Contemporary Results of Surgical Management of Peripheral Mycotic Aneurysms
Becky Long, MD, Gregory Salzler, MD, Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD, Steven A. Leers, MD, Eric Hager, MD, Michel S. Makaroun, MD, Mohammad H. Eslami, MD MPH.
UPMC, PITTSBURGH, PA, USA.
Mycotic aneurysms of the extremities occur infrequently but can cause severe life and limb complications. Traditional treatment typically includes debridement and revascularization, though in some patients ligation may be well tolerated. We reviewed our experience with these aneurysms treated with these two modalities.
A retrospective review of patients treated for peripheral mycotic aneurysms at one institution from January 2005 to December 2015 was performed under an Institutional Review Board-approved protocol. Demographics, perioperative details, and long-term outcomes were collected and standard statistical methods were used to compare treatments.
28 patients had 29 peripheral mycotic aneurysms. The majority of patients (19: 67.9%) were male and the average age was 60.1 ± 17 years. Iatrogenic causes were the most common (15: 51.7%) followed by injection drug use (5: 17.2%), osteomyelitis (2:10.5%) and bacterial endocarditis (1:3.5%). The remainder (6:20.7%) were of unknown causes. Symptoms included fever (46.4%), drainage (42.9%), rupture (35.7%), erythema (21.4%), and limb ischemia (17.9%). Staphylococcus aureus was the most common bacteria isolated (38.5%, from 7 positive blood culture and 3 positive wound culture) with 25% of these being MRSA, followed by Streptococcus species (11.5%), and other Staphylococcus (7.7%). Eight (27.6%) patients had negative cultures. The most common location was the femoral artery (58.6%), with 17.2% occurring in the popliteal artery, 13.8% in the brachial artery, 10.3% in the radial or ulnar artery, and 3.5% in the external iliac artery. 18 patients underwent procedures that included revascularization while 11 had resection/ligation without revascularization (4 femoral, 2 popliteal, 3 radial/ulnar, 1 brachial, and 1 external iliac). There was no significant difference in limb ischemia between these two groups (p=0.14). Of those who were not revascularized, one developed significant initial ischemia but died prior to amputation and the other underwent revascularization within one year after tolerating the initial ligation. Upper extremity aneurysms were more likely to be free from reintervention than those in the lower extremities (p=0.01). There was one perioperative death.
In this large series, resection or ligation of peripheral mycotic aneurysms without revascularization was well tolerated. With close follow-up of these patients, resection or ligation may obviate the more extensive reconstructive or extra-anatomic procedures in these infected fields without the need for revascularization.
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