Benjamin M E, Cohn E J, Purtill W A, Hanna D J, Lilly M P, Flinn W R
Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore 21201, USA.
J Vasc Surg. 1999 Dec;30(6):1004-15. doi: 10.1016/s0741-5214(99)70038-8.
Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals.
In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases.
Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications.
The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.
真菌性假性动脉瘤（MPA）仍是具有挑战性的临床问题。主要手术治疗包括控制出血和对感染的动脉壁进行清创。由于动脉切除后可能会出现严重缺血，血管重建一直是治疗的次要目标。标准的解剖学移植物放置或人工血管旁路移植因感染复发率高而受到影响。非解剖学重建更受青睐，其基本目标有三个：（1）使用自体移植物材料以降低再次感染的风险；（2）避免明显的尺寸不匹配；（3）将移植物放置在解剖学上难以触及的位置，因为药物滥用导致了许多此类病变。本研究回顾了最近一系列应用这些治疗目标的MPA病例。
在两年时间里，股浅静脉和腘静脉近端被用于修复5例股总动脉、1例髂总动脉、1例肱动脉和1例肾下腹主动脉的MPA。大多数患者（7例中的5例）为已知的静脉吸毒者，在注射部位有疼痛性搏动性肿块。2例患者有全身脓毒症，1例为感染性髂总动脉假性动脉瘤，1例为肾下腹主动脉MPA。所有病例均通过双功超声/计算机断层扫描诊断MPA，并通过动脉造影确诊。
5例股部MPA采用逆行小腿深静脉进行闭孔旁路移植。采用深静脉进行髂-髂交叉盆腔旁路移植手术修复髂总动脉MPA。一条深静脉还被用作“马裤式”主动脉-双髂动脉移植物以及用于肱动脉修复。几乎所有病例的培养结果均显示为金黄色葡萄球菌。重建后远端动脉灌注正常。患者术后腿部无明显肿胀。双功超声扫描未发现深静脉取材平面以下有新的静脉血栓形成。无感染并发症。
股浅静脉/腘静脉对于MPA患者的肢体血管重建可能特别有用。这种自体管道为重建提供了良好的尺寸匹配和合适的长度，因为周围的轴向动脉通常会受到影响。未发现与深静脉取材相关的具有临床意义的肢体并发症。在此类病例中进行长期随访具有挑战性，但仍需要进行以准确确定该策略的持久性。
