Opioid growth factor modulates angiogenesis.

OBJECTIVE: Induced angiogenesis has recently been attempted as a therapeutic modality in patients with occlusive arterial atherosclerotic disease. We investigated the possible role of endogenous opioids in the modulation of angiogenesis. METHODS: Chick chorioallantoic membrane was used as an in vivo model to study angiogenesis. Fertilized chick eggs were incubated for 3 days, explanted, and incubated for an additional 2 days. Three-millimeter methylcellulose disks were placed on the surface of the chorioallantoic membrane; each disk contained opioid growth factor ([Met(5)]-enkephalin; 5 microgram), the short-acting opioid receptor antagonist naloxone (5 microgram), opioid growth factor and naloxone together (5 microgram of each), the long-acting opioid antagonist naltrexone (5 microgram), or distilled water (control). A second series of experiments was performed with distilled water, the angiogenic inhibitor retinoic acid (1 microgram), and vascular endothelial growth factor (1 microgram) to further evaluate our model. The developing vasculature was imaged 2 days later with a digital camera and exported to a computer for image analysis. Total number of blood vessels, total vessel length, and mean vessel length were measured within a 100-mm(2) region surrounding each applied disk. Immunocytochemical analysis was performed with antibodies directed against opioid growth factor and its receptor (OGFr). RESULTS: Opioid growth factor had a significant inhibitory effect on angiogenesis, both the number of blood vessels and the total vessel length being decreased (by 35% and 20%, respectively) in comparison with control levels (P <.005). The simultaneous addition of naloxone and opioid growth factor had no effect on blood vessel growth, nor did naloxone alone. Chorioallantoic membranes exposed to naltrexone displayed increases of 51% and 24% in blood vessel number and length, respectively, in comparison with control specimens (P <.005). These results indicate that the opioid growth factor effects are receptor mediated and tonically active. Immunocytochemistry demonstrated the presence of both opioid growth factor and OGFr within the endothelial cells and mesenchymal cells of the developing chorioallantoic membrane vessel wall. Retinoic acid significantly reduced the number and the total length of blood vessels, whereas vascular endothelial growth factor increased both the number and the length of blood vessels in comparison with the controls (P <.0001). The magnitude of opioid growth factor's effects were comparable to those seen with retinoic acid, whereas inhibition of opioid growth factor with naltrexone induced an increase in total vessel length comparable to that for vascular endothelial growth factor. CONCLUSIONS: These results demonstrate for the first time that endogenous opioids modulate in vivo angiogenesis. Opioid growth factor is a tonically active peptide that has a receptor-mediated action in regulating angiogenesis in developing endothelial and mesenchymal vascular cells.

Deep venous thrombosis after percutaneous insertion of vena caval filters.

PURPOSE: A large multicenter study has recently questioned the overall clinical efficacy of vena caval filters, especially when inserted prophylactically, because of the subsequent development of deep venous thrombosis (DVT) at the insertion site. We examined the incidence of this complication with newer, smaller diameter percutaneous devices. METHODS: We reviewed our vascular surgery and interventional radiology clinical registries to identify patients in whom a femoral percutaneous vena caval filter had been placed from 1993 to 1998. This list was cross referenced with patients who had undergone lower extremity venous ultrasound scan examinations for the diagnosis of DVT in the vascular laboratory within a 60-day period before and after the insertion of the filter device. RESULTS: A total of 35 patients during this 5-year period had timely follow-up venous duplex scan studies performed. The indications for filter placement were DVT in 16 patients (46%), pulmonary embolus in 13 patients (37%), DVT and pulmonary embolus in three patients (9%), and prophylactically in three patients (9%) at high risk for thromboembolization. Of the patients with documented thromboembolic events, 91% (29 of 32) had contraindications to anticoagulation therapy, and the remaining 9% (3 of 32) represented failure of anticoagulation therapy. A Greenfield filter was used in 13 patients (37%), a Simon Nitinol filter was used in 11 patients (31%), and a VenaTech filter was used in nine patients (26%). The other two patients (6%) had a Bird's Nest filter inserted. At a mean follow-up period of 12 +/- 2 days (median, 6 days), there was a 40% (14 of 35) incidence of proximal DVT in venous segments without evidence of thrombus before filter insertion. The majority (71%; 10 of 14) occurred in the common femoral vein, with three located in the superficial femoral vein and one in the external iliac vein. The lowest incidence of DVT was seen with the Greenfield and Bird's Nest filters as compared with the smaller Simon Nitinol and VenaTech filters (20% vs 55%; P < .05). The highest incidence of thrombosis occurred in patients with pre-insertion pulmonary emboli (50%; 8 of 16) as compared with those patients with DVT (38%; 6 of 16) and prophylactic insertion (0%; 0 of 3). However, the subgroups were too small to attain statistical significance. CONCLUSION: There is a continuing and significant incidence of new DVT development ipsilateral to the percutaneous femoral insertion site of vena caval filters. The smaller diameter filters are not associated with a lower incidence of femoral thrombosis.

A national survey of practice patterns in the noninvasive diagnosis of deep venous thrombosis.

PURPOSE: Recent studies have recommended unilateral venous duplex scanning for the diagnosis of deep venous thrombosis (DVT) in patients who are unilaterally symptomatic. Vascular laboratory accreditation standards, however, imply that bilateral leg scanning should be performed. We examined whether actual practice patterns have evolved toward limited unilateral scanning in such patients. METHODS: A questionnaire was mailed to all 808 vascular laboratories in the United States that were accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL). To encourage candid responses, the questionnaires were numerically coded and confidentiality was assured. RESULTS: A total of 608 questionnaires (75%) were completed and returned. Most of the respondents (442; 73%) were either community-hospital or office-based laboratories, and the remaining 163 (27%) were university or affiliated-hospital laboratories. Most of the laboratories (460; 76%) had been in existence for 9 years or more, and 65% had been ICAVL-accredited in venous studies for 3 years or more. Board-certified vascular surgeons were the medical directors in 54% of the laboratories. Duplex ultrasound scanning was the diagnostic method used by 98% of the laboratories. In patients with unilateral symptoms, 75% of the laboratories did not routinely scan both legs for DVT. A large majority (75%) believe that bilateral scanning is not clinically indicated. Only 57 laboratories (14%) recalled having patients return with a DVT in the previously unscanned leg, with 93% of these laboratories reporting between one and five such patients. This observation correlated with larger volumes of venous studies performed by those laboratories (P <.05). Similarly, only 52 laboratories (12%) recalled having patients return with subsequent pulmonary emboli. Of these laboratories, only five reported proximal DVT in the previously unscanned legs of such patients. Of all these laboratories, therefore, only 1% (5 of 443) have potentially missed the diagnosis of a DVT that caused a preventable pulmonary embolus with such a policy. Among those laboratories that always perform bilateral examinations, 41% do so because of habit. Most (61%) of the laboratories that perform bilateral scanning would do unilateral scanning if it were specifically approved by ICAVL. CONCLUSION: Three quarters of the ICAVL-accredited vascular laboratories perform limited single-extremity scanning for the diagnosis of DVT in patients with unilateral symptoms. This broad clinical experience suggests that this practice is widespread in selected patients. Clinical protocols should be established to provide guidelines for local laboratory implementation.

Risk factors and outcomes following revascularization for chronic mesenteric ischemia.

Revascularization for chronic mesenteric ischemia is an infrequent vascular procedure whose objective long-term patency results have been described in relatively few patients. We reviewed our experience with such procedures and report on the objective and symptomatic long-term results. We retrospectively reviewed a consecutive series of 42 patients who underwent mesenteric arterial reconstruction of 66 vessels during an 11-year period from 1986 to 1997. All patients were treated for symptomatic chronic mesenteric ischemia. The results support the clinical efficacy and durability of visceral artery bypass procedures for patients with symptomatic chronic mesenteric ischemia. Patency rates for females were better than for males independent of graft type.

Can a one-day workshop alter surgeons' teaching practices?

BACKGROUND: A 1-day workshop, consisting of five sections with small group discussions and opportunities for practical application of participants' knowledge, was developed to enhance the teaching skills of practicing surgeons. Immediate and long-term follow-up surveys were completed by the participants. METHODS: Post-workshop evaluations were obtained from all participants who took the workshop; follow-up surveys were mailed 4 to 6 months later. RESULTS: Workshop quality was rated as good (25%) or excellent (75%) by all participants. Follow-up survey results indicated that many participants had rarely/never utilized cited references, looked for additional resources on specific topics, or referred to the section syllabus/handout materials provided during the workshop. However, 100% of the participant respondents reported that they had changed the way they teach as a result of their workshop attendance. CONCLUSION: An abbreviated course on surgical education can result in long-term changes in the participants' perceptions of their teaching practices. Further study is required to determine if these perceived changes in teaching practices, which the participants have directly attributed to their workshop attendance, have resulted in measurable improvement in their effectiveness and efficiency as teachers.

Renal revascularization in patients on dialysis.

Five patients requiring dialysis for acute pulmonary edema and uremia from severe renal artery occlusive disease underwent surgical revascularization. Three patients with oliguria had excellent outcomes and remain dialysis-independent as long as twenty-four months following operation (mean serum creatinine 2.0 mg/dl). The two patients who were anuric both had technically successful operations but remained dialysis-dependent. Diagnostic evaluation of the azotemic patient suspected to have renal arterial occlusive disease should include a history and physical examination, urinalysis, renal ultrasound, and duplex scan of the renal arteries. In appropriate patients, arteriography should then be considered if other diagnoses appear unlikely. This algorithm may help identify those patients who might benefit from renal revascularization. It appears that oliguria rather than anuria and the angiographic demonstration of a patent distal vessel and nephrogram suggest a better functional outcome after revascularization. Unfortunately, the response to surgery cannot be reliably predicted and patient selection remains a challenge, but retrieval of renal function can be achieved in some cases even if patients are already being hemodialyzed.

Thrombolytic therapy and balloon catheter thrombectomy in experimental femoral artery thrombosis: effect on arterial wall morphology.

PURPOSE: To determine vessel wall architectural changes after lytic therapy and balloon catheter thrombectomy in experimentally thrombosed arteries. MATERIALS AND METHODS: Bilateral 5-cm femoral artery occlusions were created by ligation in 14 dogs. Two dogs served as controls, and 12 animals underwent balloon catheter thrombectomy on the left and lytic therapy with urokinase on the right either 24 hours (group 1, n = 6) or 7 days (group 2, n = 6) after creation of the occlusion. After treatment, the area of thrombosis was subjected to light and scanning electron microscopy. RESULTS: The IEL was intact in all lysed arteries. IEL fractures were present in 11 of 12 arteries treated with thrombectomy. For group 1 arteries, average luminal area after thrombectomy was 5.63 mm2 +/- 0.66 versus 1.94 mm2 +/- 0.7 after lytic therapy (P < .007). Mean control artery luminal area was 2.86 mm2 +/- 0.52. Similar differences were found in group 2 arteries. With lytic therapy, scanning electron microscopy grading revealed surfaces to be intact in group 1, but moderate injury was exhibited in group 2. All arteries treated with thrombectomy had severe injury. CONCLUSIONS: Lysis of acute thrombi (group 1) preserved arterial wall architecture, with an intact IEL and no endothelial injury. Lysis of chronic thrombi (group 2) was associated with mild to moderate injury. Catheter thrombectomy caused severe injury regardless of the time of intervention. These results may help explain the poor long-term patency observed after these interventions.

Relative risks of limb revascularization and amputation in the modern era.

A retrospective review of 266 patients undergoing infrainguinal revascularization for limb salvage and/or major amputation (transmetatarsal, below-knee or above-knee) from 1984 to 1990 was conducted to determine comprehensive procedure-specific 30-day operative morbidity and mortality rates. Some 211 patients underwent 295 infrainguinal vascular reconstructions (195 primary and 100 secondary reconstructions). There were 122 major amputations in 98 patients (29 above-knee, 70 below-knee and 23 transmetatarsal). Most amputations were performed in patients with unreconstructable vascular disease, including 39 patients (41 extremities) with failed infrainguinal reconstruction. Procedure-specific morbidity and mortality rates were 48 and 2% for primary revascularization, 35 and 2% for secondary revascularization and 37 and 4%, for amputation, respectively. The difference in mortality between revascularization and amputation approached but did not achieve statistical significance. Cardiac, graft and wound complications were the major causes of morbidity in all groups. Nine of the 12 deaths were of cardiac etiology. Revascularization can be performed in almost all patients with advanced limb ischemia, with a mortality rate equivalent to, or perhaps lower than, that of amputation. When limb amputation is required, it can be performed with a mortality rate remarkably lower than that described in the older literature.

Validation of air plethysmography, photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis.

PURPOSE: The purpose of this study was to validate the diagnostic capabilities of the most commonly used noninvasive modalities for evaluation of chronic venous insufficiency. METHODS: Twenty limbs in 20 patients were studied with air plethysmography (APG), photoplethysmography (PPG), and duplex ultrasonography. Ten limbs (group 1) were clinically without any venous disease. Group 2 consisted of 10 limbs with severe, class 3 venous stasis. Duplex ultrasonography, complemented with Doppler color-flow imaging was used to examine the superficial and deep venous systems to identify reflux. RESULTS: Ultrasonography identified deep venous reflux in eight of 10 limbs in group 2. Severe superficial reflux was identified in the two remaining limbs. Seven limbs with deep reflux also demonstrated severe superficial reflux. Superficial venous reflux was identified in one leg in group 1. APG accurately separated normal limbs from those with reflux. Parameters that were significantly different (p < 0.05) between the two groups were the venous filling index, (group 1 = 1.37 +/- 1.16 ml/sec, group 2 = 29.5 +/- 6.2 ml/sec.), venous volume (group 1 = 107 +/- 10.1 ml, group 2 = 220 +/- 22.5 ml), ejection fraction (group 1 = 52.5% +/- 2.3%, group 2 = 32.5% +2- 4.6%), and residual volume fraction (group 1 = 21.4 +/- 2.0%, group 2 = 52.1% +/- 2.5%). PPG refill times were significantly shortened in group 2 versus those of group 1 (6.4 +/- 0.89 sec vs 20.2 +/- 1.1 sec). The sensitivity of PPG refill times to identify reflux was 100%, but the specificity was only 60%, whereas the sensitivity and specificity for the residual volume fraction was 100%. The venous filling index was able to identify reflux and determine whether only superficial reflux was present with a sensitivity of 100% and a specificity of 90%. The kappa coefficient of agreement between duplex scanning and APG was 0.83, whereas between duplex and PPG it was only 0.47. CONCLUSION: APG accurately identifies limbs with and without venous reflux when compared with duplex ultrasonography. APG is a better method of evaluating clinically significant venous reflux than PPG. PPG is a sensitive method of detecting reflux, but the specificity is poor, and PPG refill times cannot accurately predict the location of reflux. The combination of APG and duplex ultrasonography provides the best means of assessing venous reflux.

Prediction of postoperative complications after elective aortic surgery using stepwise logistic regression analysis.

Perioperative risk factors that contribute to postoperative morbidity have been identified for various forms of vascular disease, but it is not clear to what degree each type of disease contributes to morbidity when these diseases are seen in combination. We used stepwise logistic regression analysis to determine the relative importance of 25 risk factors in predicting postoperative complications in 100 consecutive patients undergoing elective intra-abdominal aortic surgery (59% aneurysmal disease, 37% occlusive disease, 26% renal artery lesions). Thirty-one patients developed postoperative complications, including three deaths. The most common complication was deterioration in renal function (17 patients, 24% of those at risk) followed by the need for prolonged endotracheal intubation (> 48 hours, 8%). All other events occurred uncommonly (4% or less). Stepwise logistic regression demonstrated four criteria that were significantly associated with complications. In descending order of importance these were: renal artery occlusive disease, intraoperative blood replacement, the preoperative APACHE II score, and a history of heavy smoking. Since both physiologic status and comorbid conditions contribute to morbidity and costs of elective vascular surgery, outcome studies must be adjusted to account for these preoperative characteristics. Additionally, since two-thirds of patients who have renal artery occlusive disease develop complications that prolong hospitalization, our current methods of protecting the kidney during ischemia should be improved to potentially reduce this cause of morbidity.

Influence of age on venous physiologic parameters.

PURPOSE: The incidence of deep venous thrombosis increases significantly with age. Attempts to explain this association have failed to identify factors that could be contributory. We hypothesized that age-related changes in venous physiologic parameters might contribute to an increased risk of deep venous thrombosis. METHODS: Air plethysmography was used to measure a number of physiologic parameters in two sets of patients. Group A consisted of 17 subjects (33 limbs), age range 23 to 40 years. Group B consisted of 11 subjects (22 limbs), age range 60 to 83 years. No subject in either group had peripheral vascular disease or a history of deep venous thrombosis. Parameters measured were venous volume, venous filling index, ejection volume, ejection fraction, residual volume fraction, and outflow fraction. RESULTS: Venous volume and ejection fraction were significantly reduced in Group B compared with Group A. Residual volume fraction was significantly increased in Group B compared with Group A. There were no statistically significant differences in outflow fraction, venous filling index, or ejection fraction between the two groups. CONCLUSIONS: These results suggest that the efficiency of the calf muscle pump diminishes with increasing age, possibly contributing to the increased incidence of deep venous thrombosis in the elderly.

Evaluation of celiac and mesenteric vascular disease with duplex ultrasonography.

A retrospective study of 25 patients was performed to evaluate the applicability of duplex ultrasonography to the celiac and superior mesenteric circulation. Lateral contrast aortograms were compared to the pulsed-Doppler spectral data from duplex examinations in fasting subjects. A significant correlation was identified between the celiac-aortic diastolic ratio and the degree of stenosis measured angiographically, but such a relationship could not be established for the superior mesenteric artery. These data suggest that duplex ultrasonography may not be a reliable screening test for mesenteric vascular disease.

Crossover ilioprofunda reconstruction: an expanded role for obturator foramen bypass.

The standard obturator foramen bypass extends from the aorta or iliac artery to the ipsilateral superficial femoral or popliteal artery. This operation has been both effective and versatile as an indirect bypass procedure for circumventing difficult vascular problems in the femoral triangle. A case is presented of a patient whose limb was salvaged by an obturator foramen bypass from the contralateral iliac artery to the profunda femoris artery. This unique case is compared to other published cases to emphasize the potential advantages of the profunda femoris as the preferred graft outflow in selected cases of arterial reconstruction through the obturator foramen.

Combined aortic and visceral arterial reconstruction: risks and results.

The indications, morbidity, and efficacy of combined reconstruction of the abdominal aorta and visceral arteries (renal and superior mesenteric; excluding suprarenal aortic aneurysms) were analyzed retrospectively in 29 consecutive patients who underwent surgery from June 1984 through February 1990. Seventeen men and 12 women ages 32 to 76 years (mean, 66 years) were studied. Follow-up was complete in all patients to either death or calendar year 1989 to 1990 (mean, 31.9 months; range, 2 to 66 months). All patients underwent bypass of angiographically proven severe lesions of one renal artery (19 patients), both renal arteries (8 patients), or the superior mesenteric artery and renal arteries (2 patients), in concert with synthetic distal aortic replacement for occlusive disease (10 patients) or aneurysm (19 patients). Indications for renal artery repair included severe hypertension in 13 patients, ischemic renal insufficiency in 8 patients, and lesion morphology alone in 8 patients. Operative mortality rate was 3 of 29 (10.3%), and each death was the result of multisystem organ failure. Nonfatal complications occurred in 11 of the 26 survivors (42%), and this group differed significantly from the uncomplicated 15 patients only in having a higher mean preoperative serum creatinine (2.5 +/- 1.1 mg/dl vs 1.6 +/- 0.9 mg/dl, p = 0.04, t test). The mortality rate of patients with preoperative serum creatinine greater than or equal to 2.0 mg/dl, was 15.4% (2/13 patients), compared to 6.2% (1/16) in patients with creatinine less than 2.0 mg/dl. Three late deaths occurred (2 stroke, 1 cancer). Hypertension control improved in 64% of patients overall, and in 7 of 9 patients whose major operative indication was renovascular hypertension. Renal function remained stable or improved in 12 of 15 patients (80%) with renal insufficiency, but 3 patients progressed to require dialysis. Long-term graft patency was demonstrated by angiography or on duplex scan in all studied survivors (21 patients). Although operative risks are clearly increased compared to less complex vascular procedures, careful patient selection and management will yield a favorable outcome in most patients with such combined lesions.

Ischemic gastroparesis: resolution after revascularization.

Patients with chronic nausea and vomiting frequently present challenging diagnostic and therapeutic problems. In such patients, gastroparesis of unknown cause, or "idiopathic" gastroparesis, may be the only objective finding. Two middle-aged women with nausea, vomiting, and weight loss of 10 and 26 kg over 6 and 18 months, respectively, were evaluated. Routine laboratory and barium study results were normal. Solid-phase gastric emptying studies showed severe gastroparesis in both patients. Upper endoscopies excluded gastric outlet obstruction. Gastric dysrhythmias (4-cpm and 1-cpm patterns) were recorded using cutaneous electrodes. An abdominal bruit was ascultated in one patient. Abdominal arteriograms in both patients showed total occlusion of all three major mesenteric vessels with collaterals supplied via hemorrhoidal arteries. Bypass grafting procedures of the celiac and superior mesenteric arteries in one patient and of the celiac artery in the other patient were performed. Six months after mesenteric artery revascularization, upper gastrointestinal symptoms had resolved and original weights were regained. Furthermore, normal 3-cpm gastric myoelectrical activity and normal gastric emptying of solids were restored in both patients. In these patients, chronic mesenteric ischemia resulted in a novel and reversible cause of gastroparesis, gastric dysrhythmias, and accompanying symptoms.

A rational approach to recurrent carotid stenosis.

To further characterize the incidence and morbidity of recurrent carotid stenosis, we reviewed 184 consecutive carotid endarterectomies performed in a university hospital between August 1983 and January 1988, in patients followed after operation with serial duplex ultrasonography. Recurrent stenosis of greater than 50% diameter reduction developed in eleven arteries (6.0%) at a mean interval of 10.2 +/- 7.8 months. Three of the eleven (1.6% of the total) had associated transient ischemic attack, and none had strokes. Restenosis was significantly more frequent in diabetic patients than in nondiabetic patients (13.3% vs 4.5%; p less than 0.05); and among patients whose primary stenoses had been symptomatic compared to asymptomatic (11.0% vs 1.5%; p less than 0.02). No statistically significant association with restenosis could be established for gender, hypertension, or smoking. Completion angiography and/or Doppler spectral analysis had been performed, and results were normal at the primary operation in 10 of the 11 patients. Only six of 184 arteries (3.3%) had vein patch closure, but none of these restenosed. Uneventful reoperation with patch closure was performed in three patients with transient ischemic attacks and two with preocclusive restenoses. Lesions were myointimal hyperplasia in four and atheroma in one. Three of the unoperated restenoses have shown regression on duplex scanning, but a fourth progressed to asymptomatic occlusion. Carotid restenosis is uncommon, even without routine use of vein patch angioplasty. Reoperation should be reserved for patients with associated symptoms or greater than 80% restenosis.

Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management.

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction.

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.