Volume 12 Number 2 August 1990
Letters to the Editors
80% power, a sample o f 50 pairs, and a significance level o f 0.05, a difference in the proportion o f infection between drained and undrained wounds o f 20% can be detected. Therefore any difference in complication rates greater than 20% would be identified. In conclusion, I agree that a larger study o f several hundred patients would be able to detect smaller differences in infection rates between drained and undrained wounds, which would not be detected by our study. However, from our study one can conclude that if any difference in the incidence o f such infections exists, it is less than 20%. I believe that this represents a valid contribution to our understanding o f the role o f prophylactic closed suction drains in vascular surgery and await the results of the study by Stansby, et al., which should provide further insight into this important clinical question.
Dean A. Healy, 21/£D • ;sistant Professor of Surgery Penn State University Milton S. Hershey Medical Center P.O. Box 850 Hershey, PA 17033 Infected solitary iliac artery aneurysm
To the Editors: As pointed out by Brtmkwall et al. (1 VAsc Suv,G 1989;10:381-4) isolated iliac artery aneurysms are very rare. We have recently seen a case o f a solitary lilac artery aneurysm that had been secondarily infected that I would
219
like to call to your attention. This is a heretofore not reported complication of a true iliac artery aneurysm. There are other fascinating aspects o f this case. CASE R E P O R T The patient is an 80-year-old white man who came for treatment in the spring o f 1988 with positive blood cultures for Clostridium septicum. H e was presumed to have endocarditis and was treated with 2 months o f intravenous penicillin. The septic episode resolved, and the patient remained without fever for 1 month. H e returned with a markedly elevated white blood cell count, high fever, and this time with some mild abdominal tenderness in the right lower quadrant. The patient was explored, and a cecal carcinoma and a large right iliac artery aneurysm were encountered. A right hemicolectomy was performed, and the patient was given a 7-day course o f intravenous antibiotics. The patient returned 2 weeks after this with a white blood cell count o f 18,000 and a temperature of 103 °. A C T scala o f the abdomen revealed air in the wall o f the isolated lilac artery aneurysm (Fig. 1). An aortogram was obtained and revealed diffuse artetiomegaly and an isolated aneurysm involving the right common, external, and internal iliac arteries (Fig. 2). The iliac aneurysm was then excised, mad the stump of the tight common iliac artery was closed• An extraanatomic femoral-femoral bypass procedure was then performed. Blood cultures taken just before the colon resection revealed C, septicum, and C: septicum was the only organism isolated from the wall of the aneurysm. The patient was continued on penicillin G for 2
Fig. 1. CT scan o f right iliac artery aneurysm with air in the wall that subsequently cultured C. septicum.
220
Journal of VASCULAR SURGERY
Letters. to the Editors
kind previously. Patient I of the series of Buckley and Kudsk s had an acutely expanding abdominal aomc aneurysm sandwiched between metastatic C. septicum in the pelvis and shoulder. Cultures were not taken, but this aneurysm could have been infected with C. septicum as well. I suspect the relatively avascular clot of the aneurysm in our patient with congenital arteriomegaly syndrome was seeded from the mucosal breaks in the necrotic colon tumor harboring C. septicum. A 65% mortality in C. septicum sepsis underlies the severity of the infection (usually gas gangrene) and debility of these patients?
Mark W. Asplund, 3429 Clinical Associate University of Iowa, Dept. of Surgery Organ Transplantation Department Iowa Methodist Medical Center 1200 Pleasant St. Des Moines, IA 50309 Al Molinaro, MD Department of Surgery Wansau Medical Clinic 2727 Plaza Dr. Wausau, WI 54401 REFERENCES 1. Lowry, Kraft. Isolated aneurysms of the iliac artery. Arch Surg 1978; 113:1289-93. 2. Richardson J, Greenfield LJ. Natural history of management of iliac aneurysms. J VASCSURG 1988;8:165-71. 3. Kombluth A, Danzig 1, Bernstein L. Clostridium septicum infection and associated malignancy. Medicine 1989;68:30-7. 4. Bretzke M, Bubrick M, Hitchcock C. Diffuse spreading Clostridium septicum infection, malignant disease and immune suppression. Surg Gynecol Obstet 1988;166:197-9. 5. BuckleyD, Kudsk K. Occult gastrointestinal carcinoma causing metastatic clostridial soft-tissue infection. Dis Colon Rectum 1988;31:306-10.
The treatment o f thoracic outlet syndrome: A comparison o f different operations Fig. 2. Aortogram reveals arteriomegaly and large external iliac and hypogastric artery aneurysm. months and made a fairly uneventfifl recovery and lived 10 months before dying of metastatic colon carcinoma to the liver.
Comment Neither the article by Brunkwall et al. nor reviews by Lowry and KraW or Richardson and Greenfield 2 dealing with iliac arterial aneurysm reported a true aneurysm in the iliac position becoming infected. The other interesting fact is that the organism isolated was C. septicum. Sepsis from this organism has been associated with underlying malignancy, especially of the gastrointestinal tract, 81% of the time, 35% of which are occult. 3-~ C. septicum has not been reported to cause an endovascular infection of any
To the Editors: The article by Sanders and Pearce (J VAse SURG 1989;10:626-34) reports one of the most extensive longterm reviews of the surgical treatment of neurogenic thoracic outlet syndrome (TOS). We feel that a reference to our study of the electrophysiologic appraisal could be subject to misinterpretation. For the past decade we have considered complete electrophysiologic assessment (including EMG, nerve conduction, and sensory evoked response [SER]) integral to establishing a diagnosis of neurogenic TOS. 1 The SER surpasses other electrophysiologic tests for evaluation of the brachial plexus, a primary site of neurogenic TOS symptoms. As with other electrophysiologic tests the sensitivity o f SER is reduced in early or minimal lesions and may not demonstrate abnormalities in some patients with developing symptoms.
Letters to the Editors
80% power, a sample o f 50 pairs, and a significance level o f 0.05, a difference in the proportion o f infection between drained and undrained wounds o f 20% can be detected. Therefore any difference in complication rates greater than 20% would be identified. In conclusion, I agree that a larger study o f several hundred patients would be able to detect smaller differences in infection rates between drained and undrained wounds, which would not be detected by our study. However, from our study one can conclude that if any difference in the incidence o f such infections exists, it is less than 20%. I believe that this represents a valid contribution to our understanding o f the role o f prophylactic closed suction drains in vascular surgery and await the results of the study by Stansby, et al., which should provide further insight into this important clinical question.
Dean A. Healy, 21/£D • ;sistant Professor of Surgery Penn State University Milton S. Hershey Medical Center P.O. Box 850 Hershey, PA 17033 Infected solitary iliac artery aneurysm
To the Editors: As pointed out by Brtmkwall et al. (1 VAsc Suv,G 1989;10:381-4) isolated iliac artery aneurysms are very rare. We have recently seen a case o f a solitary lilac artery aneurysm that had been secondarily infected that I would
219
like to call to your attention. This is a heretofore not reported complication of a true iliac artery aneurysm. There are other fascinating aspects o f this case. CASE R E P O R T The patient is an 80-year-old white man who came for treatment in the spring o f 1988 with positive blood cultures for Clostridium septicum. H e was presumed to have endocarditis and was treated with 2 months o f intravenous penicillin. The septic episode resolved, and the patient remained without fever for 1 month. H e returned with a markedly elevated white blood cell count, high fever, and this time with some mild abdominal tenderness in the right lower quadrant. The patient was explored, and a cecal carcinoma and a large right iliac artery aneurysm were encountered. A right hemicolectomy was performed, and the patient was given a 7-day course o f intravenous antibiotics. The patient returned 2 weeks after this with a white blood cell count o f 18,000 and a temperature of 103 °. A C T scala o f the abdomen revealed air in the wall o f the isolated lilac artery aneurysm (Fig. 1). An aortogram was obtained and revealed diffuse artetiomegaly and an isolated aneurysm involving the right common, external, and internal iliac arteries (Fig. 2). The iliac aneurysm was then excised, mad the stump of the tight common iliac artery was closed• An extraanatomic femoral-femoral bypass procedure was then performed. Blood cultures taken just before the colon resection revealed C, septicum, and C: septicum was the only organism isolated from the wall of the aneurysm. The patient was continued on penicillin G for 2
Fig. 1. CT scan o f right iliac artery aneurysm with air in the wall that subsequently cultured C. septicum.
220
Journal of VASCULAR SURGERY
Letters. to the Editors
kind previously. Patient I of the series of Buckley and Kudsk s had an acutely expanding abdominal aomc aneurysm sandwiched between metastatic C. septicum in the pelvis and shoulder. Cultures were not taken, but this aneurysm could have been infected with C. septicum as well. I suspect the relatively avascular clot of the aneurysm in our patient with congenital arteriomegaly syndrome was seeded from the mucosal breaks in the necrotic colon tumor harboring C. septicum. A 65% mortality in C. septicum sepsis underlies the severity of the infection (usually gas gangrene) and debility of these patients?
Mark W. Asplund, 3429 Clinical Associate University of Iowa, Dept. of Surgery Organ Transplantation Department Iowa Methodist Medical Center 1200 Pleasant St. Des Moines, IA 50309 Al Molinaro, MD Department of Surgery Wansau Medical Clinic 2727 Plaza Dr. Wausau, WI 54401 REFERENCES 1. Lowry, Kraft. Isolated aneurysms of the iliac artery. Arch Surg 1978; 113:1289-93. 2. Richardson J, Greenfield LJ. Natural history of management of iliac aneurysms. J VASCSURG 1988;8:165-71. 3. Kombluth A, Danzig 1, Bernstein L. Clostridium septicum infection and associated malignancy. Medicine 1989;68:30-7. 4. Bretzke M, Bubrick M, Hitchcock C. Diffuse spreading Clostridium septicum infection, malignant disease and immune suppression. Surg Gynecol Obstet 1988;166:197-9. 5. BuckleyD, Kudsk K. Occult gastrointestinal carcinoma causing metastatic clostridial soft-tissue infection. Dis Colon Rectum 1988;31:306-10.
The treatment o f thoracic outlet syndrome: A comparison o f different operations Fig. 2. Aortogram reveals arteriomegaly and large external iliac and hypogastric artery aneurysm. months and made a fairly uneventfifl recovery and lived 10 months before dying of metastatic colon carcinoma to the liver.
Comment Neither the article by Brunkwall et al. nor reviews by Lowry and KraW or Richardson and Greenfield 2 dealing with iliac arterial aneurysm reported a true aneurysm in the iliac position becoming infected. The other interesting fact is that the organism isolated was C. septicum. Sepsis from this organism has been associated with underlying malignancy, especially of the gastrointestinal tract, 81% of the time, 35% of which are occult. 3-~ C. septicum has not been reported to cause an endovascular infection of any
To the Editors: The article by Sanders and Pearce (J VAse SURG 1989;10:626-34) reports one of the most extensive longterm reviews of the surgical treatment of neurogenic thoracic outlet syndrome (TOS). We feel that a reference to our study of the electrophysiologic appraisal could be subject to misinterpretation. For the past decade we have considered complete electrophysiologic assessment (including EMG, nerve conduction, and sensory evoked response [SER]) integral to establishing a diagnosis of neurogenic TOS. 1 The SER surpasses other electrophysiologic tests for evaluation of the brachial plexus, a primary site of neurogenic TOS symptoms. As with other electrophysiologic tests the sensitivity o f SER is reduced in early or minimal lesions and may not demonstrate abnormalities in some patients with developing symptoms.
