Cinà C S, Arena G O, Fiture A O, Clase C M, Doobay B
Division of Vascular Surgery, Department of Surgery, Hamilton Health Sciences Corporation, General Site, ON, Canada.
J Vasc Surg. 2001 Apr;33(4):861-7. doi: 10.1067/mva.2001.111977.
We report three cases of ruptured mycotic thoracoabdominal aortic aneurysms (TAAAS) and a review of the literature. Escherichia coli and Streptococcus pneumoniae (2 patients) were the responsible organisms. Surgical management consisted of wide debridement of necrotic tissue and in situ repair with a Dacron graft. Antibiotics were administered intravenously in the hospital and continued orally after discharge for at least 6 weeks, until clinical and laboratory parameters were normalized. A review of the literature showed that Gram-negative microorganisms are found in 47% of mycotic TAAAs. A trend toward increased mortality for these organisms, compared with Gram-positive microorganisms, was observed (P =.09). Lifelong antimicrobial therapy is controversial. No difference in survival or recurrence rate was found between series advocating lifelong therapy and those suggesting prolonged (6 weeks to 12 months) therapy (median follow-up period, 18 and 19 months, respectively). In situ repair with synthetic material can be successful if prompt confirmation of infection is obtained, all possibly infected tissue is resected, and antibiotic therapy based on sensitivity data is administered for a prolonged period. A short-term survival rate as high as 82% can be expected with this strategy, but data on long-term survival rates are limited. Polytetrafluoroethylene-expanded grafts, homografts, and antibiotic-bonded grafts may offer advantages over Dacron grafts, but data are insufficient to draw conclusions. Careful long-term follow-up is an important element of the treatment of these patients. We suggest antibiotic treatment until biochemical parameters of inflammation (white cell count, erythrocyte sedimentation rate, or C-reactive protein) return to normal and a computerized tomography scan every 3 months for 1 year, then annually.
我们报告了3例感染性胸腹主动脉瘤破裂（TAAAS）病例并对文献进行了综述。大肠埃希菌和肺炎链球菌（2例患者）为致病微生物。手术治疗包括广泛清创坏死组织并用涤纶补片进行原位修复。在医院静脉给予抗生素，出院后继续口服至少6周，直至临床和实验室指标恢复正常。文献综述显示，47%的感染性胸主动脉瘤中发现革兰阴性微生物。与革兰阳性微生物相比，这些微生物的死亡率有升高趋势（P = 0.09）。终生抗菌治疗存在争议。主张终生治疗的系列研究与建议延长治疗（6周至12个月）的系列研究之间，在生存率或复发率方面未发现差异（中位随访期分别为18个月和19个月）。如果能迅速确诊感染、切除所有可能感染的组织并根据药敏数据进行长期抗生素治疗，使用合成材料进行原位修复可能会成功。采用该策略有望获得高达82%的短期生存率，但长期生存率的数据有限。膨体聚四氟乙烯移植物、同种异体移植物和抗生素结合移植物可能比涤纶移植物更具优势，但数据不足以得出结论。对这些患者进行仔细的长期随访是治疗的重要环节。我们建议持续抗生素治疗直至炎症的生化指标（白细胞计数、红细胞沉降率或C反应蛋白）恢复正常，在1年内每3个月进行一次计算机断层扫描，之后每年进行一次。
