Ann Thorac Surg 2000;70:968-969
© 2000 The Society of Thoracic Surgeons
Invited commentary
Invited Commentary
Miralem Pasic, MD, PhDa,
Roland Hetzer, MD, PhD
a Deutsches Herzzentrum Berlin, Klinik fur Herz-, Thorax- und Gefässchirurgie, Augustenburger Platz 1, D-13353 Berlin, Germany
e-mail: pasic{at}dhzb.de
Invited commentary
The authors report the management of mycotic aneurysm—a localized infection of the aortic or arterial wall—arising at the site of aortic coarctation. First, it was treated with antibiotics and was then successfully operated on using an in situ prosthetic (Dacron) tube graft for aortic replacement.
This is a rare entity and the management of a patient in this situation is not well defined. Several controversies are still present, such as type of surgical treatment, timing of operative intervention, type of material used for aortic reconstruction, and the duration of postoperative antibiotic therapy. Mycotic aneurysm can be treated by an extraanatomic or in situ vascular reconstruction. The preferable material for the in situ technique is a homograft because it may resist severe infection. Homograft material can be applied fresh or, after cryopreservation, stored in a tissue bank for later use. However, the application of homograft is not the only variable that influences the outcome after in situ treatment of a mycotic aneurysm. Inadequate excision of the infected local tissue during operation can cause failure of reconstruction. If the infected tissue or fluid remain in a closed wound without the possibility for drainage, it may cause failure of the reconstruction despite the use of homograft material. Another useful measure to control infection in an operative field is the local application of antibiotics. Also, some additional supportive measures may be necessary for in situ reconstruction in the aortic position, such as the use of a muscle flap or omentopexy, and omitting the so-called "graft-inclusion-technique" for aortic reconstruction.
In conclusion, in situ treatment of mycotic aneurysm should encompass:
- the use of a homograft (more preferable than a prosthetic material);
- the excision of the infected part of the aortic/arterial wall and debridement of all the infected adjacent tissue; and
- additional supportive measures including local antibiotic application, drain placement for local irrigation with an antiseptic solution and, if indicated, omentopexy.
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Endarteritis and false aneurysm complicating aortic coarctation
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Ann. Thorac. Surg. 2000 70: 966-968.
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