J Thorac Cardiovasc Surg 2008;135:1404-1405
© 2008 The American Association for Thoracic Surgery
Reply to the Editor
I-Hui Wu, MD,
Ron-Bin Hsu, MD,
Fang-Yue Lin, MD, PhD
Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
We appreciate Dr Ugurlucan's comments on the issue of mycotic aortic aneurysms treated by endovascular approach. We believe that the endovascular stent graft is superior in some ways to open surgical repair for the treatment of mycotic aortic aneurysms, especially in the emergency setting for debilitated patients with critical aortic segment involvement. In a recent published literature review by Kan and colleagues,1
the endovascular treatment strategy was noted to have 30-day and 2-year survivals of 89.6% and 82.2%, respectively. To date, however, there is still no level I evidence to convince us that endovascular treatment is the criterion standard for mycotic aortic aneurysm.
In Taiwan, the abdominal aortic stent graft was approved by Department of Health for clinical use only after July 2005, and the thoracic stent graft was approved after November 2006. In our published article,2 patients were treated through 2006, before the endovascular stent graft era in Taiwan. Since 2006, we have performed endovascular stent graft placement in patients with ruptured mycotic aortic aneurysm. In our preliminary data, there have been 4 patients with ruptured mycotic abdominal and thoracic aortic aneurysms treated by the endovascular technique. Of these, 1 patient required a total visceral artery debranching procedure for the ruptured suprarenal mycotic aneurysm simultaneously with the stent graft placement. The pathogen is similar to our published database2 as nontyphoid Salmonella. There was one in-hospital death with new development of aortoduodenal fistula. There was another death later than 30 days from the non–aneurysm-related cause of uncontrolled septic shock. The other 2 patients require long-term oral antibiotic therapy. There were no cerebral vascular events or stent graft–related deaths among these 4 patients.
This seems to be a result comparable to that of open surgical repair. We are still not sure, however, whether for those with aortoesophageal aneurysm, aortobronchial aneurysm, or residual abscess in the image study further débridement and elective open surgical grafting will be necessary after stent graft placement, once the patient condition has been stabilized. In addition, for mycotic aneurysms involving the aortic arch or visceral arterial segment, the hybrid debranching procedure or fenestrated branching technique for the stent graft placement still carries some morbidity and mortality risk. The optimal use of endovascular stent graft for mycotic aortic aneurysm needs to be clarified in further studies.
References
- Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg 2007;46:906-912.[Medline]
- Hsu RB, Lin FY. Surgery for infected aneurysm of the aortic arch. J Thorac Cardiovasc Surg 2007;134:1157-1162.[Abstract/Free Full Text]
