感染性弓部大動脈瘤の治療成績

Surgical Outcomes of Mycotic Aneurysm of the Aortic Arch

感染性大動脈瘤は非常にまれな疾患であり，その外科治療成績は経験のある施設でも2001年の報告で死亡率36％に及ぶ1）．近年では外科治療成績は以前に比べると改善しており，30日死亡率8.7％であった2）．一方で血管内治療の進歩はめざましく，感染性動脈瘤へも適応され3），30日死亡率5.0％であった2）．上述のような背景があるにもかかわらず，感染性弓部大動脈瘤への治療アプローチは解剖学的特徴をふまえると外科治療に限られる．2019年のレビューでは感染性弓部大動脈瘤に限った外科治療成績は惨憺たるものであった4）．

Mycotic aneurysm of the aortic arch is a rare, but critical entity. We reviewed our surgical experience of mycotic aneurysm of the aortic arch. Between January 2007 and December 2015, we operated on six patients who had mycotic aneurysm of the aortic arch. The mean age was 72 years old, and four males were included. Preoperative white blood cell count was 18,266/μl and C-reactive peptide was 18.5 μg/dl, respectively. The initial presentations included fever （n＝2）, hoarseness （n＝2）, weakness of a leg （n＝1）, dyspnea （n＝1） and hemoptysis （n＝1）. Preoperative blood cultures were positive in three patients. All patients underwent a total aortic arch repair with a four-branched vascular tube, and five received pedicled omental grafting. One patient who did not receive pedicled omental grafting died of recurrence of infection on postoperative day 21, and the other died of multi-organ failure on postoperative day 77. We experienced tracheostomy （n＝1）, minor stroke （n＝1）, and atrial fibrillation （n＝1）. During the follow-up period, no recurrence of infection was observed in four survivors. Our surgical strategy is satisfactory to achieve good clinical outcomes.