Title
[症例報告]Staged surgical management of abdominal aortic
aneurysm with Klebsiella pneumoniae infection : A case report
Author(s)
Kusaba, Akira; Koja, Kageharu; Sunagawa, Kazuya; Kamada,
Yoshihiko; Kuda, Tomoharu; Sakuda, Hitosi; Tamaki, Masato;
Tamashiro, Mamoru; Matsubara, Shinobu; Nakao, Kiyoshi
Citation
琉球医学会誌 = Ryukyu Medical Journal, 17(2): 105-108
Issue Date
1997
URL
http://hdl.handle.net/20.500.12001/3371
Staged surgical management of abdominal aortic aneurysm
with Klebsiella pneumoniae infection: A case report
Akira Kusaba, Kageharu Koja, Kazuya Sunagawa, Yoshihiko Kamada,
Tomoharu Kuda, Hitosi Sakuda, Masato Tamaki, Mamoru Tamashiro,
Shinobu Matsubara and Kiyoshi Nakao*
Second Department of Surgery, Faculty of Medici花e, University of the Ryukyus, Okinawa 903-01, Japan.
"Division of Surgery, Yonabaru Chuo Hospital, Okinawa 901-03, Japan
(Received on March 3, 1997, accepted on May 27, 1997)
ABSTRACT
A 65-year-old Japanese man with an infected saccular aneurysm in the terminal abdomi-nal aorta and septicemia with a high fever over 41℃ related to a liver abscess was
success-fully treated by an initial aneurysmectomy with axillo-bifemoral prosthetic bypass and by a secondary anatomical aorto-bifemoral prosthetic bypass. A preoperative blood culture grew Klebsiella pneumoniae. An abdominal CT scan and aortography revealed a protrusive saccular aneurysm in the terminal abdominal aorta, associated with compressive thrombo-sis of the inferior vena cava (IVC) and left common iliac vein. Aneurysmectomy with thor-ough debridement of the retroperitoneal tissues was initially performed. The aortic stump was oversewn and arterial circulation was restored to the bilateral lower extremities by an axillo-bifemoral prosthetic bypass graft. The occluded ilio-caval venous trunk was recon-structed simultaneously by thrombectomy. After continuous oral administration of antibi-otic for 5 months, the arterial continuity was secondarily reverted in the anatomical route using an aorto-bifemoral prosthetic bypass. Thus, we are able to recommend staged surgi-cal management of infected abdominal aortic aneurysms for the prevention of
postopera-tive graft infection and delayed blowout of the sewn aortic stump. Ryukyu Med. J., 17{2)
105-108, 1997
Key words: infected aortic aneurysm, abdominal aorta, staged arterial reconstruction, Klebsiella pneumomae
INTRODUCT ION
Although infected abdominal aortic aneurysm are un-common lesions, they are insidious and carry a high risk of morbidity and mortality from uncontrolled sepsis and arte-rial blowout. Success in conventional management of these aortic lesions usually involves early diagnosis, intensive an-tibiotic therapy, and prompt aneurysmectomy with aortic hgation or sewing followed by extra-anatomic bypass graft-ing. However, aortic closure has often been complicated by aneurysmal dilation and blowout during the follow-up
periodト We report a case of infected abdominal aortic
aneurysm, which was successfully treated by a staged ana-tomical arterial reconstruction.
CASE REPORT
On August 6th, 1994, a 65-year-old Japanese man with high fever due to a right lobe liver abscess (S7)
was hospitalized. CT scan revealed a liver abscess (Fig. la). He was treated with percutaneous drainage of the abscess and intravenous antibiotic therapy. Klebsiella pneumoniae was detected in the abscess. Although the high fever was alleviated 7 days later, it relapsed with the appearance of low back pain 10 days later. CT scan revealed a protruded lesion, lxlcm in size, on the right side wall of the terminal abdominal aorta. The patient was referred to our hospital on September 6, 1994. His body temperature was 41℃ pulse rate 100/min, respira-tion 22/min, and blood pressure 160/90mmHg. A pulsatile mass with systolic murmurs and moderate ten-derness was present in the abdomen at the right aspect of the navel. Laboratory studies showed Hb 9.6 /dl, WBC 12,600/cmm and CRP 6.05mg/dl. An aortogram
re-vealed a saccular protrusion on the right side wall of the terminal abdominal aorta (Fig. lb). Thrombosis of the inferior vena cava at the lho-caval venous Junc-tion and of the left common iliac vein was demonstrated
106 Staged management of infected abdominal aortic aneurysm
Fig. 2 A schema of the surgical procedure: Initial aneurysmectomy with extraanatomic bypass and a secondary aorto-bifemoral bypass in the anatomical route.
Fig. 1 A preoperative upper abdominal computed tor?ograph showing a liver abscess (a), and a preoperative angiograph showing a saccular protrusion On the right side wall of the terminal aorta (b), and complete occlusion of the left iliac veins (c).
by venography (Fig. lc). Klebsiella pneumoniae was positive in blood culture. Infected abdominal aortic an-eurysm related to the liver abscess was diagnosed. In-travenous antibotic therapy was ineffective for the high fever and positive CRP, and the low back pain increased suggesting impending rupture of the aneurysm.
Emergency surgery was performed on September 19th, 1994. An axillo-bifemoral prosthetic bypass was created initially. A laparotomy found an irregular in-fected aortic aneurysm, the size of a man's fist, on the right side wall of the terminal abdominal aorta. The aneurysm involved bilateral common iliac arteries and adhered closely to the small intestine, inferior vena cava and the left common iliac veins. The infected an-eurysm including bilateral common iliac arteries and surrounding retropentoneal tissues were completely ex-cised, followed by thorough irrigation with saline solu-tion. The aortic stump was sewn just distal to the inferior mesenteric artery by a turnover sewing tech-nique using 3-0 polypropylene interrupted mattress su-tures (Fig. 2). Thrombectomy of the occluded vena cava and left common iliac vein were performed
simul-taneously. Microscopic examination of the resected
aneurysmal wall showed a foci with abscess formation and profuse infiltration of neutrophils, lymphocytes, plasma cells and with destruction of elastic fibers and muscular structures. However the microbiologic study of the aortic wall was negative. The patient was treated postoperatively with intravenous infusion of cefotiam 2 ど/d and became afebrile with normalization of CRP 2
days after the operation. We planned to perform an
anatomic aorto-bifemoral prosthetic bypass grafting 5 months later. Despite the patients afebrihty with
normal WBC count and normal CRP level, he was given oral antibiotics for 5 months. On February 6, 1995, 5 months after the initial operation, the arterial continuity was restored by an anatomic aort0-bifemoral prosthetic bypass. The proximal anastomosis of the by-pass graft was made to the infrarenal abdominal aorta in an end-to-end fashion, and distal to the previously im-planted prosthetic grafts for axillo-bifemoral bypass at both groins. The previously implanted axillo-bifemoral bypass was removed. The patient has since been healthy with good function of the implanted aorto-bifemoral bypass graft and without any signs of infection for 22 months after the second operation.
DI SCUSSION
The mycotic or infected abdominal aortic aneurysms (AAA) are uncommon lesions with catastrophic vascular complications. Optimal conventional management for in-fected AAA comprises early diagnosis, intensive antibiotic therapy, and timely surgical management, i.e. resection of the infected aorta, complete debridement of the contami-nated retroperitoneal tissues, and aortic closure followed by extra-anatomic prosthetic bypass.
During the past decade, several authors have suggested that mycotic AAA or infected prosthetic graft could be sue-cessfully treated by in situ prosthetic graft interposition after complete debridement and thorough irrigation of the contaminated retropentoneal space, especially in younger patients in good condition without evidence of local suppuration '". Atnip61 reported 16 prolonged survivals in situ prosthetic reconstruction for 20 mycotic AAA patients, and Walker et al.H reorted an early survival rate of over
in 23 in situ aortic reconstructions for infected abdomi-nal aortic grafts. However, in situ prosthetic grafting in a contaminated field, risks several postoperative problems of early and late mortality, as high as 20-60% even in re-cent series"14'. These patients have had life threatening complications, including persistent bacteria and/or suture line disruption of the aortic anastomosis due to persistent in-fection in the retroperitoneal space. In situ prosthetic graft-ing might be an appropriate procedure for carefully selected candidates characterized by well-recognized infectious lesions and negative microbiological blood cultures'". Despite recent progress in antibiotic therapy, excision of the infected aorta and complete debndement of retropentoneal tissues followed by extraanatomic bypass grafting remains the procedure of choice for the majority of patients with infected AAA. How-ever, this management has been fraught with subsequent risks of aortic stump blowout with a mortality rate of over 80%. Reilly reported 3 deaths related to Heated aoト tic stump disruption following surgical management for
abdominal aortic prosthetic graft infections2)and simi-lar aortic stump blowouts 3-7 months after aortic closure have been reportedl
We have previously experienced at risk patients who
died of blowout of the sewn abdominal aortic stump after re-moval of infected aortic prosthetic grafts'5'. These patients were treated surgically by aneurysmectomy with complete debridement and in situ Dacron bifurcation grafting for AAA ruptured into the duodenum. Unfortunately, graft in-fection occurred postoperatively. The infected graft was re-moved using the turnover sewing technique of the aortic stump. Distal circulation was restored by bilateral axillo-femoral bypass. However, the patient died of a sudden epi-sode of aortic stump blowout into the third portion of the
duodenum 6 months after aortic sewing. We concluded
that ligation or sewn closure of the sclerotic abdominal aorta in the contaminated field risks aneurysmal dilata-tion and blowout during the follow-up period. On the basis of this experience, we considered that arterial recon-struction after aortic closure shou】d be restored in the anat-omic route after complete control of infectious reactions in the retroperitoneal space, and before the development of aneurysmal dilatation or blowout of the aortic stump, probably・4 to 6 months after aortic closure. In the pre-sent case, a staged anatomical reconstruction using an aorto-bifemoral prosthetic bypass was performed after 5
months of oral antibiotic therapy. The patient has been well without any infectious reactions 20 months after the staged surgery.
In conclusion, in the surgical management of active AAA infection with septicemia, we consider excision of the infected aorta and turnover sewing of the aorta fol-lowed by extraanatomic prosthetic bypass to be the basic and ideal procedure. The arterial continuity should be re-stored by staged anatomic prosthetic grafting before deveL opment of aortic stump disruption.
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