Case reports
Mycotic Aneurysm of the Suprarenal Aorta Secondary to Streptococcus pneumoniae: An Unusual Pathogen Hugh A. Gelabert, MD, William J. Quifiones-Baldrich, MD, Los Angeles, California
Mycotic aneurysms of the suprarenal aorta are rare lesions, accounting for less than 1% of aortic reconstructions for aneurysmal disease. The bacteriology of these lesions differs from the infrarenal aneurysms and primarily consists of Gramnegative organisms. We report an unusual case of an 87-year-old man successfully treated for a ruptured mycotic suprarenal aortic aneurysm caused by Streptococcus pneumoniae. We have not seen a previously reported case where this pathogen has been associated with a suprarenal mycotic aneurysm. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of these aneurysms is summarized. (Ann Vasc Surg 1991 ;5:529-532). KEY WORDS:
Mycotic aneurysm; suprarenal aorta.
Suprarenal mycotic aneurysms of the aorta are rare, accounting for less than 1% of aortic reconstructions for aneurysmal disease [1]. Most are pseudoaneurysms which lack a complete arterial wall and often consist of a contained retroperitoneal leak. The bacteriology of suprarenal mycotic aneurysms differs from infrarenal aneurysms. To date, the most common organisms are Gram-negative, primarily Salmonella. Suprarenal mycotic aneurysms frequently involve the arterial trunks to the abdominal viscera. Thus, anatomic considerations often require unorthodox reconstructive ap-
proaches such as placing a prosthetic graft in a contaminated area. This paper reports the case of an 87-year-old man who was treated for a mycotic aneurysm of the suprarenal aorta. Review of the English language literature reveals 25 cases of suprarenal mycotic aneurysms [2,3], but none of these reported an instance where Streptococcus pneumoniae was directly associated with suprarenal mycotic aneurysms. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of suprarenal mycotic aortic aneurysms is summarized.
From the Division of Vascular Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests: William J. Quihones-Baldrich, MD, Associate Professor of Surgery, UCLA School of Medicine, 10833 Le Conte Avenue, #72-248 CHS, Los Angeles, California 90024-6904.
CASE REPORT A 87-year-old black man presented with a five-week history of pain in his epigastrium and back. In addition, he complained of anorexia and weight loss. His medical history included arthritis and hypertension. He had re-
529
530
MYCOTIC ANEURYSM OF THE SUPRARENAL AORTA
ANNALSOF
VASCULAR SURGERY
penicillin (Pen Vee K, 500 mg b.i.d.). He is now 24 months post-surgery and is in good condition without evidence of recurrent infection or ~raft complications.
DISCUSSION
Fig. 1. Computerized tomographic image of area of rupture in lower thoracic, upper abdominal aorta. Findings are consistent with leaking aortic aneurysm or pseudoaneurysm.
quired a pacemaker because of complete heart block. His medications included aspirin and nifedipine. He denied cigarette smoking and had no history of diabetes, cancer. or myocardial infarction. Vital signs included a temperature of 36.8~ blood pressure of 150/80 mmHg, and a heart rate of 80 beats per minute. Physical examination was remarkable for eplgastric tenderness, without s~gns of peritonitis. Bowel sounds were active and no masses were palpable. The vascular examination revealed good pulses at all sites except the right popliteal artery and its distal branches which were absent. No bruits were noted. Laboratory studies revealed a hematocrit of 31.2. platelet count of 413.000. and white blood cell count of 14.3. Serum electrolytes, liver enzymes, urine analysis, and a chest radiograph were normal. The electrocardiogram (EKG) showed complete heart block and a paced cardiac rhythm. A computerized tomographic (CT) scan of the patient's abdomen revealed a contained suprarenal collection which was consistent with a leaking aorta or a pseudoaneurysm (Fig. 1). An arteriogram demonstrated a saccular defect in the aortic wall between the left renal artery and the superior mesenteric artery (Fig. 2). At surgery, the aneurysm was approached through a seventh interspace thoracoabdominal incision. The aneurysm arose from a sharply demarcated defect in the aortic wall just lateral to the celiac artery. There was no evidence of gross infection. After debridement of the affected portions of the aorta, the resultant defect involved the left posterior wall of the aorta behind the celiac trunk, and a circumferential segment of the aorta between the celiac trunk and the diaphragm. An in situ Dacron aortic graft was fashioned to replace this portion of the aorta. The distal anastomosis was tailored to include the ostia of the celiac artery and the superior mesenteric artery. Sections of the involved aorta were cultured and revealed Streptococcus pneurnoniae. Postoperatively, this patient was treated for 28 days with cefazolin. Subsequently, he has been placed on a lifelong regimen of oral
Most mycotic aneurysms involve the infrarenal aorta. The bacteriology of these aneurysms has undergone a dramatic change since the introduction and widespread use of broad-spectrum antibiotics. While the predominant organism cultured from these aneurysms in the early 1960s was Salmonella [4,5], current data would indicate thai Staphylococcus is now the most c o m m o n pathogen [1,6,7]. Furthermore. Gram-positive organisms now account for more of these infections than Gramnegative organisms. Mycotic aneurysms of the suprarenal aorta differ, with Salmonella remaining the predominant pathogen recorded to date. In a recent review of mycotic aneurysms of the suprarenal aorta. Salmonella accounted for seven of 11 cases [2]. Streptococcus pneumoniae is not commonly associated with mycotic aneurysms: while a few cases are recorded, it clearly remains a sporadic pathogen. A recent series by Chan and associates recorded 22 mycotic aneurysms at various positions along the aorta [1]. Staphylococcus aureus was the mosl common pathogen, accounting for seven cases. Salmonella was isolated in four patients. Two Streptococcus pneumoniae infections are reported in this series, but it is unclear which aortic segments were involved. To our knowledge, Streptococcus pneumoniae has not been previously reported in association with suprarenal mycotic aneurysms. Osier is credited with establishing the term "mycolic" and for correlating the presence of arterial infection with aneurysmal disease [8]. Eppinger described the pathogenesis of mycotic aneurysms and coined the term embolo-mycotic to describe the embolic origin of the arterial infection. He further demonstrated a bacterial role by culturing the same organism from the vegetative lesions and the wall of an aneurysm in a patient with endocarditis [9]. Crane divided mycotic aneurysms into primary and secondary types. Primary aneurysms were those not associated with endocarditis or infectious focus. Secondary types were those which tbrmed as a consequence of a precedent endocarditis, spreading by direct extension or by septic emboli [10]. Blum proposed the term cryptogenic mycotic aneurysm to describe aneurysms arising in the absence of an obvious infection. Presumably, these were the result of a transient bacteremia in the presence of atherosclerotic disease [11]. Barker postulated that intimal disruption was important in the development of mycotic aneurysms. Thus congenital, traumatic and acquired intimal defects could facilitate
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MYCOTIC A N E U R YSM OF THE S U P R A R E N A L AORTA
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Fig. 2. (A) Anteroposterior view of lower thoracic and superior abdominal aorta, showing area of contained rupture. Note visceral vessels emanating just below xiphoid process, with what appears to be aortic discontinuity. (B) Lateral view of rupture area in lower thoracic, upper abdominal aorta. Note takeoff of celiac axis just below area of rupture, with superior mesenteric artery taking off segment of relatively normal aorta.
the development of these aneurysms [12]. Hawkins and Yeager amplified this to include atherosclerotic plaque disruption of the intima [13]. Finseth and Abbott classified mycotic aneurysms as primary, secondary (or embolomycotic) and cryptogenic. Primary mycotic aneurysms arise from direct extension of an adjacent suppurative focus. Secondary mycotic aneurysm resulted from septic emboli, most commonly due to endocarditis. Cryptogenic mycotic aneurysms Were consequent to bacteremia [14]. Alternative classifications have been developed. Patel described the aneurysms on the basis of the arterial wall (normal, atherosclerotic, etc.) and the infectious source [15]. Wilson proposed another classification of mycotic aneurysms based on similar criteria, yet he returned the term mycotic to the original meaning relating to a septic embolus from an endocarditis vegetation [16]. Further complicating the definition of a mycotic
aneurysm is the observation that not all aortic infections bear equal consequence. Clinical series reporting the results of bacterial cultures in the repair of aortic aneurysms have demonstrated up to 30% of emergency cases and 15% of elective cases are performed in the presence of "colonized tissues" [17]. This contrasts sharply with low rates of prosthetic graft infection, Surgical goals in the management of suprarenal mycotic aneurysms are directed at debridement of infected tissues and reconstruction of the arterial supply to the viscera and the lower extremities. A recent report specifically addressing suprarenal mycotic aneurysm reconstruction places the reinfection and mortality at about 10% each [2]. Arterial homograft has been used in the repair of mycotic aortic aneurysms with dismal results. Brown and colleagues noted a 100% mortality for these reconstructions as of 1984 [7]. Similar results are found in the experimental work of Foster and
532
MYCOTIC A N E U R YSM OF THE S U P R A R E N A L AORTA
co-workers who used aortic homografts for arterial replacement in the presence of infection [18]. Extraanatomic bypass of mycotic aneurysms to allow for control of sepsis and restoration of lower body circulation has been reported by Reddy and associates [19]. These reconstructions have the disadvantage of lower patency with catastrophic loss of arterial blood supply to all of the abdominal viscera. Reinfection of the extraanatomic graft and septic death have been recorded in up to 13% of mycotic aortic aneurysms [7]. In situ reconstruction of suprarenal mycotic aneurysms with prosthetic graft has been recently advocated by several authors [1-3,7,20]. When combined with debridement of grossly infected tissue and appropriate antibiotics, the outcome is dramatically improved. The reported series would suggest that anastomotic disruption occurs in less than 5% of cases. The combined mortality from all cases for the suprarenal mycotic aneurysm is about 13%. This is better than the previously reported 32% mortality [2]. Suprarenal mycotic aneurysms differ from the infrarenal mycotic aneurysms in several significant ways: Gram-negative infections predominate. Salmonella is the most commonly reported organism, and the anatomy presents unique difficulties for reconstruction. The elements for success in management of suprarenal mycotic aneurysms appear to be prompt recognition of the problem, liberal use of intraoperative Gram stain and bacterial culture, thorough debridement of infected arterial tissues. and appropriate use of broad-spectrum antibiotics. In addition, in situ prosthetic reconstruction of the arterial defect, and lifelong oral suppressive antibiotics seem safe and effective. REFERENCES 1. CHAN FY. CRAWFORD ES. COSELLI JS. et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47(2):193-203. 2. ATNIP RG. Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in-situ aortic and visceral reconstruction. J Vasc Surg 1989:10:635-641.
mmm
ANNALS OF VASCULARSt3RGERY
3 SEMEL L. SZMALC F. BREDENBERG CE. Management of suspected mycotic suprarenal aortic aneurysm. Ann Vasc Surg 1989:3:380-383. 4. BENNETT DE. CHERRY JK. Bacterial infection of aortic aneurysms. A m J Surg 1967:113:321-326. 5. MUNDTH ED, DARLING RC, ALVARADO RH, et al. Surgical management of mycotic aneurysms and the complications of infections in vascular reconstructive surgery. A m J Surg 1969:117:460-470. 6. JARRETT F. DARLING RC. MUNDTH ED. et al. The management of infected arterial aneurysms, d Cardiovasc Surg 1977;18:361-366. 7. BROWN SL. BUSUTTIL RW, BAKER JD. et al. Bacteriological and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541-547. 8. OSLER W. The Gulstonian lectures on malignant endocarditis. Br Med J 1885:March 7:467-470. 9. EPPINGER H. Pathogenesis (Histogenesis and Aetiologie) der Aneurysm ein Schlieoclick des Aneurysma equ: Verminosum. Arch Klin Chit 1887:35:404. 10. CRANE AR. Primary multilobular mycotic aneurysm of the aorta. Arch Pathol 1937:24:634-641. 11. BLUM L. KEEFER EBC Cryptogenic mycotic aneurysm. Ann Surg 1962;155:398-405 12. BARKER WF. Mycotic aneurysms. Ann Surg 1954:139:84-89. 13. HAWKINS J. YEAGER G. Primary mycotic aneurysms. Surgery 1956:40:747. 14. FINSETH F. ABBOTT WM. One-stage operative therapy for Salmonella mycotic abdominal aortic aneurysm. Ann Surg 1978;179:8-11. 15 PATEL S. JOHNSTON KW. Classification and management of mycotic aneurysms. Surg Gynecol Obstet 1977;144: 691-694. 16. WILSON SE. VAN WAGENEN P. PASSARO E. Arterial infection. Curt Probl Surg 1978,15:6-89. 17. ERNST CB, CAMPBELL HC. DAUGHERTY ME. et al. Incidence and significance of intraoperative bacterial cultures during abdominal aortic aneurysmectomy. Ann Surg 1977:185:626-633. 18. FOSTER JH. BERZINS T. SCOTT HW Jr. An experimental study of arterial replacement in the presence of bacterial infection. Surg Gynecol Obstet 1959:108:141-148. 19 REDDY DL. LEE RE, OH HK. Suprarenal mycotic aortic aneurysm: surgical management and follow-up. J Vasc Surg t986:6:917-920. 20. EWART JM, BURKE TJ. BUNT TJ. Spontaneous abdominal aortic infections: essentials of diagnosis and management. Am Surg 1983;49:37-50,
Mycotic Aneurysm of the Suprarenal Aorta Secondary to Streptococcus pneumoniae: An Unusual Pathogen Hugh A. Gelabert, MD, William J. Quifiones-Baldrich, MD, Los Angeles, California
Mycotic aneurysms of the suprarenal aorta are rare lesions, accounting for less than 1% of aortic reconstructions for aneurysmal disease. The bacteriology of these lesions differs from the infrarenal aneurysms and primarily consists of Gramnegative organisms. We report an unusual case of an 87-year-old man successfully treated for a ruptured mycotic suprarenal aortic aneurysm caused by Streptococcus pneumoniae. We have not seen a previously reported case where this pathogen has been associated with a suprarenal mycotic aneurysm. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of these aneurysms is summarized. (Ann Vasc Surg 1991 ;5:529-532). KEY WORDS:
Mycotic aneurysm; suprarenal aorta.
Suprarenal mycotic aneurysms of the aorta are rare, accounting for less than 1% of aortic reconstructions for aneurysmal disease [1]. Most are pseudoaneurysms which lack a complete arterial wall and often consist of a contained retroperitoneal leak. The bacteriology of suprarenal mycotic aneurysms differs from infrarenal aneurysms. To date, the most common organisms are Gram-negative, primarily Salmonella. Suprarenal mycotic aneurysms frequently involve the arterial trunks to the abdominal viscera. Thus, anatomic considerations often require unorthodox reconstructive ap-
proaches such as placing a prosthetic graft in a contaminated area. This paper reports the case of an 87-year-old man who was treated for a mycotic aneurysm of the suprarenal aorta. Review of the English language literature reveals 25 cases of suprarenal mycotic aneurysms [2,3], but none of these reported an instance where Streptococcus pneumoniae was directly associated with suprarenal mycotic aneurysms. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of suprarenal mycotic aortic aneurysms is summarized.
From the Division of Vascular Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests: William J. Quihones-Baldrich, MD, Associate Professor of Surgery, UCLA School of Medicine, 10833 Le Conte Avenue, #72-248 CHS, Los Angeles, California 90024-6904.
CASE REPORT A 87-year-old black man presented with a five-week history of pain in his epigastrium and back. In addition, he complained of anorexia and weight loss. His medical history included arthritis and hypertension. He had re-
529
530
MYCOTIC ANEURYSM OF THE SUPRARENAL AORTA
ANNALSOF
VASCULAR SURGERY
penicillin (Pen Vee K, 500 mg b.i.d.). He is now 24 months post-surgery and is in good condition without evidence of recurrent infection or ~raft complications.
DISCUSSION
Fig. 1. Computerized tomographic image of area of rupture in lower thoracic, upper abdominal aorta. Findings are consistent with leaking aortic aneurysm or pseudoaneurysm.
quired a pacemaker because of complete heart block. His medications included aspirin and nifedipine. He denied cigarette smoking and had no history of diabetes, cancer. or myocardial infarction. Vital signs included a temperature of 36.8~ blood pressure of 150/80 mmHg, and a heart rate of 80 beats per minute. Physical examination was remarkable for eplgastric tenderness, without s~gns of peritonitis. Bowel sounds were active and no masses were palpable. The vascular examination revealed good pulses at all sites except the right popliteal artery and its distal branches which were absent. No bruits were noted. Laboratory studies revealed a hematocrit of 31.2. platelet count of 413.000. and white blood cell count of 14.3. Serum electrolytes, liver enzymes, urine analysis, and a chest radiograph were normal. The electrocardiogram (EKG) showed complete heart block and a paced cardiac rhythm. A computerized tomographic (CT) scan of the patient's abdomen revealed a contained suprarenal collection which was consistent with a leaking aorta or a pseudoaneurysm (Fig. 1). An arteriogram demonstrated a saccular defect in the aortic wall between the left renal artery and the superior mesenteric artery (Fig. 2). At surgery, the aneurysm was approached through a seventh interspace thoracoabdominal incision. The aneurysm arose from a sharply demarcated defect in the aortic wall just lateral to the celiac artery. There was no evidence of gross infection. After debridement of the affected portions of the aorta, the resultant defect involved the left posterior wall of the aorta behind the celiac trunk, and a circumferential segment of the aorta between the celiac trunk and the diaphragm. An in situ Dacron aortic graft was fashioned to replace this portion of the aorta. The distal anastomosis was tailored to include the ostia of the celiac artery and the superior mesenteric artery. Sections of the involved aorta were cultured and revealed Streptococcus pneurnoniae. Postoperatively, this patient was treated for 28 days with cefazolin. Subsequently, he has been placed on a lifelong regimen of oral
Most mycotic aneurysms involve the infrarenal aorta. The bacteriology of these aneurysms has undergone a dramatic change since the introduction and widespread use of broad-spectrum antibiotics. While the predominant organism cultured from these aneurysms in the early 1960s was Salmonella [4,5], current data would indicate thai Staphylococcus is now the most c o m m o n pathogen [1,6,7]. Furthermore. Gram-positive organisms now account for more of these infections than Gramnegative organisms. Mycotic aneurysms of the suprarenal aorta differ, with Salmonella remaining the predominant pathogen recorded to date. In a recent review of mycotic aneurysms of the suprarenal aorta. Salmonella accounted for seven of 11 cases [2]. Streptococcus pneumoniae is not commonly associated with mycotic aneurysms: while a few cases are recorded, it clearly remains a sporadic pathogen. A recent series by Chan and associates recorded 22 mycotic aneurysms at various positions along the aorta [1]. Staphylococcus aureus was the mosl common pathogen, accounting for seven cases. Salmonella was isolated in four patients. Two Streptococcus pneumoniae infections are reported in this series, but it is unclear which aortic segments were involved. To our knowledge, Streptococcus pneumoniae has not been previously reported in association with suprarenal mycotic aneurysms. Osier is credited with establishing the term "mycolic" and for correlating the presence of arterial infection with aneurysmal disease [8]. Eppinger described the pathogenesis of mycotic aneurysms and coined the term embolo-mycotic to describe the embolic origin of the arterial infection. He further demonstrated a bacterial role by culturing the same organism from the vegetative lesions and the wall of an aneurysm in a patient with endocarditis [9]. Crane divided mycotic aneurysms into primary and secondary types. Primary aneurysms were those not associated with endocarditis or infectious focus. Secondary types were those which tbrmed as a consequence of a precedent endocarditis, spreading by direct extension or by septic emboli [10]. Blum proposed the term cryptogenic mycotic aneurysm to describe aneurysms arising in the absence of an obvious infection. Presumably, these were the result of a transient bacteremia in the presence of atherosclerotic disease [11]. Barker postulated that intimal disruption was important in the development of mycotic aneurysms. Thus congenital, traumatic and acquired intimal defects could facilitate
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MYCOTIC A N E U R YSM OF THE S U P R A R E N A L AORTA
A
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B
Fig. 2. (A) Anteroposterior view of lower thoracic and superior abdominal aorta, showing area of contained rupture. Note visceral vessels emanating just below xiphoid process, with what appears to be aortic discontinuity. (B) Lateral view of rupture area in lower thoracic, upper abdominal aorta. Note takeoff of celiac axis just below area of rupture, with superior mesenteric artery taking off segment of relatively normal aorta.
the development of these aneurysms [12]. Hawkins and Yeager amplified this to include atherosclerotic plaque disruption of the intima [13]. Finseth and Abbott classified mycotic aneurysms as primary, secondary (or embolomycotic) and cryptogenic. Primary mycotic aneurysms arise from direct extension of an adjacent suppurative focus. Secondary mycotic aneurysm resulted from septic emboli, most commonly due to endocarditis. Cryptogenic mycotic aneurysms Were consequent to bacteremia [14]. Alternative classifications have been developed. Patel described the aneurysms on the basis of the arterial wall (normal, atherosclerotic, etc.) and the infectious source [15]. Wilson proposed another classification of mycotic aneurysms based on similar criteria, yet he returned the term mycotic to the original meaning relating to a septic embolus from an endocarditis vegetation [16]. Further complicating the definition of a mycotic
aneurysm is the observation that not all aortic infections bear equal consequence. Clinical series reporting the results of bacterial cultures in the repair of aortic aneurysms have demonstrated up to 30% of emergency cases and 15% of elective cases are performed in the presence of "colonized tissues" [17]. This contrasts sharply with low rates of prosthetic graft infection, Surgical goals in the management of suprarenal mycotic aneurysms are directed at debridement of infected tissues and reconstruction of the arterial supply to the viscera and the lower extremities. A recent report specifically addressing suprarenal mycotic aneurysm reconstruction places the reinfection and mortality at about 10% each [2]. Arterial homograft has been used in the repair of mycotic aortic aneurysms with dismal results. Brown and colleagues noted a 100% mortality for these reconstructions as of 1984 [7]. Similar results are found in the experimental work of Foster and
532
MYCOTIC A N E U R YSM OF THE S U P R A R E N A L AORTA
co-workers who used aortic homografts for arterial replacement in the presence of infection [18]. Extraanatomic bypass of mycotic aneurysms to allow for control of sepsis and restoration of lower body circulation has been reported by Reddy and associates [19]. These reconstructions have the disadvantage of lower patency with catastrophic loss of arterial blood supply to all of the abdominal viscera. Reinfection of the extraanatomic graft and septic death have been recorded in up to 13% of mycotic aortic aneurysms [7]. In situ reconstruction of suprarenal mycotic aneurysms with prosthetic graft has been recently advocated by several authors [1-3,7,20]. When combined with debridement of grossly infected tissue and appropriate antibiotics, the outcome is dramatically improved. The reported series would suggest that anastomotic disruption occurs in less than 5% of cases. The combined mortality from all cases for the suprarenal mycotic aneurysm is about 13%. This is better than the previously reported 32% mortality [2]. Suprarenal mycotic aneurysms differ from the infrarenal mycotic aneurysms in several significant ways: Gram-negative infections predominate. Salmonella is the most commonly reported organism, and the anatomy presents unique difficulties for reconstruction. The elements for success in management of suprarenal mycotic aneurysms appear to be prompt recognition of the problem, liberal use of intraoperative Gram stain and bacterial culture, thorough debridement of infected arterial tissues. and appropriate use of broad-spectrum antibiotics. In addition, in situ prosthetic reconstruction of the arterial defect, and lifelong oral suppressive antibiotics seem safe and effective. REFERENCES 1. CHAN FY. CRAWFORD ES. COSELLI JS. et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47(2):193-203. 2. ATNIP RG. Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in-situ aortic and visceral reconstruction. J Vasc Surg 1989:10:635-641.
mmm
ANNALS OF VASCULARSt3RGERY
3 SEMEL L. SZMALC F. BREDENBERG CE. Management of suspected mycotic suprarenal aortic aneurysm. Ann Vasc Surg 1989:3:380-383. 4. BENNETT DE. CHERRY JK. Bacterial infection of aortic aneurysms. A m J Surg 1967:113:321-326. 5. MUNDTH ED, DARLING RC, ALVARADO RH, et al. Surgical management of mycotic aneurysms and the complications of infections in vascular reconstructive surgery. A m J Surg 1969:117:460-470. 6. JARRETT F. DARLING RC. MUNDTH ED. et al. The management of infected arterial aneurysms, d Cardiovasc Surg 1977;18:361-366. 7. BROWN SL. BUSUTTIL RW, BAKER JD. et al. Bacteriological and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541-547. 8. OSLER W. The Gulstonian lectures on malignant endocarditis. Br Med J 1885:March 7:467-470. 9. EPPINGER H. Pathogenesis (Histogenesis and Aetiologie) der Aneurysm ein Schlieoclick des Aneurysma equ: Verminosum. Arch Klin Chit 1887:35:404. 10. CRANE AR. Primary multilobular mycotic aneurysm of the aorta. Arch Pathol 1937:24:634-641. 11. BLUM L. KEEFER EBC Cryptogenic mycotic aneurysm. Ann Surg 1962;155:398-405 12. BARKER WF. Mycotic aneurysms. Ann Surg 1954:139:84-89. 13. HAWKINS J. YEAGER G. Primary mycotic aneurysms. Surgery 1956:40:747. 14. FINSETH F. ABBOTT WM. One-stage operative therapy for Salmonella mycotic abdominal aortic aneurysm. Ann Surg 1978;179:8-11. 15 PATEL S. JOHNSTON KW. Classification and management of mycotic aneurysms. Surg Gynecol Obstet 1977;144: 691-694. 16. WILSON SE. VAN WAGENEN P. PASSARO E. Arterial infection. Curt Probl Surg 1978,15:6-89. 17. ERNST CB, CAMPBELL HC. DAUGHERTY ME. et al. Incidence and significance of intraoperative bacterial cultures during abdominal aortic aneurysmectomy. Ann Surg 1977:185:626-633. 18. FOSTER JH. BERZINS T. SCOTT HW Jr. An experimental study of arterial replacement in the presence of bacterial infection. Surg Gynecol Obstet 1959:108:141-148. 19 REDDY DL. LEE RE, OH HK. Suprarenal mycotic aortic aneurysm: surgical management and follow-up. J Vasc Surg t986:6:917-920. 20. EWART JM, BURKE TJ. BUNT TJ. Spontaneous abdominal aortic infections: essentials of diagnosis and management. Am Surg 1983;49:37-50,
