A tibioperoneal trunk mycotic pseudoaneurysm successfully treated with ligation.

We present the case of a 68-year-old man with a tibioperoneal trunk mycotic pseudoaneurysm, a rarity in the modern age of antibiotics. We describe the patient's hospitalizations and workups that ultimately led to this diagnosis and our management with open ligation without bypass. This case highlights the importance of combining a thorough history and physical examination with laboratory and imaging data while keeping in mind a broad differential diagnosis.

Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease.

INTRODUCTION: Patients undergoing midline incision for abdominal aortic reconstruction appear to be at greater risk for postoperative incision hernia compared with patients undergoing celiotomy for general surgical procedures. Controversy exists as to whether incidence of abdominal wall hernia and increased risk for incision hernia is higher in patients with abdominal aortic aneurysm (AAA) than in patients operated on because of aortoiliac occlusive disease (AOD). We conducted a prospective multi-institutional study to assess frequency of incision hernia after aortic surgery through a midline laparotomy and of previous abdominal wall hernia. METHODS: Patients with AAA (n = 177) or AOD (n = 82) from three major institutions were prospectively enrolled in the study and examined. Data collected included demographic data, cardiopulmonary risk factors, smoking status, history of previous or current abdominal wall hernia (incision, inguinal, umbilical, femoral), previous midline incision, suture type, and postoperative complications. At a minimum of 6 months after laparotomy, patients were evaluated clinically for a new incision hernia. Differences were tested with the unpaired t test, X(2) test, or Fisher exact test, and multiple logistic regression was used to control for confounding variables. RESULTS: Mean follow-up of the cohort was 32.8 +/- 2.3 months. Rate of abdominal wall hernia and inguinal hernia in patients with AAA versus AOD was 38.4% versus 11% (P =.001) and 23.7% versus 6.1% (P =.003), respectively. Rate of postoperative incision hernia in patients with AAA was 28.2%, and in patients with AOD was 11.0% (P =.002). Adjusting for age, smoking, chronic obstructive pulmonary disease, body mass index, diabetes, bowel obstruction, and suture type, patients with AAA had almost a ninefold risk for postoperative incision hernia formation (odds ratio [OR], 8.8; P =.0049). CONCLUSION: Compared with patients with AOD, patients with AAA have a higher frequency of abdominal wall hernia and inguinal hernia, and are at significant increased risk for development of incision hernia postoperatively. The higher frequency of hernia formation in patients with AAA suggests the presence of a structural defect within the fascia. Further studies are needed to delineate the molecular changes of the aorta and its relation to the abdominal wall fascia.

Ruptured abdominal aortic aneurysm and quality of life.

This study was undertaken to examine the community hospital experience in managing ruptured abdominal aortic aneurysm, and to assess the quality of life in survivors of the abdominal aortic aneurysm procedure. Study parameters included a retrospective chart review with prospective follow-up at a 369-bed, university-affiliated, community teaching hospital. Eighty-one consecutive patients undergoing surgery for ruptured abdominal aortic aneurysm between 1991 and 2000 were included. Main outcome measures included mortality and quality of life, as assessed by the SF-36 health survey. The overall perioperative mortality rate was 34.6%, significantly less (p < 0.005) than the 50% mortality rate reported in the literature. Predictor variables significantly related to mortality were age (p < 0.002), preoperative creatinine (p < 0.026), use of suprarenal clamp (p < 0.0001), acute renal failure (p < 0.0001), myocardial infarction (p < 0.0001), respiratory failure (p < 0.0001), and tobacco use (p < 0.05). Multiple regression analysis found that three predictor variables--myocardial infarction, respiratory failure, and use of a suprarenal clamp--predicted 25% of the variability in mortality (p < 0.0001). The quality-of-life analyses showed that the majority of the patients for whom follow-up data could be obtained (n = 26), reported the same or better quality of life compared to SF-36 norms for age-matched individuals. Results from this community hospital sample suggest that ruptured abdominal aortic aneurysm repair can be accomplished in this setting with an acceptable survival rate, and subsequent quality of life that meets or exceeds that of an age-matched sample.