Woon Colin Y L, Sebastian Mathew G, Tay Kiang-Hiong, Tan Seck-Guan
Department of Surgery, Singapore General Hospital, Singapore.
Am J Surg. 2008 Jan;195(1):66-72. doi: 10.1016/j.amjsurg.2007.01.032.
To study the clinical presentation, management and eventual outcome of patients with mycotic abdominal aortic aneurysms managed with aortic exclusion and extra-anatomic reconstruction.
A retrospective chart review of 18 cases treated at a single institution.
Medical records of 18 patients admitted to our institution from October 1997 to July 2006 with a diagnosis of mycotic abdominal aortic aneurysms were reviewed. In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered. Seventeen patients had surgical debridement, aneurysm exclusion, and extra-anatomic reconstruction. The antibiotics were continued in the postoperative period for 6 weeks.
Immunosuppression was present in 72%, with diabetes mellitus present in 56%. Salmonella sp was the causative organism in 72% of cases. Most patients presented late, with a 67% incidence of contained rupture. Seventy-two percent needed early or emergency surgery with less than 1 week of preoperative antibiotics. Disease-specific mortality was 39% (7/18). There was 1 late death during the mean follow-up period of 34 +/- 26 months. One patient with an infrarenal aneurysm arising relatively close (neck, 2 cm) to the renal arteries died on table when proximal ligatures cut through the friable aortic wall, resulting in uncontrollable exsanguination. One third of patients on long-term graft surveillance developed mild to moderate stenosis at the anastomotic site.
Empirical antibiotics must be started early, aiming to achieve 1 week of antibiotics prior to surgery. In the Asian population, 3 characteristics are apparent: (1) most patients are immunocompromised; (2) patients present late in the course of disease; and (3) Salmonella is usually responsible. Extra-anatomic bypass may provide a safe option for revascularization of mycotic aneurysms of the iliac arteries and infrarenal aorta.
研究采用主动脉隔绝术和解剖外血管重建术治疗的真菌性腹主动脉瘤患者的临床表现、治疗方法及最终结局。
对在单一机构接受治疗的18例患者进行回顾性病历分析。
回顾了1997年10月至2006年7月间我院收治的18例诊断为真菌性腹主动脉瘤患者的病历。所有病例均经腹部计算机断层扫描确诊，并给予经验性肠外抗生素治疗。17例患者接受了手术清创、动脉瘤隔绝术和解剖外血管重建术。术后抗生素持续使用6周。
72%的患者存在免疫抑制，56%的患者患有糖尿病。72%的病例中病原菌为沙门氏菌属。大多数患者就诊较晚，67%的患者存在局限性破裂。72%的患者需要在术前使用抗生素不足1周的情况下进行早期或急诊手术。疾病特异性死亡率为39%（7/18）。在平均34±26个月的随访期内有1例晚期死亡。1例肾下动脉瘤距肾动脉较近（瘤颈2 cm）的患者在手术台上死亡，近端结扎线穿透脆弱的主动脉壁，导致无法控制的大出血。三分之一接受长期移植物监测的患者在吻合部位出现轻至中度狭窄。
必须尽早开始经验性抗生素治疗，目标是在手术前使用抗生素1周。在亚洲人群中，有3个特点较为明显：（1）大多数患者存在免疫功能低下；（2）患者在疾病过程中就诊较晚；（3）通常由沙门氏菌引起。解剖外旁路术可能为髂动脉和肾下腹主动脉真菌性动脉瘤的血管重建提供一种安全的选择。
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