or insult may have occurred [16].

Although it has been shown that immunosuppressive treatment may increase arterial allograft patency and prevent aneurysmal degeneration [17, 18], this was not considered feasible under the infective conditions of mycotic aneurysms. However, unlike in other studies, all of the allografts in this study were matched for blood type [19].

Although antibiotic therapy may control the symptoms of sepsis associated with mycotic aortic aneurysm, it does not heal the lesion or prevent rupture [9, 20]. The required duration of antibiotic therapy remains a matter of opinion. Most authors advocate 4 to 6 weeks [21]. For cases involving repair of mycotic aneurysms with prosthetic material, Chan and colleagues [21] recommended permanent antibiotic therapy, as late recurrent infections have been reported [22].

It was believed that using any prosthetic material to treat mycotic aortic aneurysms of the thoracic aorta, in which extraanatomic reconstruction was not possible, would present a high risk of recurrent infection. The use of allograft material may reduce the rate of late postoperative infections and improve survival [19]. In this study, only 1 patient exhibited recurrent infection.

However, as shown in patient 1, allograft patch plasty can be performed on well-circumscribed mycotic aneurysms to repair the defect in the aortic wall. Complete debridement of all necrotic tissue and patch closure of the cavity to viable tissue without tension are essential features for preventing reinfection and recurrent aneurysm formation [23]. For cases involving greater inflammatory involvement of the aortic wall, we recommend replacing the affected part of the aorta with allograft material. If it is necessary to use a composite graft because of prosthetic valve infection or aortic annulus abscess, an allograft composite graft should be used. A prosthetic graft may be used as a patch or conduit if no homologous material is available [12].

In conclusion, the use of aortic allograft material to replace mycotic aortic aneurysms is a promising and effective concept, capable of bringing thoracic aortic infections into complete remission.

View larger version (126K): [in this window] [in a new window]   Fig 2. . Allograft patch reconstruction of a mycotic aortic aneurysm at the site of the anastomosis of a heart transplant recipient (patient 5). After resection of the tissue of both rims, a direct anastomosis of the posterior aspect of the aorta was created, and a wedge-shaped allograft patch plasty was performed using allograft material. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (84K): [in this window] [in a new window]   Fig 3. . Allograft patch reconstruction of the descending aorta in patient 8.

View larger version (88K): [in this window] [in a new window]   Fig 5. . Allograft aortic root and ascending aortic replacement, reconstruction of subaortic curtain with allograft mitral leaflet, and closure of jet lesion in patient 3. (LCA = left coronary artery; RCA = right coronary artery.)

View larger version (87K): [in this window] [in a new window]   Fig 6. . Allograft aortic root and ascending aortic replacement in a case of prosthetic valve infection and a mycotic aneurysm at the previous cannulation site (patient 4). (LCA = left coronary artery; RCA = right coronary artery.)

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christoph Knosalla Yuguo Weng Roland Hetzer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Knosalla, C. Articles by Hetzer, R. Search for Related Content PubMed PubMed Citation Articles by Knosalla, C. Articles by Hetzer, R. Related Collections Related Article