Jayaraman Sudha, Richardson Damien, Conrad Miles, Eichler Charles, Schecter William
Department of Surgery, University of California, San Francisco, CA 94110, USA.
Ann Vasc Surg. 2012 Aug;26(6):819-24. doi: 10.1016/j.avsg.2011.11.031. Epub 2012 Apr 24.
Arterial injury and infection due to repetitive injection drug use can result in mycotic pseudoaneurysm predisposing to hemorrhage, distal embolism, limb loss, and death. We hypothesized that debridement of the infected artery, followed by immediate vascular reconstruction, results in successful limb salvage in these patients.
The setting was a county hospital. A retrospective review of all patients diagnosed with lower extremity pseudoaneurysms by the Departments of Surgery and Radiology between 2000 and 2009 was conducted. Outcome measures were patient characteristics, site(s) of lesion, type and results of imaging, type of operation, length of hospital stay, and complications.
Sixteen patients had 17 pseudoaneurysms. One of the patients had two mycotic pseudoaneurysms in the same region separated by a period of 10 months. Culture of the wall of the first pseudoaneurysm was not performed. The second pseudoaneurysm was culture positive. The 15 remaining mycotic pseudoaneurysms were all culture positive. Nine patients were men, and the median age of the patient group was 37 years. Common femoral pseudoaneurysms were the most frequent (76%). Symptoms included swelling (94%), pain (82%), and erythema (75.6%). A rapidly expanding pulsatile expansile mass was present in four of the patients. Computed tomography and percutaneous angiography were done in seven and four of the patients, respectively, and were diagnostic in all cases studied. Resection and reconstruction with autologous vein was the most common procedure (seven), followed by cadaveric grafting (four), synthetic grafting (two), ligation (two), and primary repair (two). Muscle flaps were used in 76.5% of the cases. Complications included anastomotic dehiscence (n = 3), acute thrombosis (n = 1), ischemia (n = 1), abscess (n = 1), and compartment syndrome (n = 1). Three of these patients required a second vascular reconstruction. One patient ultimately required an amputation. No postoperative deaths occurred. Methicillin-resistant Staphylococcus aureus was cultured from 13 of the 16 arterial walls.
Methicillin-resistant Staphylococcus aureus is the predominant organism causing mycotic aneurysms of the common and superficial femoral arteries owing to injection drug use at San Francisco General Hospital. Wide debridement of the infected artery and reconstruction with an in-line reversed saphenous vein or cryopreserved vascular allograft is a safe and effective method of treatment. Long-term follow-up studies are needed to determine the durability of this method of treatment.
反复注射吸毒导致的动脉损伤和感染可引发感染性假性动脉瘤，进而易导致出血、远端栓塞、肢体丧失和死亡。我们推测，对感染动脉进行清创，随后立即进行血管重建，可使这些患者成功挽救肢体。
研究地点为一家县医院。对2000年至2009年间外科和放射科诊断为下肢假性动脉瘤的所有患者进行回顾性研究。观察指标包括患者特征、病变部位、影像学检查类型及结果、手术类型、住院时间和并发症。
16例患者共患有17个假性动脉瘤。其中1例患者在同一区域先后出现2个感染性假性动脉瘤，间隔时间为10个月。未对第一个假性动脉瘤的瘤壁进行培养。第二个假性动脉瘤培养呈阳性。其余15个感染性假性动脉瘤培养均呈阳性。9例患者为男性，患者组的中位年龄为37岁。股总动脉假性动脉瘤最为常见（76%）。症状包括肿胀（94%）、疼痛（82%）和红斑（75.6%）。4例患者出现迅速增大的搏动性肿物。分别有7例和4例患者进行了计算机断层扫描和经皮血管造影，所有检查病例均具有诊断价值。自体静脉切除重建是最常见的手术方式（7例），其次是尸体血管移植（4例）、人工血管移植（2例）、结扎（2例）和一期修复（2例）。76.5%的病例使用了肌瓣。并发症包括吻合口裂开（3例）、急性血栓形成（1例）、缺血（1例）、脓肿（1例）和骨筋膜室综合征（1例）。其中3例患者需要再次进行血管重建。1例患者最终需要截肢。无术后死亡病例。16例动脉壁中有13例培养出耐甲氧西林金黄色葡萄球菌。
在旧金山总医院，耐甲氧西林金黄色葡萄球菌是因注射吸毒导致股总动脉和股浅动脉感染性动脉瘤的主要病原体。对感染动脉进行广泛清创，并用顺行倒置大隐静脉或冷冻保存的同种异体血管进行重建是一种安全有效的治疗方法。需要进行长期随访研究以确定该治疗方法的持久性。
