Temporary Prosthetic Shunt to Permanent Aortic Prosthesis in a Patient with an Infected Thoracoabdominal Aneurysm to Shorten Ischemia Time

Abstract

High operative mortality of infected thoracoabdominal aortic aneurysms (ITAA) is partly attributable to ischemic injury during aortic clamping. We report a 62-year-old man with biliary cirrhosis, who developed a rapidly enlarging ITAA secondary to thoracolumbar osteomyelitis. Additional infectious foci were found in the pubic and ischial bones and in the left lung. Blood cultures gave growth of streptococcus pneumoniae. The aneurysm was repaired through a thoracoabdominal incision with a Dacron prosthesis. Prior to aneurysm repair, a prosthetic shunt was anastomosed end – to- side to the aortic prosthesis and to the descending aorta using a side-biting clamp. The shunt allowed perfusion of the lower body and of renal and visceral vessels after 45 minutes, the time needed to resect infected tissue and complete the distal anastomosis. The proximal anastomosis and orthopedic treatment of the spinal osteomyelitis could be performed, while the lower body and visceral organs were perfused. Postoperatively, the patient developed hypotension and increasing lactacidosis. Laparotomy revealed intestinal infarction, and gut resection was performed. Following a temporary improvement, he developed multiorgan failure and candida sepsis and died after 32 days. No atheroemboli were found in arteries of resected intestines. Portal hypertension most likely was present and it could be calculated that minimum intestinal perfusion pressure the night after the operation could have been in the range of 30-37 mm Hg, which probably was not enough to maintain aerobic metabolism. In the presence of aortic atheromas it may be advisable to divert blood to the shunt from an axillary artery.