Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

Purpose: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems . Primary surgical management includes control of hemorrhage and debridemen t of the infected arterial wall. Because critical ischemia may develop afte r arterial resection, revascularization has been a secondary goal of treatm ent, Standard anatomic graft placement or prosthetic bypass grafting has be en compromised by a high rate of recurrent infection, Extra-anatomic recons truction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk. of reinfection; (2) the avoi dance of significant size mismatches; and (3) graft placement that is anato mically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. Methods: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), com mon iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Mos t patients (5 of 7) were known intravenous drug users, who had a painful pu lsatile mass in an injection area. Two patients had systemic sepsis, one pa tient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of dupl ex/computed tomography scanning and confirmed by means of arteriography in all cases. Results: Obturator bypass grafting was performed by using a reversed deep l eg vein in the five femoral MPAs, An ilioiliac, cross-pelvic bypass graftin g procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a '"pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means o f cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. Conclusion: The superficial femoral/popliteal veins may be particularly use ful for limb revascularization in patients with MPAs, This autogenous condu it provides an excellent size-match and a suitable length for reconstructio n, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-u p is challenging in such cases, but will be required to accurately determin e the durability of this strategy.