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Background: Arterial bypass tunneling via the obturator foramen (OFB) can be performed to circumvent groin infections during lower extremity revascularization. The objective of this study is to report safety and efficacy outcomes of OFB in the setting of infected femoral pseudoaneurysms and infected prosthetic femoral bypass grafts., Methods: A multihospital, single-entity healthcare system retrospective review was conducted for all patients who underwent OFB between January 2014 through June 2020. Any patient >18 years of age who underwent OFB in the setting of groin infection with a minimum of 30 days follow-up was included in the trial. Demographic, operative, and clinical characteristics of patients were gathered during chart review. Statistical analysis was performed using Microsoft Excel and R studio., Results: Seventeen patients underwent OFB during the defined time-period. Demographic data are presented in the first table (Demographic Characteristics). Mean American Society of Anesthesiologists score was 3.25. Mean estimated blood loss was 500 mL. Mean operative time was 307 min. Mean follow-up time was 8.5 months (range 0-35 months). In total, 41.2% patients underwent fluoroscopic-guided tunneling, and, when compared to blind tunneling, showed no difference in intraoperative complications or operative time (P value 0.3). In total, 52.9% of patients required ICU admission resulting in a mean number of 0.8 ICU days. The overall mean length of stay was 16.8 days. Two major amputations were reported during follow-up. Patient mortality within 30 days was 0%. Primary patency within 30 days was 100%. Intravenous drug use was not associated with an increased number of subsequent groin wound procedures (P value 0.3). Intravenous drug use was not associated with concomitant methicillin-resistant Staphylococcus aureus infection (P value 0.3)., Conclusion: OFB is a safe and effective surgical option in patients who are unable to undergo anatomic tunneling during lower extremity bypass. OFB is associated with favorable rates of primary patency and amputation-free survival at midterm follow-up., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We aimed to study variables affecting limb outcome following ligation of infected femoral pseudoaneurysms in intravenous drug abusers (IVDA)in the emergency setting and to propose an algorithm for management., Design: Prospective study., Methods: We studied short-term outcomes of 26 IVDA presenting with infected femoral pseudoaneurysms who underwent arterial ligation, hematoma evacuation, and debridement. Long-term results pertaining to limb functionality were unfeasible, as all patients were lost to follow-up. We aimed to study the potential predictors that might impact limb outcome in the emergency setting, namely: 1) mode of presentation (impending versus ruptured), 2) site of arterial ligation (above versus below inguinal ligament), 3) presence or absence of pedal Doppler flow post-ligation, and 4) ankle brachial pressure index (ABI) pre- and post-ligation., Results: Arterial ligation without revascularization was done in 19 (73.1%) of our patients, requiring no further intervention for limb salvage during their hospital stay. Four patients (15.4%) required iliopopliteal bypass, and 3 patients (11.5%) required major amputations (2 hip disarticulations and one above-knee amputation). In total, 23 limbs (88.5%) were salvaged. Proximal arterial ligation was done below the inguinal ligament (common femoral artery) in 21 patients (80.8%), while in the remaining 5 patients (19.2%), higher ligation was done above the inguinal ligament (external iliac artery). All 19 patients who were compensated had pedal Doppler flow post-ligation, and 18 of them had arterial ligation done below the inguinal ligament. The mean preoperative ABI (±SD) was 0.87 ± 0.34, and the mean postoperative ABI (±SD) was 0.37 ± 0.27. The mean change in ABI (±SD) was 0.50 ± 0.32., Conclusions: Arterial ligation with local debridement alone is a safe procedure and would have salvaged 73.1% of limbs in this study. However, implementing a selective approach for post-ligation revascularization and our proposed algorithm increased limb salvage rate to 88.5%. The detection of pedal Doppler flow after ligation can stratify patients in whom urgent revascularization might not be required for limb salvage. Additionally, all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Totally occluded aortic aneurysm is a rare pathology. The medical history and the evolution are unknown. We present a case of a regularly followed up 60-year-old man with chronic thrombosed aneurysm, presenting with mycotic acute rupture. As an original treatment, the patient was treated by aortic ligation without distal revascularization. A literature review from 1974 to 2015 enhances the contemporary understanding of the pathology, by exploring the thrombus interaction, pressure, and the wall shear stress. The literature review confirms the poor prognosis and concludes of a necessary closer follow-up for chronic occluded aneurysm., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This is the first reported case in which a mycotic aneurysm refractory to the first medical treatment was treated with a Pipeline embolization device (PED), and the first case of a mycotic aneurysm from Brucella treated by endovascular therapy. A 35-year-old man presented with left eye pain and ptosis, and fever for 2 weeks. Before symptom onset, he visited Vietnam where he developed a flu-like illness; however, antibiotics were ineffective. We suspected Brucella as the most likely infectious etiology for the patient's intracavernous aneurysm. Since the aneurysm did not reduce in size following 2 weeks of antibiotic therapy, we placed a PED in the left internal carotid artery. Follow-up angiogram 4 months later showed no residual aneurysm, and cranial nerve palsies had completely resolved. From the results of this case, it appears that flow diverter stenting may be a safe and effective treatment of mycotic aneurysms of the cavernous segment of ICA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture., (Copyright © 2018 Elsevier Inc. All rights reserved.)

A 68-year-old man, presented with 3 week history of infective symptoms and mild haemoptysis. Past medical history included severe emphysema and a chronic right upper lobe (RUL) cavity. He was discharged from follow-up a year ago in view of clinical and radiological stability; previous bronchoscopic examinations yielded no specific diagnosis. CT scan on admission confirmed complex cavitary consolidation of RUL. He developed massive haemoptysis requiring intubation and ventilation. CT pulmonary angiogram (CTPA) revealed 16 mm RUL pulmonary artery (PA) aneurysm which was successfully embolized. Sputum cultures, aspergillus antigen and rapidity of clinical progression suggested a diagnosis of subacute invasive aspergillosis (SAIA), prompting treatment with Voriconazole. Bronchoscopy showed blood ooze from RUL even after embolization. Unfortunately, patient continued to deteriorate and succumbed to profound septicaemia., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

To report a clinical case of mycotic thoracic aortic aneurysm. To describe and illustrate the spectrum of MDCT findings, analysing the pathophysiology, diagnostic evaluation and therapeutic management. To emphasis the early non-invasive diagnosis as a way to overall survival improvement. A mycotic aneurysm is an uncommon vascular lesion resulting from arterial wall destruction by infection, generally involving the peripheral arteries or aorta and rarely the cerebral and visceral arteries. Defined as a lobulated saccular outpouching of the wall communicating with the lumen, it is surrounded by oedema, hematoma and/or fibro-inflammatory tissue. Due the non-specific and delayed - or even absent - manifestations, a high degree of clinical suspicion is necessary to achieve a timely treatment and prognosis improvement. In this setting, radiologic evaluation - mainly by MDCT angiography - is essential, allowing detection, characterization and complications assessment before treatment planning.

Competing Interests: Competing interests: None declared.

Objective: Reported are initial 12-month outcomes of patients with chronic symptomatic aortic dissection managed by the Streamliner Multilayer Flow Modulator (SMFM; Cardiatis, Isnes, Belgium). Primary end points were freedom from rupture- and aortic-related death, and reduction in false lumen index. Secondary end points were patency of great vessels and visceral branches, and freedom of stroke, paraplegia, and renal failure., Methods: Out of 876 SMFM implanted globally, we have knowledge of 542. To date, 312 patients are maintained in the global registry, of which 38 patients were identified as having an aortic dissection (12.2%). Indications included 35 Stanford type B dissections, two Stanford type A and B dissections, and one mycotic Stanford type B dissection., Results: There were no reported ruptures or aortic-related deaths. All cause survival was 85.3% Twelve-month freedom from neurologic events was 100%, and there were no incidences of end-organ ischemia, paraplegia or renal insult. Morphologic analysis exhibited dissection remodeling by a reduction in longitudinal length of the dissected aorta, and false lumen volume. A statistically significant reduction in false lumen index (P = .016) at 12 months, and a borderline significant increase in true lumen volume (P = .053) confirmed dissection remodeling., Conclusions: The SMFM is an option in management of complex pan-aortic dissection. Results highlight SMFM implantation leads to dissection stabilization with no further aneurysm progression, and no retrograde type A dissection. Thoracic endovascular aneurysm repair by SMFM ensued in freedom from aortic rupture, neurologic stroke, paraplegia and renal failure. Further analysis of the global registry data will inform long-term outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A 65-year-old man presented with an infected perivisceral aortic aneurysm after previous treatment of an abdominal aortic aneurysm with an endograft. On presentation, he was septic and had occlusion of the celiac, superior mesenteric, inferior mesenteric, and bilateral renal arteries. He underwent a three-stage procedure: first, axillobifemoral bypass; then resection of the thoracoabdominal aorta; and finally bypass from the ascending aorta to the celiac and superior mesenteric arteries with a rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The abdominal pain resolved, and the patient remains symptom free 10 months postoperatively. This rare surgical revascularization technique offered a nontraditional solution to a difficult surgical issue., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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.

Electrocardiographic voltage has been used to determine the presence of left ventricular hypertrophy for about 70 years. Varying electrocardiographic criteria have been applied. We have found total 12-lead QRS voltage to be most useful in this regard. We measured total 12-lead QRS voltage in 24 patients in whom an ascending aortic aneurysm was resected and histologic study of its wall was classic of syphilitic aortitis. In these 24 patients total 12-lead QRS voltage ranged from 57 to 161 mm, averaging 120 ± 32 in the 11 men and 106 ± 24 mm in the 13 women. If normal 12-lead QRS voltage in adults is considered to be >175 mm not a single one of the 24 patients had normal voltage. Indeed, most were in the low normal area. Thus, this study provides some evidence via this indirect means that the heart itself is infrequently involved by syphilitic aortitis which produces an ascending aortic aneurysm of sufficient size to warrant resection., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We describe a patient with ascending aorta aneurysm and bovine aortic arch who initially presented with fever. A 65-year-old man with a 2-month history of intermittent fever was referred to our hospital and diagnosed as having a gonococcal ascending aorta aneurysm with penetrating ulcers. He was successfully treated by resection of the ascending aorta and ulcers, replacement of the aortic valve, and prolonged postoperative antibiotic therapy., (© The Author(s) 2014.)

This study reports 6 cases of hemoptysis originating from infectious pulmonary artery pseudoaneurysms (PAPs). Selective pulmonary angiography revealed PAPs in 5 cases, and segmental pulmonary artery embolization was performed using coils and gelatin sponge particles. Systemic arterial embolization also was performed in 5 cases because of inadequate initial control or for shunts from systemic to pulmonary arteries. At a median follow-up time of 9 months (range, 25 d to 25 mo), no recurrence occurred, although 2 patients died of respiratory failure. Segmental artery embolization combined with systemic artery embolization may be useful in patients with hemoptysis secondary to PAPs., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Endocarditis is an uncommon presentation of Kingella kingae infection in children. A previously healthy 17 month old child was referred to our emergency department for evaluation of fever lasting eleven days, aphthous stomatitis and a new systolic murmur. Within a few hours of admission, antibiotic therapy was initiated for a presumptive diagnosis of bacteremia and within 24 hours after admission, gram negative coccobacilli were growing in the blood culture. In addition, echocardiography demonstrated a mycotic aneurysm of the ascending aorta with a mobile vegetation. The presumptive diagnosis of Kingella kingae endocarditis was made. Further evaluation by MRI revealed frontal and occipital cerebral infarcts. Due to the presence of presumed septic emboli in conjunction with progressive left ventricular dysfunction, the child was urgently taken to the operating room where aggressive debridement of the infected tissue was performed and the aortic aneurysm was repaired. The patient had an uneventful post-operative course. This case emphasizes the need for a high index of suspicion when evaluating children with community acquired infection. In addition, it also demonstrates the importance of early diagnosis and appropriate treatment of K. kingae endocarditis.

This pictorial essay reviews the pathophysiology and causes of mycotic aneurysms, their typical imaging appearances, mimics of mycotic aneurysms on CT, and treatment options. Correctly diagnosing mycotic aneurysms is critical for patient morbidity and mortality, as infected aneurysms are at extremely high risk of rapid growth and sudden rupture. The presence of a constellation of suggestive imaging features, as well as concerning patient symptomatology, should raise the possibility of a mycotic aneurysm.

Purpose: To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes., Methods: Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation >6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR)., Results: Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.0±6.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.12±0.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p=0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p=0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p<0.002, HR 4.02, 95% CI 1.70 to 9.49)., Conclusion: There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

We present a 52-year-old male with a syphilitic aortic arch aneurysm accompanied by relevant extensive cerebral infarction. He was admitted to a local hospital for sudden loss of consciousness, where he was diagnosed with serious cerebral infarction. During his treatment, a multilocular aortic arch aneurysm involving the arch vessels was found incidentally. He was transferred to our hospital for surgical treatment. A preoperative routine laboratory test for syphilis was highly positive, which suggested that the aneurysm was likely caused by syphilis and the cerebral infarction was also induced by the involvement of syphilitic aortitis or arteritis. After 2 weeks of antibiotic therapy for syphilis, total arch replacement was performed successfully using meticulous brain protection with antegrade selective cerebral perfusion and deep hypothermia. He recovered without any further cerebral deficits. The pathological examination of the surgical specimen showed some characteristic changes of syphilitic aortitis.

In contrast to autogenous arteriovenous (AV) fistulae where true aneurysms are the most frequent type, aneurysms in prosthetic AV grafts are mostly false aneurysms and less frequently anastomotic ones. Indications for repair comprise false aneurysms exceeding twofold the graft diameter, those with rapid enlargement or with skin thinning or erosion, the ruptured, those causing pain or severely limiting the cannulable area and the infected ones. They can be managed either with conventional surgery or with endovascular techniques; However, conventional surgery represents the current standard treatment consisting of either aneurysm resection and interposition graft in situ or resection/exclusion and bypass via a new route to avoid a potentially contaminated area.

Purpose: To report the use of multilayer uncovered stent to treat primary infected juxtarenal aortic aneurysm., Case Report: A 50-year-old man was admitted to hospital for rapid onset of intractable abdominal pain and high fever. Computed tomographic scan showed 2 juxtarenal saccular aneurysms of abdominal aorta with morphologic and clinical changes compatible with infectious etiology. Patient was treated with multilayer flow-modulating stent. Follow-up imaging showed persistent aneurysm exclusion and continuous aneurysm shrinkage of the sac until complete regression to a normal aortic configuration was seen at 1 year. During follow-up (24 months), patient continued to do well, and there was no recurrence of infection., Conclusion: Multilayer stent appeared to be an acceptable treatment option for primary infected juxtarenal aortic aneurysms. Aneurysmal sac completely disappeared and visceral branches remained patent at 2-year follow-up. However, longer follow-up is necessary to evaluate the long-term patency of involved visceral arteries.

Purpose: This study was designed to determine the clinical presentation, characteristics, and management of aneurysm/pseudoaneurysm formation (APF) in dialysis access fistulas., Methods: The treatment methods and outcomes of 31 patients who underwent surgery for APF in dialysis access fistulas were retrospectively reviewed over a 9-year period., Results: We performed 1558 operations for arteriovenous fistulas (AVFs) between 2000 and 2009 at our centre. Of the 1558 operations, 35 were carried out for APFs (2.2%) on 31 patients. Thirty of these operations were restorative. Twenty-two (71%) of these patients had their original access done elsewhere, and all corrective surgeries were performed at our hospital. Approximately 52% of the subjects were female, with a mean age of 45.7 ± 17 years. The mean duration of end-stage renal disease was 70.2 ± 51.5 months. The mean number of AVFs per patient was 2.2 ± 1.5. Synthetic grafts were used in five patients (16.1%). Most of the procedures were left-sided (67.7%) and brachial-cephalic fistulas (48.3%). Among 31 complications, 22 were arterial/venous aneurysms (71%) and nine were pseudoaneurysms (29%). Fourteen patients (46.6%) were treated by excision of the aneurysm and primary suture repair. The post-intervention primary patencies for all revised APFs were 68%, 56%, and 52% at 1, 6, and 12 months, respectively. Dysfunction of AVF (16.1%) and bleeding (12.9%) were the most encountered complications after aneurysmectomy., Conclusion: Reformative operations should be considered in cases of urgency and irresponsiveness to endovascular surgery rather than closing the fistulas directly, as it prolongs the duration of AVF patency.

A 1-month-old girl underwent right modified Blalock-Taussig shunt (mBTS) for pulmonary atresia with hypoplastic right ventricle. Five months after palliation, she suffered from sepsis and progressive desaturation following otitis media. Computed tomography and angiography revealed a pseudoaneurysm surrounding the mBTS graft. After stabilization of the infection, we performed pseudoaneurysm resection, shunt-graft removal, and the bidirectional Glenn (BDG) procedure under cardiopulmonary bypass. Her condition improved, and she was discharged on the 17th day after surgery. When parameters for the partial right heart bypass should permit, the BDG procedure can be a beneficial recovery procedure for the cases of infected pseudoaneurysm after mBTS in Fontan candidates.

Described in the article is a clinical case report concerning surgical treatment of a 65-year-old male patient presenting with a ruptured infectious aortic arch aneurysm. He was subjected to an operation consisting in prosthetic repair of the ascending portion of the aorta and aortic arch with a homograft under conditions of artificial circulation, deep hypothermia, and antegrade cerebral perfusion.

Pediatric aneurysms are rare diseases distinct from classical adult aneurysms and therefore require different treatment strategies. Apart from saccular aneurysms that are more commonly found in older children, three major pathomechanisms may be encountered: trauma, infection, and dissection. The posterior circulation and more distal locations are more commonly encountered in children compared to adults, and there is an overall male predominance. Clinical findings are not only confined to subarachnoid hemorrhage but may also comprise mass effects, headaches or neurological deficits. In traumatic aneurysms, the skull base and distal anterior communicating artery are commonly affected, and the hemorrhage occurs often delayed (2-4 weeks following the initial trauma). Infectious aneurysms are mostly bacterial in origin, and hemorrhage occurs early after a septic embolic shower. Dissecting aneurysms are the most often encountered aneurysm type in children and can lead to mass effect, hemorrhage, or ischemia depending on the fate of the intramural hematoma. Treatment strategies in pediatric aneurysms include endosaccular coil treatment only for the "classical berry-type" aneurysms; in the other instances, parent vessel occlusion, flow reversal, surgical options, or a combined treatment with bypass and parent vessel occlusion have to be contemplated.

Primary aortoenteric fistula is most commonly caused from erosion of the bowel wall by an abdominal aortic aneurysm. Septic aortitis with pseudoaneurysm formation and finally erosion into the duodenum represents a rare cause that has been described in very few patients in the literature. We present a rare clinical case of Salmonella aortitis and associated infrarenal aortic pseudoaneurysm that evolved into an aortoduodenal fistula. A 51-year-old man was admitted in our hospital with symptoms and signs of sepsis caused by Salmonella bacteremia. Imaging studies revealed an infrarenal aortic pseudoaneurysm. The patient presented hemodynamic instability, and during emergency laparotomy a fistula was found between the third portion of the duodenum and a false aneurysm arising from a nonaneurysmal grossly infected aorta. The affected aortic segment was excised and the intestinal defect was repaired. The aortic stumps were sutured and an axillobifemoral bypass was performed. The patient had an uncomplicated postoperative course., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: We analyzed the hemodynamic changes induced by femoral artery ligation with concomitant thrombectomy in intravenous drug abusers with infected femoral artery pseudoaneurysm (IFAP) and their clinical significance., Methods: Between January 2000 and November 2007, a total of 55 patients presented to our clinic with IFAP. Among these patients, 54 were treated by femoral artery ligation with concomitant thrombectomy. Open collateral circulations were assessed by intraoperative angiography, including detection of mean artery pressure (MAP) of back-flow from the profunda femoris artery and the superficial femoral artery after operation. Patients were followed up for 3-72 months (mean 35). The data were then subjected to statistical analysis., Results: Preoperative death occurred in one patient due to acute onset of drug addiction in the ward. Preoperatively, massive necrosis developed in the left limb of the only patient with bilateral IFAPs. All 54 patients underwent femoral artery ligation with concomitant thrombectomy, including nine cases of ligation of the external iliac artery and one case of above-knee limb amputation. All wounds were completely healed within 3 months. Six late deaths (11.1%), resulting solely from refractory drug addiction, were observed during the follow-up period, of which two occurred 2 years, one 4 years, and three 5 years postoperatively. No toe amputations were noted during the follow-up period. Fourteen patients (25.9%) developed intermittent claudication. One postoperative limb was lost. Of all 54 patients, 38 were subjected to collateral circulation assessment by intraoperative angiography. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. Four preferred types of iliac-femoral collaterals were defined. Postoperatively, compared to the external iliac artery, the MAP levels of back-flow from the profunda femoris artery and the superficial femoral artery significantly dropped to 43.89+/-2.75 and 18.08+/-2.76 mm Hg, respectively., Conclusion: As a result of femoral artery ligation without reconstruction, well open collateral circulations and acceptable distal arterial runoff blood are seen, which suggests that this procedure is a reliable alternative to the emergent treatment of IFAPs in drug addicts. However, arterial reconstruction may be used as a backup approach if necessary during observation., (Copyright 2009 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Brachial artery pseudoaneurysms secondary to intravenous drug abuse represent a limb-threatening problem to patients and a technical challenge to the vascular surgeon. Here information is reported about a patient with metachronous bilateral giant brachial artery pseudoaneurysms secondary to intravenous drug use that were successfully treated with excision of the aneurysm and ligation of the brachial artery. Furthermore, a review of the current literature on the treatment of brachial artery aneurysm is presented.

Background: Arterial groin infections in drug addicts are associated with a risk of amputation and are potentially lethal. Primary revascularization with an obturator bypass represents a potential alternative to local revision and arterial ligation alone. We report our experience with this approach., Patients and Methods: From January 1999 until December 2005 twelve drug addicts were treated due to arterial infections in the groin. In eight patients (seven men, one woman, 31 years old on average), the defect in the artery could not be repaired and ligation of the femoral vessels led to critical ischemia. Therefore, an iliaco-popliteal bypass via the foramen obturatorium was implanted either primarily or secondarily. In three patients a cryopreserved homologous vein was used, five patients received alloplastic grafts., Results: Four of eight obturator bypasses were implanted primarily. In the other four patients the initial treatment was limited to local debridement and artery ligation and an obturator bypass was implanted at a later date. Two grafts occluded within the first 30 days. Thereof one was successful thrombectomized. The other patient had no critical ischemia and he refused further surgery. Three more grafts occluded at 74, 90 and 103 days after surgery. No patient demonstrated signs of graft infection and all groin incisions healed uneventfully. A lower limb amputation became necessary in one patient even though the reconstruction was patent due to embolisation of mycotic material. All patients remained drug dependent throughout the followup time which was 3 months on average and ranged from one to 40 months., Conclusions: The patency of obturator bypasses was 75% at one month. This appears low, especially if one considers the youthful age of the patients and the absence of arterial occlusive disease. Nevertheless, the amputation rate also remained low. Therefore, we feel that this technique may contribute to limb salvage in groin infections in drug addicts.

Background: Intracranial infectious aneurysms (IA) are infrequent, but can be fatal., Objectives: To compare the clinical profile of IAs associated with intravascular/systemic infection like infective endocarditis with that associated with local infections like meningitis, orbital cellulitis and cavernous sinus thrombosis., Methods: We analysed all cases of IA, treated in this Institute from 1976 to 2003, in order to identify prognostic factors., Results: There were 25 persons (mean age 24.8+/-17.3 years, males 17) with 29 IA (carotid circulation 19, vertebrobasilar circulation 10). Headache (83%) and fever (67%) were the most common presenting symptoms. In contrast to noninfectious aneurysms, intracerebral haemorrhage (60%) and focal signs were more common than subarachnoid haemorrhage (7%) with IA. Sources of infection were cardiac (10), meningitis (12), orbital cellulitis (2) or uncertain (1). Infective agents included bacteria (18), fungi (4), and tubercle bacilli (3). Fifteen IA were distal and 14 were proximal. IAs associated with meningitis were proximal (75%) while those associated with cardiac diseases preferentially involved carotid territory and were distal (p=0.013). The overall mortality was 32%. Survivors were younger than those who expired (p=0.015). Of the sixteen patients treated medically, seven recovered (44%), others (56%) had treatment failure (three died and six required surgery later). Another five patients underwent early surgery (one died). Mortality of IA was significantly higher with meningitis, fungal aetiology and vertebrobasilar location., Conclusions: IAs associated with local infections like meningitis had different clinical profile as compared to IAs associated with intravascular/systemic infections like infective endocarditis.

Elastolytic matrix metalloproteinases play a central role in the development of chronic atherosclerotic aortic aneurysms, but mycotic aortic aneurysms are a distinct and unusual form of aneurysm disease caused by bacterial infection. Mycotic aortic aneurysms follow a more rapid and unpredictable course than chronic aneurysm disease and they exhibit a predilection for the suprarenal aorta, further implying unique pathophysiologic mechanisms. The purpose of this study was to examine the nature and source of elastin-degrading enzymes in mycotic aortic aneurysm. Bacterial isolates and aortic tissues were obtained from four consecutive patients undergoing surgical repair of suprarenal mycotic aortic aneurysm. Using an in vitro 3H-labeled elastin degradation assay, elastin-degrading enzyme activity was only observed in the bacteria-conditioned medium from an isolate of Pseudomonas aeruginosa. Elastin-degrading enzyme activity in the aortic tissue homogenate of this patient was abolished by the serine protease inhibitor, phenylmethylsulfonyl fluoride, but it was not suppressed by the metalloproteinase inhibitor, ethylenediamine tetraacetic acid (EDTA). In contrast, elastin-degrading enzyme activity in the bacterial-conditioned medium was decreased by about half by both phenylmethylsulfonyl fluoride and EDTA. Elastin substrate zymography revealed two phenylmethylsulfonyl fluoride-inhibitable elastin-degrading enzyme activities in the aortic tissue homogenate that corresponded to human neutrophil elastase (approximately 30 kDa) and its stable complex with alpha 1-proteinase inhibitor (approximately 80 kDa), but no activity attributable to Pseudomonas elastase, a 33-kDa metal-dependent enzyme. Human neutrophil elastase was readily detected throughout mycotic aortic aneurysm tissues by immunohistochemistry, but elastolytic metalloproteinases were only occasionally observed. The results of this study suggest that the elastin-degrading enzyme produced in mycotic aortic aneurysm are largely serine proteases of host neutrophil origin, rather than elastases produced by the infecting microorganisms or the macrophage-derived metalloproteinases typically observed in atherosclerotic aneurysm disease. Further studies will be needed to extend these findings to a larger number of patients with mycotic aortic aneurysm and those caused by additional microorganisms.

Mycotic aneurysms of the abdominal aorta are potentially fatal but uncommon. We report the MRI and MRA features of an abdominal aortic mycotic aneurysm in a patient who presented with nonspecific low back pain. By delineating the saccular nature of the aneurysm and identifying the coexistence of vertebral enhancement, MRI was crucial for the final diagnosis. A potential pitfall of contrast-enhanced MRA is also demonstrated.

Due to the advent of antibiotics, mycotic aneurysms, also known as infective aneurysms, now represent only 2.5-5% of all aneurysms. The existing research on this topic is old and scarce. It is highly probably that a neuroscience nurse will care for this type of patient at some point during his/her career. The patient with a mycotic aneurysm is usually critically ill. A 46% mortality has been noted and is related to the multiple problems of these types of patients. Currently, if and when to surgically intervene is controversial. The case of "Mr. C.", a patient at the Montreal Neurological Hospital who developed a mycotic aneurysm secondary to subacute bacterial endocarditis, will be presented. His course in hospital, the medical management and treatment as well as the nursing care and educational needs will be described.

Two years after a Staphylococcus aureus septicaemia, in a patient with dermatopolymyositis occurred an infectious aneurysm of abdominal aorta with contiguous pyogenic spondylodiscitis. Coexistence of both pathologies is rare and physiopathological mechanisms still remain uncertain. However, many arguments in the present case report are in favour of the initial responsibility of an infectious aneurysm. Main interest in early diagnosing infectious aneurysm, allowed by new investigations such as magnetic resonance imaging and marked leukocyte bone scanning, is the prevention of major complications. Antibiotherapy and surgical removal of infectious aneurysm must be quickly achieved in every case.

New conduction defects in the setting of native valve infective endocarditis (IE) are commonly believed to be associated with direct extension beyond the free valve area. At University Hospital in Newark, among 100 cases of IE, in none of five instances of associated conduction defects (excluding first-degree heart block) was this the case. In neither of two instances of direct extension of valve infection was this accompanied by a new conduction defect. To explore this relationship, autopsy, surgical, and echocardiographic findings from other institutions were combined with these data. Among 47 instances of new conduction defects in IE, only 60% could be related to direct extension of valve infection. The cause was coronary embolization in 4% and unknown in 36%. Among 119 cases of complicated valve lesions, significant conduction defects were documented by ECG in only 15%. In IE the appearance of new conduction abnormalities may often result from causes other than extension of valve infection. Furthermore, complicated valve lesions may often be present without electrocardiographic evidence, indicating interruption of normal conduction pathways.

Gas-forming mycotic aneurysms are extremely rare. A case is reported in which rupture of a gas-forming mycotic aneurysm of the distal abdominal aorta due to Clostridium paraputrificum occurred in an elderly male with a myeloproliferative disorder and a necrotic carcinoma of the colon.