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Zhang M, Zhang H, Tang B, Fu J, Yan H, Luo H. Outcomes of Covered Stents With Vacuum Sealing Drainage For Treatment of Infected Femoral Pseudoaneurysms in Intravenous Drug Addicts. Ann Vasc Surg 2021; 81:300-307. [PMID: 34780965 DOI: 10.1016/j.avsg.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE For treatment of infected femoral artery pseudoaneurysms (IFAPs) with the covered stent, debridement technique is important but frequently ignored. Our study aims to review our experience and outcomes of patients undergoing covered stents placement and debridement with vacuum sealing drainage (VSD). METHODS This study retrospectively analyzed 41 intravenous drug addicts with IFAP who received covered stent implantation and debridement with VSD from January 2015 to December 2020. The diagnosis was based on the previous history of local injection and the presence of pulsatile mass at the injection site. All cases were confirmed by CT angiography (CTA), ultrasound, or digital subtraction angiography (DSA). Technical success, time of wound care, and clinical outcomes were evaluated. RESULTS Technical success was achieved in all patients. The interval from diagnosis to treatment was 26 ± 11 hours. The time of continuous drainage with VSD was 18.79 ± 6.56 days. 38 patients (92.68%) with fresh granulation tissue were sutured and discharged from the hospital. Stents in 31(91.18%) of 34 cases were patent during follow-ups. Three patients had stent occlusion caused by thrombosis, and two of them were complicated with stent infection. The two infectious stents were removed and the femoral arteries were ligated. One of them received open-surgical reconstruction with the great saphenous because of claudication. Two patients were admitted to the hospital for rebleeding caused by drug abuse relapse. CONCLUSIONS Covered stents placement is convenient and rapid to control massive hemorrhage in IFAPs of intravenous drug abuse. Early debridement of infected tissue with continued VSD may shorten the time of wound care and make the incidence of stent infection relatively low. Meanwhile, the patency in a short time follow-up is acceptable. These results indicate that covered stents implantation with VSD may be a safe, effective, and feasible measure for the treatment of IFAPs.
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Affiliation(s)
- Mingyi Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Fu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyan Yan
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Wygant CM, Cohle SD. Fatal rupture of pseudoaneurysm following angioplasty. Cardiovasc Pathol 2020; 50:107268. [PMID: 32858206 DOI: 10.1016/j.carpath.2020.107268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 01/16/2023] Open
Abstract
We report the sudden unexpected death from exsanguination of a 60-year-old white female who underwent balloon angioplasty of her right popliteal artery via a right common femoral arteriotomy 3 weeks before death. This resulted in a mycotic pseudoaneurysm of the right femoral artery that ruptured, causing fatal exsanguination. A pseudoaneurysm is an arterial wall defect in which part of the wall consists of fibrin and fibrous tissue, lacking components of the normal arterial wall, that is intima, media, and adventitia. Pseudoaneurysms result from traumatic arterial injury, infection, rupture of a true aneurysm, or surgery. A literature search revealed no reports with the patient dying unexpectedly outside the hospital. Immediate surgical intervention and antibiotic therapy are preferred treatments.
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Affiliation(s)
- Cassandra Maria Wygant
- Department of Pathology and Laboratory Medicine, Spectrum Health, Blodgett Campus, Grand Rapids, MI 49506, USA
| | - Stephen David Cohle
- Department of Pathology and Laboratory Medicine, Spectrum Health, Blodgett Campus, Grand Rapids, MI 49506, USA.
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Samarakoon LB, Ho DCY, Tan YK, Kum SWC, Lim DM. Infected femoral pseudoaneurysms in intravenous drug abusers: a decade of experience from a Singapore tertiary centre. Singapore Med J 2020; 62:135-138. [PMID: 32147737 DOI: 10.11622/smedj.2020011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION A pseudoaneurysm (or false aneurysm) is a haematoma that communicates with an artery through a disruption in the arterial wall. The femoral artery is the most common injection site among drug users, and infected femoral pseudoaneurysms are the most common vascular complications. METHODS A retrospective review of medical records of intravenous drug abusers (IVDAs) who presented with infected femoral pseudoaneurysms from January 2006 to December 2016 was carried out. Patients who had pseudoaneurysms due to other aetiologies or trauma were excluded. RESULTS A total of 27 patients with infected femoral pseudoaneurysms were identified. The majority were male (92.6%) and of Malay ethnicity (55.6%). Median age was 50 (range 31-62) years. Commonly abused drugs were buprenorphine (or Subutex; 59.3%) and midazolam (or Dormicum; 51.9%). Groin pain and swelling (100.0%), fever (66.7%) and presence of a pulsatile mass (51.9%) were the most common presenting symptoms. Diagnosis was confirmed via computed tomography angiography in all patients. 25 patients underwent upfront arterial ligation with debridement, among whom three patients required concurrent surgical revascularisation. Only two patients underwent ultrasonography-guided thrombin injection - one eventually required surgery and the other was lost to follow-up. Postoperative complications included wound infection (42.3%), bleeding (11.5%) and necrotising fasciitis eventually resulting in limb loss (3.8%). There were no associated mortalities. CONCLUSION Infected pseudoaneurysms in IVDAs pose a unique challenge to vascular surgeons. We found that simple ligation and debridement was a safe and effective option for such patients.
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Affiliation(s)
| | | | - Yih Kai Tan
- Department of General Surgery, Changi General Hospital, Singapore
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Bakr AAE, Harding J, Mahmood A, Srinivasamurthy D. Stent graft exclusion of a mycotic profunda femoris artery pseudoaneurysm with 2-year follow-up. BMJ Case Rep 2019; 12:12/6/e229087. [PMID: 31160301 DOI: 10.1136/bcr-2018-229087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Mycotic pseudoaneurysms develop at sites of intimal disruption where bacterial invasion occurs. The conventional treatment involves arterial ligation, excision and debridement, followed by a bypass procedure at a later point. Recently, covered stent grafts have been used to treat mycotic arterial aneurysms either as temporary or definitive procedures. However, this is associated with a risk of stent graft infection, recurrence and rupture. There is a paucity of long-term results on the durability of such endovascular stent graft procedures in mycotic arterial pseudoaneurysms. We describe a successful endovascular covered stent repair of a mycotic profunda femoris artery pseudoaneurysm and follow-up of this repair at 2 years.
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Affiliation(s)
| | - James Harding
- Vascular Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Asif Mahmood
- Vascular Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Abstract
RATIONALE We present a rare case of multiple tuberculous mycotic aneurysm. Multiple aneurysms caused by tuberculosis (TB) are difficult to treat. Here, we discuss a treatment modality using a microcore stent graft. PATIENT CONCERNS A 73-year-old man with pain in the back and on the right side of the chest associated with dry cough, presented with an inability to walk since 1-month. DIAGNOSES A diagnosis of multiple aneurysms caused by TB was made, based on computed tomography (CT) scan and positive T-spot and Xpert tests. INTERVENTIONS We administered the empirical anti-TB regimen (pyrazinamide, isoniazid, rifampicin, and ethambutol) and performed endovascular repair using microcore stent graft. OUTCOMES The post-operative hemodynamic analysis indicated that the patient's aneurysms no longer had a risk of rupture, and blood flow in the major branches of the aorta had been maintained. However, the patient could not survive due to a pulmonary infection acquired during recuperation at a local hospital. LESSONS For multiple tuberculous mycotic aneurysms, anti-TB therapy is inadequate and the microcore stent graft is a feasible option that can improve the hemodynamics in the aneurysms.
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Affiliation(s)
- Shenyu Zhao
- Department of Vascular Surgery, First Affiliated Hospital of Chongqing Medical University
| | - Zhe Wang
- Department of Vascular Surgery, First Affiliated Hospital of Chongqing Medical University
| | - Yong Li
- Department of Respiratory Medicine, People's Hospital of Tongliang District
| | - Hong Wang
- Academy of Life Sciences of Chongqing Medical University
| | - Yu Zhao
- Department of Vascular Surgery, First Affiliated Hospital of Chongqing Medical University
- Yuanjiagang, Yuzhong District, Chongqing, China
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Rossetti P, Perini P, Ucci A, Carolla G, Freyrie A, Quintavalla R. Surgical Treatment of a High-Flow Femoro-Femoral Arteriovenous Fistula in an Intravenous Drug Abuser. Ann Vasc Surg 2018; 51:327.e15-327.e19. [PMID: 29772331 DOI: 10.1016/j.avsg.2018.02.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/18/2018] [Accepted: 02/23/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND We report the surgical treatment of a high-flow femoro-femoral arteriovenous fistula (AVF), a rare complication of intravenous drug abuse. METHODS A 36-year-old woman with history of intravenous heroin and cocaine abuse presented with right lower limb edema, inguinal bruit, and heart failure. Duplex ultrasound examination (DUS) and computed tomography angiography showed a large, high-flow AVF involving the common femoral vein and the superficial femoral artery, which is associated with thrombosis of the great saphenous vein and an important inflammation in the right groin, without active bleeding. Under general anesthesia, the patient underwent open surgical repair of the AVF through a right-groin cutdown. The 3-cm-long AVF was repaired with the interposition of a bovine pericardium patch that is sewn from inside the femoral vein through a longitudinal venotomy with a continuous 5-0 polypropylene suture. RESULTS The venotomy was repaired with a 5-0 polypropylene running suture. No perioperative or postoperative complications were recorded. The inguinal bruit resolved, the arteries recovered good pulsatility, and the lower limb edema promptly reduced. A 6-month DUS confirmed the patency of the femoral arteries and veins and the absence of AVF or infection signs in the right groin. CONCLUSIONS Surgical repair of femoro-femoral AVF in drug abusers by biologic patch interposition is a challenging, but feasible, and effective technique with encouraging midterm results in terms of patency and resistance to infections.
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Affiliation(s)
- Pietro Rossetti
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alessandro Ucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Gaetano Carolla
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Roberto Quintavalla
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Parma, Italy
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Xu J, Zheng Z, Yang Y, Zhang W, Zhao H, E B, Zheng M. Clinical evaluation of covered stents in the treatment of superficial femoral artery pseudoaneurysm in drug abusers. Mol Med Rep 2018; 17:4460-4466. [PMID: 29344667 PMCID: PMC5802221 DOI: 10.3892/mmr.2018.8431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 12/04/2017] [Indexed: 01/04/2023] Open
Abstract
The present study aimed to investigate the technical feasibility and initial clinical outcomes of a covered stent for the endovascular treatment of superficial femoral artery (SFA) pseudoaneurysm in drug abusers. A total of 29 drug abuse patients with SFA pseudoaneurysm, as confirmed by color Doppler sonography, were enrolled to the present study between January 2012 and May 2014. All patients were treated percutaneously by implantation of a covered stent. Physical examination and lower extremity computed tomography angiography were performed at 1 and 9 months postoperation. Furthermore, the ankle-brachial index (ABI) of all patients was measured. The results indicated that placement of the covered stent was technically successful in all 29 patients. All of the ruptured pseudoaneurysms were successfully sealed with no cases of intraprocedural mortality. In addition, all patients' conditions improved rapidly; active hemorrhage subsidence and vascular bruit disappearance were immediately detected following implantation of the covered stent. During the follow-up period, pain was markedly alleviated and pulsatile mass was decreased as time increased. No complaints or complications were documented. A total of 9 months postoperation, pain and pulsatile mass were not detected. The patency rate of the stent was 100%, and no migration, occlusion or infection was detected. In addition, the ABI was significantly improved, from 0.52±0.09 to 0.97±0.37 (P<0.01). In conclusion, the placement of a covered stent may be considered a promising approach to provide an effective, safe and minimally invasive option for the treatment of SFA pseudoaneurysm in drug abusers.
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Affiliation(s)
- Jian Xu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Zhao Zheng
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yong Yang
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Wei Zhang
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Bei E
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
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Rammell J, Kansal N, Bhattacharya V. Management options in the treatment of femoral pseudoaneurysms secondary to intravenous drug abuse: A case series. Int J Surg Case Rep 2017; 36:30-33. [PMID: 28528282 PMCID: PMC5440756 DOI: 10.1016/j.ijscr.2017.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/26/2017] [Accepted: 04/30/2017] [Indexed: 11/16/2022] Open
Abstract
Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to their optimum management. Excision and ligation of the femoral artery without revascularisation is the most common operative intervention. With the identification and optimisation of suitable patients, revascularisation can be performed in the emergency setting. Current endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure. Ligation of the common femoral artery without revascularisation is both safe and effective as most patients will avoid critical ischaemia.
Introduction Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to the optimum management of these patients. Whilst emergency revascularisation options are available, excision and ligation of the femoral artery remains the most common operative intervention but risks leaving the patient with critical ischaemia or intermittent claudication. This case series reviewed the outcomes of 4 patients who underwent excision-ligation without revascularisation of an infected femoral pseudoaneurysm at a district general hospital. Presentation Four patients (2 male, 2 female) with infected femoral pseudoaneurysms presented via the emergency room with diagnosis confirmed with contrast cross-sectional imaging. All patients underwent emergency excision and ligation of the pseudoaneurysm without revascularisation. One patient returned to theatre with critical ischaemia necessitating a hindquarter amputation. The remaining 3 patients were discharged without claudication symptoms. Conclusion With the identification of suitable patients and pre-operative optimisation, revascularisation can be performed in the emergency setting with an extra-anatomical bypass appearing to confer the best results. Currently endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure, however, there are several case reports documenting successful outcomes when using a stent graft alongside a prolonged course of antibiotics. For the majority of patients, excision-ligation without revascularisation is both safe and effective as few are left with symptoms of limb ischaemia.
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Affiliation(s)
- James Rammell
- Department of Vascular Surgery, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX, United Kingdom.
| | - Nisheeth Kansal
- Department of Vascular Surgery, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX, United Kingdom
| | - Vish Bhattacharya
- Department of Vascular Surgery, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX, United Kingdom
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Domanin M, Romagnoni G, Romagnoli S, Rolli A, Gabrielli L. Emergency Hybrid Approach to Ruptured Femoral Pseudoaneurysm in HIV-positive Intravenous Drug Abusers. Ann Vasc Surg 2016; 40:297.e5-297.e12. [PMID: 27908808 DOI: 10.1016/j.avsg.2016.07.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/06/2016] [Accepted: 07/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic traumatism of the common femoral artery due to intravenous injection in drug abusers, in association with local infections and arterial wall weakening caused by human immunodeficiency virus (HIV), can lead to the development of pseudoaneurysms (PSAs). Rupture of PSA is a dramatic event in such patients, and its correction is difficult and controversial. Most of the cases reported describe open surgical elective options, which consist in ligation, repair, or substitution of the damaged arterial segment, using when possible biological grafts. In literature, few cases describe an endovascular repair with covered stent deployment. METHODS We present 2 cases of HIV-positive intravenous injection in drug abusers who needed emergency treatment for active bleeding in ruptured PSA of the right common femoral artery. In both cases, under general anesthesia needed for lack of patient's compliance and unstable hemodynamics, a short dissection to the distal superficial femoral artery was required. RESULTS Then, maintaining a manual compression on the bleeding site to stop hemorrhage, we deployed a covered stent graft in the site of the arterial breakdown through a retrograde approach. CONCLUSIONS The favorable results and progressive healing of wound and local infections persuaded us not to perform any further surgical correction. The absence of recurrences and late complications, after 3 years in the first case and 1 year in the second one, lead us to consider this hybrid endovascular approach as a valuable alternative to open surgery in HIV intravenous injection in drug abuser patients, in particularly when emergency conditions occur.
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Affiliation(s)
- Maurizio Domanin
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - Giovanni Romagnoni
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Silvia Romagnoli
- Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Antonio Rolli
- Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Livio Gabrielli
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
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Blanco Amil CL, Gallego Ferreiroa C, Fraga Muñoz E, Encisa de Sá JM. Post-traumatic femoropopliteal pseudo-aneurysm in a patient allergic to heparins. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Grus T, Lambert L, Rohn V, Klika T, Grusová G, Michálek P. Juxtarenal Mycotic Aneurysm as a Complication of Acute Exacerbation of Chronic Cholecystitis Treated by Resection and Replacement by a Fresh Allograft. Prague Med Rep 2016; 117:54-60. [PMID: 26995203 DOI: 10.14712/23362936.2016.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
We present a case of a female patient with infectious (mycotic) juxtarenal abdominal aneurysm with atypical symptoms beginning as acute exacerbation of chronic cholecystitis. Apart from common antibiotic treatment, the patient successfully underwent resection of the diseased segment and replacement by a fresh allograft in order to reduce the risk of infection of the graft, but with the need of subsequent life-long immunosuppressive therapy. Perioperative monitoring of the spinal cord by near infrared spectroscopy was used to identify possible spinal ischemia. The choice of the fresh allograft was based on our experience supported by review of the literature.
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Affiliation(s)
- Tomáš Grus
- 2nd Department of Surgery - Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Lukáš Lambert
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic.
| | - Vilém Rohn
- 2nd Department of Surgery - Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Tomáš Klika
- 2nd Department of Surgery - Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Gabriela Grusová
- 4th Department of Medicine - Department of Gastroenterology and Hepatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Pavel Michálek
- Department of Anaesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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