Infected aneurysms of neck and limb arteries: a retrospective multicenter study

Necrotizing Fasciitis Secondary to Mycotic Femoral Aneurysm: A Narrative Review of Diagnosis and Management Strategies

This comprehensive literature review aims to investigate the pathophysiology, clinical manifestations, diagnostic tools, and treatment options for necrotizing fasciitis secondary to mycotic femoral aneurysm, a rare and potentially lethal infectious disease, particularly focusing on any changes throughout the years for an update of the current literature. The pathophysiology of necrotizing fasciitis and mycotic femoral aneurysms is a complex and multifaceted process that typically involves bacterial infections as a common precursor to the onset of these conditions. This can potentially lead to the formation of an aneurysm. As the infection progresses, it can spread from the aneurysm to surrounding soft tissues, resulting in significant tissue damage, obstructed blood circulation, and ultimately culminating in cell death and necrosis. Clinical manifestations of these conditions are diverse and encompass a range of symptoms, such as fever, localized pain, inflammation, skin changes, and other indicators. It is worth noting that skin color can influence the presentation of these conditions, and in patients with diverse skin tones, certain symptoms may be less noticeable due to a lack of visible discoloration. Imaging, laboratory findings, and clinical presentation are important components of the diagnosis of mycotic aneurysms. CT scans are a reliable tool for identifying specific features of infected femoral aneurysms, and elevated inflammatory laboratory results can also suggest a mycotic aneurysm. In the case of necrotizing fasciitis, clinicians should maintain a high level of suspicion as this condition is rare but life-threatening. Clinicians will need to view the big picture when an infection may be caused by necrotizing fasciitis, considering CT imaging, blood work, and clinical presentation of the patient without delaying surgical intervention. By incorporating the diagnostic tools and treatment options outlined in this review, healthcare professionals can improve patient outcomes and reduce the burden of this rare and potentially lethal infectious disease.

Infective Native Extracranial Carotid Artery Aneurysms: A Systematic Review

BACKGROUND

Infective native extracranial carotid artery aneurysms are rare, and their management is variable due to a lack of evidence assessing outcomes.

METHODS

We performed a systematic literature review following PRISMA guidelines to identify all reported cases of infective native extracranial carotid artery aneurysms between January 1970 and March 2021.

RESULTS

This study identified 193 infective native aneurysms of the extracranial carotid artery from 154 sources. Patients were predominantly male (71.4%), and age ranged from 6 months to 89 years old. The most common presenting features were a neck mass and fever, but also included hemorrhage, respiratory distress, and neurological symptoms. Most aneurysms were located in the internal carotid artery (47.4%). Staphylococcus (23.3%) was the most commonly identified causative pathogen, followed by Mycobacterium tuberculosis (20.9%). Most appeared to become infected by direct local spread. Treatment strategies involved open surgical methods in 101 cases and an endovascular approach in 41 cases. In 4 cases, a hybrid method involving concurrent endovascular and open surgical management was undertaken. In 5 cases, there was antibiotic treatment alone. In the open surgery-treated group, the complication rate was 20.8% compared to 13.2% in the endovascular group. Mortality rate was 5.6%.

CONCLUSIONS

Our review identified 193 cases of infective native extracranial carotid artery aneurysms. Direct local spread of a staphylococcus infection was the commonest cause. Endovascular management was associated with fewer early complications than open surgical management.

A Case Report: Ruptured Popliteal Aneurysm Caused by Haemophilus Influenzae Infection

Mycotic aneurysms arise from infection of an arterial wall secondary to septic emboli from endocarditis. Although rare, most mycotic aneurysms involve the abdominal aorta, with Staphylococcus aureus and Salmonella spp being the most common causative organisms. We report a case of an 81-year-old woman with a ruptured mycotic popliteal aneurysm from Haemophilus influenzae infection.

Persistent mycotic superficial femoral artery pseudoaneurysm after endovascular treatment: a case report

Mycotic pseudoaneurysms of the superficial femoral artery (SFA) are rare and are usually secondary to colonization of an atherosclerotic plaque during an episode of bacteremia. We describe the case of a 68 year-old diabetic male who presented to the Emergency Department with pyrexia and a painful expanding mass in the left thigh. He had a history of diarrhea and had been treated 16 days earlier for an SFA pseudoaneurysm that had been excluded with a covered stent with no adjunctive antibiotic therapy. Angio CT showed an abscess surrounding femoral vessels and stent thrombosis. Under general anesthesia, we performed extensive debridement, removal of the endovascular material, SFA ligation, and empirical antibiotic therapy. Blood and tissue cultures were positive for Escherichia coli. At the 3-months follow up visit, the patient reported he had no claudication. In selected patients, mycotic pseudoaneurysms can be treated by SFA ligation.

Mycotic (Infected) Pseudoaneurysm, a Diagnostic Challenge - Case Series

Mycotic pseudoaneurysm (or infected pseudoaneurysm) is an infectious arteritis, leading to the destruction of the arterial wall with the formation of a blind, saccular outpouching contiguous with the arterial lumen. Delayed management or non-management of mycotic pseudoaneurysms is associated with high morbidity and mortality due to complications such as arterial rupture, hemorrhage, and fulminant sepsis. Earlier diagnosis of mycotic pseudoaneurysm is essential for time management. Multidetector computed tomography (MDCT) is a widely used imaging modality for detecting the mycotic pseudoaneurysm, its characterization, and vascular mapping. MDCT findings of mycotic pseudoaneurysm are blind, saccular outpouching of an artery with irregular arterial wall, perivascular soft-tissue mass, or edema. Uncommon results of MDCT include arterial lumen thrombosis, arterial wall calcification, and perivascular gas. Management of mycotic pseudoaneurysm includes endovascular stenting with graft repair, endovascular embolization, open surgery, medical therapy (intravenous antibiotics), or a combination of these. We report three cases of mycotic pseudoaneurysm affecting aortic isthmus, a segmental branch of the pulmonary artery, and the internal mammary artery. All cases posed a diagnostic challenge, which only on subsequent imaging revealed to be a mycotic pseudoaneurysm.

A rare case of Listeria monocytogenes causing mycotic aneurysm of the common femoral artery: A case report

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Immunosuppressed patients may not display typical clinical or biochemical features associated with mycotic aneurysms.

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Clinicians should have a high index of suspicion for infective aetiology when treating aneurysmal disease in immunocompromised patients.

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It is important to obtain intraoperative tissue samples for histopathology and microbiological assessment in immunocompromised patients for detection of rare pathogens.

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Autogenous vein should be used in infected surgical fields to avoid the risk of prosthetic graft infection.

Introduction

Mycotic aneurysms are an uncommon occurrence, withStaphylococcus and Salmonella species found to be the causative pathogen in up to 95% of cases. We believe this is the first described case of a common femoral artery mycotic aneurysm due to Listeria monocytogenes.

Presentation of case

A 66-year-old male presented with a two-month history of an increasing painful mass in his left groin, on the background of immunosuppression treatment for ankylosing spondylitis. He was afebrile on assessment, with a normal white cell count. Contrast enhanced CT scan showed a common femoral artery aneurysm, with no infective features. His aneurysm was excised and repaired with a Dacron tube graft. L. monocytogenes was cultured from the aneurysm tissue, and he was commenced on appropriate antibiotic treatment. The prosthetic graft was also replaced with a venous bypass of the aneurysm.

Discussion

L. monocytogenes is a rare cause of mycotic aneurysm with less than 40 cases reported in the literature. Immunosuppression is a recognised risk factor for Listerial infections. Immunocompromised patients may not display typical clinical or biochemical features associated with a mycotic aneurysm. Prosthetic graft infections are associated with significant mortality, with excision of the prosthetic material and venous reconstruction associated with good outcomes for eradicating infection.

Conclusion

This report highlights the importance of obtaining intraoperative tissue samples for microbiological and histopathological assessment in immunocompromised patients. This is important for the detection of rare organisms such as L.monocytogenes, requiring targeted antibiotic therapy. Inappropriate treatment of Listerial infections can result in serious invasive illness.

Mycotic Carotid Artery Pseudoaneurysm Following Stenting

Carotid stenting is assuming an important role in the management of carotid disease. Surgeons although hesitant to embrace catheter treatment for the management of primary carotid artery disease, are more enthusiastic regarding it's use in the treatment of recurrent stenoses. This report suggests that caution should be exercised in the selection of patients to be treated with carotid stenting for recurrent disease.

Multiple Mycotic Aneurysms of the Abdominal Aorta Illustrated on MDCT Scanner

Infective mycotic aneurysm of the aorta is a rare and life-threatening disease. A patient presenting with constitutional symptoms and pulsatile abdominal mass should raise a suspicion of mycotic aneurysm. Early detection of aortic mycotic lesions in such patients should play a key role in the treatment of aortic aneurysms. Multiple mycotic aneurysms of abdominal aorta in a young male are a rare manifestation of the disease. Multidetector computerized tomography (CT) is an essential tool in identifying the etiology, pathogenesis, protean manifestations of systemic tuberculosis, and ultimately deciding the course of treatment.

Meningitis complicated by mycotic aneurysms

Mycotic aneurysms complicated by vasospasm and strokes represent a rare manifestation of bacterial meningitis. We describe a healthy woman diagnosed with bacterial meningitis and mycotic aneurysms, who received both antibiotic and corticosteroid therapy. This approach fostered a significant radiologic improvement in her mycotic aneurysms as evidenced by serial angiographic examinations. During her course, she developed vasospasm and strokes and required intra-arterial verapamil. More importantly and as a result of these combined therapies, the patient experienced a substantial clinical improvement. This case allows the description of mycotic aneurysms epidemiology, clinical presentation and complications. In addition, our vignette bestows the relevance of serial neurologic examinations and radiologic testing during the acute vasculopathy period. Current conservative and interventional therapeutic options are briefly discussed.

Cause of internal hemorrhage determined after exhumation: Report of one case

A 36-year-old woman consulted the medical emergency unit of a private health center for abdominal pain and gastroenteritis of 5 days duration. Acute right pyelonephritis was diagnosed. Five hours after admission she became unconscious in a state of clinical shock. She was transferred to an intensive care unit but resuscitation attempts were unsuccessful and she died 3h later. Three days after death, she was buried in the family vault. Five days after the burial, her husband lodged a complaint with the public prosecutor because he had not received a clear explanation from the physicians concerning the cause of his wife's death. After analysis of the medical records of the deceased by two forensic pathologists, a medicolegal autopsy was ordered by the public prosecutor. The corpse was exhumed and autopsy performed 9 days after death. Massive hemoperitoneum was diagnosed with a macroscopically ruptured subcapsular hematoma. Pathological study confirmed acute right pyelonephritis and demonstrated the precise cause of the hemorrhage: rupture of the hepatic artery at the hilar part, following infectious arteritis which was probably secondary to the acute pyelonephritis. To the best of our knowledge, this is the first published report of such a case.

Extracranial Internal Carotid Artery Mycotic Aneurysm: Case Report and Review

Mycotic aneurysms of the internal carotid artery (ICA) are rare and often difficult to diagnose. They can have nonspecific signs and symptoms, an unclear etiology, and can lead to severe morbidity and mortality if left untreated. We present a case of a 47-year-old woman with an apparent mycotic aneurysm of the extracranial ICA associated with Klebsiella pneumonia. We discuss the various clinical findings and radiographic imaging that lead to this unusual diagnosis and the details of our surgical treatment, which included excision of the mycotic aneurysm and reconstruction with a greater saphenous vein interposition graft. We also review the literature on mycotic aneurysms of the ICA, including the radiologic modalities available to diagnose this condition, epidemiology, pathophysiology, and treatment options.

Infected (mycotic) aneurysms: spectrum of imaging appearances and management

Infected aneurysms are uncommon. The aorta, peripheral arteries, cerebral arteries, and visceral arteries are involved in descending order of frequency. Staphylococcus and Streptococcus species are the most common causative pathogens. Early clinical diagnosis of infected aneurysms is challenging owing to their protean manifestations. Clinically apparent infected aneurysms are often at an advanced stage of development or are associated with complications, such as rupture. Nontreatment or delayed treatment of infected aneurysms often has a poor outcome, with high morbidity and mortality from fulminant sepsis or hemorrhage. Current state-of-the-art imaging modalities, such as multidetector computed tomography and magnetic resonance imaging, have replaced conventional angiography as minimally invasive techniques for detection of infected aneurysms in clinically suspected cases, as well as characterization of infected aneurysms and vascular mapping for treatment planning in confirmed cases. Doppler ultrasonography allows noninvasive assessment for infected aneurysms in the peripheral arteries. Imaging features of infected aneurysms include a lobulated vascular mass, an indistinct irregular arterial wall, perianeurysmal edema, and a perianeurysmal soft-tissue mass. Perianeurysmal gas, aneurysmal thrombosis, aneurysmal wall calcification, and disrupted arterial calcification at the site of the infected aneurysm are uncommon findings. Imaging-guided endovascular stent-graft repair and embolotherapy can be performed in select cases instead of open surgery. Familiarity with the imaging appearances of infected aneurysms should alert the radiologist to the diagnosis and permit timely treatment, which may include endovascular techniques.

Infected upper extremity aneurysms: a review

OBJECTIVES

To review the occurrence of mycotic aneurysm affecting upper extremity arteries.

DESIGN

Literature review.

MATERIALS AND METHODS

A MEDLINE search from 1950 until 2007 and an extensive manual search were carried out using bibliographies from relevant published papers including cases involving arteries distal to the subclavian.

RESULTS

A total of 149 cases (68 papers) were identified. The brachial artery was the most frequently reported site, mostly associated with drug abuse, catheterization procedures or endocarditis. Since 1950 arterial trauma (drug abuse or catheterization) was the commonest cause. Gram positive organisms were the most frequent microbes involved. Acknowledging a limited follow-up, most patients did well when surgical therapy was promptly instituted.

CONCLUSIONS

Infected upper extremity aneurysms have been rarely described. IV drug abusers are a unique high-risk group for mycotic aneurysms in the upper extremities, most importantly in the axillary and brachial arteries. When rapidly performed, arterial ligation, primary repair or reconstruction with autogenous conduits was associated with favorable outcomes.

Infected False Aneurysms of the Limbs Secondary to Chronic Intravenous Drug Abuse: Analysis of Perioperative Considerations and Operative Outcomes

PURPOSE

To discuss the perioperative considerations and operative outcomes of 26 intravenous (i.v.) drug abusers who presented with infected false aneurysms of the limbs.

METHODS

The subjects were 20 men and 6 women with pseudoaneurysms (mean age 34 years, range 19-53 years). The femoral and brachial arteries were most commonly involved. All patients, except for those with active bleeding, underwent digital subtraction angiography or Doppler ultrasonography, or both. Treatment consisted of excision and ligation of the aneurysm and local debridement, followed by revascularization with a vein graft or vein patch angioplasty.

RESULTS

The presenting symptoms and signs included a pulsatile mass (69%), ischemic pain (23%), active bleeding (38.5%), signs of inflammation (61.5%), and positive blood culture (31%). Bleeding complications developed in two patients, who underwent subsequent extra-anatomic bypass. One of these patients had hip disarticulation and eventually died. None of the remaining patients had claudication or required an amputation. The mean follow-up period was 24 months (range: 3-50 months). Only five (19.2%) patients received drug rehabilitation, whereas the remaining patients admitted to continued drug abuse after discharge from hospital.

CONCLUSIONS

Limb salvage with immediate revascularization is safe and achieves functionality; therefore, its use is justified. Recidivism and continued abuse is the usual consequence after discharge from hospital, making recovery difficult.

Occult carotid pseudoaneurysm following streptococcal throat infection

Pseudoaneurysm of the internal carotid artery (PAICA) is a rare complication of neck space infection. An 8-year-old girl presented with odynophagia (painful swallowing), trismus and left peritonsillar swelling. Abscess was suspected, but aspiration was dry. The PAICA was diagnosed on computed tomography. The aneurysm and involved left internal carotid artery were occluded endovascularly. She has made an uneventful recovery.

Surgical treatment of femoral artery infected false aneurysms in drug abusers

BACKGROUND

Post-traumatic femoral artery infected false aneurysms (pfa-IFA) in drug abusers are very common in modern societies, but their surgical management remains controversial.

METHODS

A review was undertaken of the English-language literature between 1967 and 2004 for relevant articles describing at least four cases of pfa-IFA in drug-addict populations. The available surgical treatment options are discussed.

RESULTS

Recent surgical therapeutic reports favour aneurysm ligation and excision (Lig-Exc) and local debridement (Ld) with observation-selective (delayed) revascularization in cases where limb viability is threatened, or Lig-Exc and Ld alone without vascular reconstruction. The former method carries the risk of delayed decision on attempted extremity salvage (12.1% amputation rate), accepting early (13.5%) and late (7.5%) claudication rate, and although the latter method has much lower early and late amputation rates (5.7 and 6.3%, respectively), it results in a high percentage of claudication and disability (early, 54.4%; late, 44.3%). Immediate (routine) revascularization using either in situ or extra-anatomic bypass has also been associated with high complication rates. Even when it occurs through non-infected tissue planes, the risk of graft infection (early, 21.1%; late, 32.4%) is of great concern, and the possibility of sepsis (together with anastomotic dehiscence (14%) and even amputation) is high (early, 9.8%; late, 11.3%). Reversing the order of revascularization produces zero early complication rates, but long-term follow up reveals that 5.5% of patients have graft infection and 5.5% have had amputation. The follow up rates reported in the literature are poor (only 31.7% completed), and are also sometimes inaccurate.

CONCLUSIONS

No surgical treatment for pfa-IFA has been proved to be safe in terms of the overall surgical complications. Longer follow-up periods are needed to provide accurate results.