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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Chahrour MA, Sharafuddin MJ. Infective native arterial aneurysms and inflammatory abdominal aortic aneurysms: An overview with a focus on emergency settings. Semin Vasc Surg 2024; 37:258-276. [PMID: 39152004 DOI: 10.1053/j.semvascsurg.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 08/19/2024]
Abstract
Infective native arterial aneurysms and inflammatory aortic aneurysms are rare but morbid pathologies seen by vascular surgeons in the emergency setting. Presentation is not always clear, and a full workup must be obtained before adopting a management strategy. Treatment is multidisciplinary and is tailored to every case based on workup findings. Imaging with computed tomography, magnetic resonance, or with fluorodeoxyglucose-positron emission tomography aids in diagnosis and in monitoring response to treatment. Open surgery is traditionally performed for definitive management. Endovascular surgery may offer an alternative treatment in select cases with acceptable outcomes. Neither technique has been proven to be superior to the other. Physicians should consider patient's anatomy, comorbidities, life expectancy, and goals of care before selecting an approach. Long-term pharmacological treatment, with antibiotics in case of infective aneurysms and immunosuppressants in case of inflammatory aneurysms, is usually required and should be managed in collaboration with infectious disease specialists and rheumatologists.
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Affiliation(s)
- Mohamad A Chahrour
- Division of Vascular Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mel J Sharafuddin
- Memorial Hospital Central, University of Colorado Healthcare, 1400 E Boulder St, Colorado Springs, CO 80909.
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3
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Iannacone EM, Soletti G, Perezgrovas-Olaria R, Lau C, Girardi LN. Thoracoabdominal aortic aneurysmectomy in the high-risk patient. J Thorac Cardiovasc Surg 2024; 167:1695-1702. [PMID: 36184317 DOI: 10.1016/j.jtcvs.2022.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/02/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study objective was to provide a review of outcomes and management strategies for high-risk scenarios in the open repair of thoracoabdominal aortic aneurysms. METHODS Series examining the open repair of thoracoabdominal aortic aneurysms were reviewed to identify well-described high-risk scenarios and summarize expected outcomes and management strategies in the current era. RESULTS The efforts of many have led to improved outcomes for patients undergoing the inherently challenging open repair of thoracoabdominal aortic pathologies. Several well-described high-risk scenarios include those related to preoperative comorbid conditions (preoperative pulmonary dysfunction, low ejection fraction, and renal dysfunction), anatomically high-risk cases (extent II repairs), and those with acute presentations (rupture, mycotic aneurysms, acute complicated type B aortic dissection). Several operative and perioperative techniques have been developed to mitigate the risk in these formidable cases. CONCLUSIONS Challenges remain for several high-risk scenarios in thoracoabdominal aortic aneurysm repair. Judicious patient selection, meticulous surgical, and critical care strategies have greatly decreased the risk for many high-risk patients.
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Affiliation(s)
- Erin M Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Suwanruangsri V, Bokerd S, Chinchalongporn W, Chanchitsopon V, Inlao P, Kaviros P. Midterm outcomes of endovascular treatment for infected aortic aneurysms: Single center experience. Vascular 2024; 32:303-309. [PMID: 36395486 DOI: 10.1177/17085381221140170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVE The standard treatment of infected aortic aneurysms is open surgical repair but mortality rates remain high with the common cause of death being sepsis. Endovascular treatment of infected aortic aneurysms is another option and here we report the midterm outcomes of endovascular treatment for infected aortic aneurysms. METHODS Thirty-four patients with infected aortic aneurysms underwent endovascular and hybrid repair between December 2012 and June 2021. The patients were evaluated for early and midterm outcomes including postoperative mortality, morbidity, recurrent aortic infection, and midterm survival. RESULTS There were 34 patients who presented with infected aortic aneurysms with a mean age of 66.7 years (range, 26-89). Most of the patients presented with abdominal pain (94.1%) and fever (50.0%). The rate of positive blood culture for organisms was 32.4%. Salmonella was the most common organism. The procedures for treatment were endovascular repair using straight endograft, aorto-uni-iliac (AUI) endograft, bifurcated endograft, and thoracic endograft. Other procedures were endovascular repair with sandwich technique, chimney or periscope technique, and hybrid operation. The rate of in-hospital mortality and morbidity were 11.8% and 17.6%, respectively. Mean follow-up time was 21 months (range, 1-70). During the follow-up period, 7 (23.3%) patients had recurrent infection of aortic aneurysms and 5 patients required reoperation. Four patients died from septicemia and one patient died from cardiac disease. Male patients were more likely to have recurrent infection compared to females. The cumulative survival at 1 year and 2 years were 86.3% and 80.5%, respectively. CONCLUSION In this retrospective review of the endovascular treatment in the patients who presented with infected aortic aneurysms showed acceptable early and midterm outcomes.
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Affiliation(s)
- Veera Suwanruangsri
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Surakiat Bokerd
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Wanchai Chinchalongporn
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Virapat Chanchitsopon
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Peerapong Inlao
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Pruesttipong Kaviros
- Division of Vascular Surgery, Department of Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
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Juszczak M, Mann H, Riste M, Woodhouse A, Sörelius K, Claridge M, Adam DJ. Complex Endovascular Repair of Paravisceral Infective Native Aortic Aneurysms. J Endovasc Ther 2024; 31:223-231. [PMID: 36062747 DOI: 10.1177/15266028221119333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the early and mid-term outcome of complex endovascular repair (EVAR) for paravisceral infective native aortic aneurysms (INAA). METHODS Interrogation of a prospectively maintained database identified consecutive patients who underwent non-elective complex EVAR for paravisceral INAAs in a single institution between December 2013 and June 2020. All patients were considered to have definite INAAs based on diagnostic criteria. Patients who had prior aortic repair were excluded. RESULTS A total of 26 patients (19 men; mean age 67 years [SD = 11.4]; median diameter 60 mm [IQR: 55-73]) with acute symptomatic (n = 24) or contained ruptured (n = 2) aneurysms underwent surgeon-modified fenestrated EVAR (SM-FEVAR; n = 24) or chimney-periscope EVAR (CHIMPS; n = 2). Median observed follow-up was 36.2 months (18.3-53.5). Nine patients had positive venous blood cultures and a further seven had recent or concomitant infection. All patients received pre- and post-operative antibiotic therapy and rifampicin-soaked endografts. A total of 95 vessels were targeted for preservation and 86 were stent-grafted. One vessel occluded intra-operatively and a further 3 occluded within 30 days. The 30-day/in-hospital mortality was 11.5% (n = 3), and the estimated 1- and 3-year survival (±SD) was 85% ± 7%. Infection-related complications (IRCs) occurred in two patients: both developed new INAA within 30 days of index repair and were treated by EVAR with no mortality. Estimated 3-year freedom from late re-intervention was 100%. One patient required infrarenal EVAR for a non-infective aneurysm at 43 months. CONCLUSION Complex EVAR for paravisceral INAAs is associated with acceptable early and mid-term outcomes and is an acceptable alternative to open surgery. We propose that these patients are managed with long-term antimicrobials, impregnation of graft material with rifampicin, and rigorous post-operative surveillance. CLINICAL IMPACT A multi-disciplinary approach is required to deliver the best possible outcome for patients with this challenging aortic pathology.
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Affiliation(s)
- Maciej Juszczak
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Harvinder Mann
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Riste
- Department of Infectious Disease, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Woodhouse
- Department of Infectious Disease, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Claridge
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Vascular Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Li HL, Kwan KJS, Chan YC, Cheng SW. Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review. Ann Vasc Surg 2024; 100:172-183. [PMID: 37898457 DOI: 10.1016/j.avsg.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA). METHODS A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location. RESULTS Forty-eight articles were included, encompassing a total of 1,358 patients (75.8% male; mean age 66.9 years; 1,372 aneurysms) treated by open (49.8%) or endovascular (50.2%) repair. Salmonella spp., and Staphylococcus spp. were the most prevalent pathogens in Asian and European countries respectively. An increasing number of descending thoracic MAAs were managed by endovascular repair (27.9% vs. 12.8%). Early mortality rates for supra- and infra-renal MAAs managed by endovascular repair were lower than OSR (suprarenal 5.4% vs. 43.2%; infrarenal 1.8% vs. 16.7%). Overall, endovascular repair demonstrated lower intraoperative (1.0% vs. 1.8%) and early mortality (6.5% vs. 15.9) rates than OSR. However, endovascular repair was associated with higher late sepsis rate (5.7% vs. 0.9%) and reintervention rate (17.6% vs. 7.3%). Pooled survival rates at 1- and 5-year were similar between the 2 groups. CONCLUSIONS Current literature suggest that endovascular repair is an effective and safe alternative to OSR for descending thoracic, suprarenal, and infrarenal MAAs. However, endovascular repair is associated with higher risk of infection-related complications and reintervention during follow-up.
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Affiliation(s)
- Hai-Lei Li
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Kristine J S Kwan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiu Che Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
| | - Stephen W Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Frankel WC, Green SY, Amarasekara HS, Orozco-Sevilla V, Preventza O, LeMaire SA, Coselli JS. Early and late outcomes of surgical repair of mycotic aortic aneurysms: A 30-year experience. J Thorac Cardiovasc Surg 2024; 167:578-587. [PMID: 35643768 DOI: 10.1016/j.jtcvs.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 02/17/2022] [Accepted: 03/16/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Mycotic aortic aneurysm and its associated complications are often catastrophic. In this study, we examined the early and late outcomes of surgical repair of mycotic aortic aneurysm at our center over the last 3 decades. METHODS We retrospectively reviewed our prospectively maintained aortic surgery database with supplemental adjudication of medical records. Aortic infection was confirmed through clinical, radiological, intraoperative, pathological, and treatment evidence. RESULTS Seventy-five patients (median age, 68 years; interquartile range, 62-74) who underwent surgical repair of a mycotic aortic aneurysm between 1992 and 2021 were included. Almost all patients (n = 72; 96%) presented with symptoms, including 26 patients (35%) with rupture, and many underwent urgent or emergency repair (n = 64; 85%). Sixty-one patients underwent open repair, and 14 patients underwent hybrid or endovascular repair. Infection-specific adjunct techniques included rifampin-soaked grafts (n = 16), omental pedicle flaps (n = 21), and antibiotic irrigation catheters (n = 8). There were 15 early deaths (20%), including 10 of the 26 patients (38%) who presented with rupture; however, persistent stroke, paraplegia or paraparesis, and renal failure necessitating dialysis were uncommon (each <5%). Almost all early survivors (52/60; 87%) were discharged with long-term antibiotic therapy. Estimated survival at 2, 6, and 10 years was 55.7% ± 5.8%, 39.0% ± 5.7%, and 26.9% ± 5.5%, respectively. CONCLUSIONS A substantial proportion of patients with mycotic aortic aneurysm present with rupture and generally require urgent or emergency repair. Operative mortality and complications are common, especially for patients who present with rupture, and late survival is poor.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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9
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Lau C, Soletti G, Weinsaft JW, Rahouma M, Al Zghari T, Olaria RP, Harik L, Yaghmour M, Dimagli A, Gaudino M, Girardi LN. Risk profile and operative outcomes in patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 166:1548-1557.e2. [PMID: 37164052 DOI: 10.1016/j.jtcvs.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To compare operative and long-term outcomes between patients with and without Marfan syndrome undergoing thoracoabdominal aortic aneurysm repair. METHODS We identified all consecutive patients undergoing thoracoabdominal aortic aneurysm repair between 1997 and 2022. Primary outcome was composite of major adverse events. Secondary outcomes were individual complications and long-term survival. Inverse probability of treatment weighting was performed. Weighted Kaplan-Meier curves were used to estimate long-term survival. Multivariable analysis identified factors associated with major adverse events. RESULTS Six hundred eighty-four patients underwent open thoracoabdominal aortic aneurysm repair. Ninety (13.1%) had Marfan syndrome, whereas 594 (86.9%) did not. Marfan patients were younger (46 years [range, 36-56 years] vs 69 years [range, 61-76 years]; P < .001). Extent II or III aneurysms (57 out of 90 [63.3%] vs 211 out of 594 [35.6%]; P < .001) and type I or III chronic dissection (77 out of 90 [85.3%] vs 242 out of 594 [40.8%]; P < .001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in major adverse events between groups (12 out of 90 [13.3%] vs 100 out of 594 [16.8%]; P = .49). Operative mortality was similar between groups (3 out of 90 [3.3%] vs 28 out of 594 [4.7%]; P = .75). Unweighted survival at 10 years was 78.7% vs 46.8% (P = .001). Weighted Kaplan-Meier curves showed no difference in long-term survival (adjusted hazard ratio, 0.79; 95% CI, 0.32-1.99; P = .62; Log-rank P = .12). At multivariable analysis, renal insufficiency (odds ratio, 2.29; 95% CI, 1.43-3.68; P < .01) and urgent/emergency procedure (odds ratio, 2.17; 95% CI, 1.35-3.48; P < .01) were associated with major adverse events, whereas Marfan syndrome was not (odds ratio, 1.56; 95% CI, 0.69-3.49; P = .28). CONCLUSIONS Open thoracoabdominal aortic aneurysm repair can be performed with similar operative outcomes in patients with and without Marfan syndrome despite differing risk profiles. Operative/perioperative strategies must be tailored to specific needs of each patient to optimize outcomes.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Talal Al Zghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohammad Yaghmour
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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10
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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11
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Cox K, Sundaram RD, Popescu M, Pillai K, Kermali M, Harky A. A review on the deeper understanding of inflammation and infection of the thoracic aorta. Vascular 2023; 31:257-265. [PMID: 35469491 PMCID: PMC10021126 DOI: 10.1177/17085381211060928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To review the current literature regarding infection and inflammation of the thoracic aorta and to summarise its aetiologies, pathogenesis and clinical presentation. Additionally, the authors sought to compare diagnostic methods and to analyse the different management options. METHOD A comprehensive electronic search using PubMed, MEDLINE, Scopus and Google Scholar was conducted to find relevant journal articles with key search terms including: 'aortitis', 'thoracic aortic infection' and 'surgical management of infected thoracic aortic aneurysms'. Prominent publications from 1995 till present (2021) were analysed to achieve a deeper understanding of thoracic aorta infection and inflammation, and the information was then collated to form this review. RESULTS The literature review revealed that infectious causes are more prominent than non-infectious causes, with Gram positive bacteria such as Staphylococcus, Enterococcus and Streptococcus accounting for approximately 60% of the infections. The authors also noted that Staphylococcus Aureus was associated with poorer outcomes. Key diagnostic tools include MRI and multi-slice CT imaging, which are useful imaging modalities in defining the extent of the disease thus allowing for planning surgical intervention. Surgical intervention itself is extremely multifaceted and the rarity of the condition means no large-scale comparative research between all the management options exists. Until more large-scale comparative data becomes available to guide treatment, the optimal approach must be decided on a case-by-case basis, considering the benefits and drawback of each treatment option. CONCLUSION A high index of suspicion and a comprehensive history is required to effectively diagnose and manage infection and inflammation of the thoracic aorta. Differentiating between infectious and inflammatory cases is crucial for management planning, as infectious causes typically require antibiotics and surgical intervention. Over the years, the post treatment results have shown significant improvement due to earlier diagnosis, advancement in surgical options and increasingly specific microbial therapy.
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Affiliation(s)
- Kofi Cox
- Faculty of Medicine, RinggoldID:4915St George's Hospital Medical School, University of London, London, UK
| | | | - Mara Popescu
- Faculty of Medicine, RinggoldID:405987King's College London, London, UK
| | - Kiran Pillai
- Faculty of Medicine, RinggoldID:4915St George's Hospital Medical School, University of London, London, UK
| | - Muhammed Kermali
- Faculty of Medicine, RinggoldID:4915St George's Hospital Medical School, University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, RinggoldID:156669Liverpool Heart and Chest Hospital, Chester, UK
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12
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Infectious Aortitis of Thoracic Aortic Aneurysm From Clostridium Septicum. JACC: CASE REPORTS 2023; 10:101783. [PMID: 36974051 PMCID: PMC10039385 DOI: 10.1016/j.jaccas.2023.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 03/17/2023]
Abstract
A 71-year-old male presented with 1-day history of back pain. Imaging displayed an enlarging thoracic aortic aneurysm with gas in the aortic wall. Blood cultures grew Clostridium septicum. He underwent resection, debridement, and in situ aortic replacement with a rifampin-soaked graft under deep hypothermic circulatory arrest. His recovery was uncomplicated. (Level of Difficulty: Beginner.).
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13
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Jutidamrongphan W, Kritpracha B, Sörelius K, Chichareon P, Chongsuvivatwong V, Sungsiri J, Rookkapan S, Premprabha D, Juntarapatin P, Tantarattanapong W, Suwannanon R. Predicting Infection Related Complications After Endovascular Repair of Infective Native Aortic Aneurysms. Eur J Vasc Endovasc Surg 2023; 65:425-432. [PMID: 36336285 DOI: 10.1016/j.ejvs.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 09/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) as surgical treatment for infective native aortic aneurysm (INAA) is associated with superior survival compared with open surgery, but with the risk of infection related complications (IRCs). This study aimed to assess the association between baseline clinical and computed tomography (CT) features and the risk of post-operative IRCs in patients treated with EVAR for INAA. It also sought to develop a model to predict long term IRCs in patients with abdominal INAA treated with EVAR. METHODS All initial clinical details and CT examinations of INAAs between 2005 and 2020 at a major referral hospital were reviewed retrospectively. The images were scrutinised according to aneurysm features, as well as peri-aortic and surrounding organ involvement. Data on post-operative IRCs were found in the patient records. Cox regression analysis was used to derive predictors for IRCs and develop a model to predict five year IRCs after EVAR in abdominal INAA. RESULTS Of 3 780 patients with the diagnosis of aortic aneurysm or aortitis, 98 (3%) patients were treated with EVAR for abdominal INAAs and were thus included. The mean follow up time was 52 months (range 0 ‒ 163). The mean transaxial diameter was 6.5 ± 2.4 cm (range 2.1 ‒14.7). In the enrolled patients, 38 (39%) presented with rupture. The five year IRC rate in abdominal INAAs was 26%. Female sex, renal insufficiency, positive blood culture, aneurysm diameter, and psoas muscle involvement were predictive of five year IRC in abdominal INAA after EVAR. The model had a C-index of 0.76 (95% CI 0.66 - 0.87). CONCLUSION Pre-operative clinical and CT features have the potential to predict IRC after endovascular aortic repair in INAA patients. These findings stress the importance of rigorous clinical, laboratory, and radiological follow up in these patients.
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Affiliation(s)
| | - Boonprasit Kritpracha
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Karl Sörelius
- Department of Vascular Surgery, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ply Chichareon
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Jitpreedee Sungsiri
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Sorracha Rookkapan
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Dhanakom Premprabha
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Pong Juntarapatin
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Ruedeekorn Suwannanon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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14
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 424] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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15
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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16
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Muacevic A, Adler JR. Mycotic Thoracic Aortic Aneurysm: Epidemiology, Pathophysiology, Diagnosis, and Management. Cureus 2022; 14:e31010. [PMID: 36349070 PMCID: PMC9632233 DOI: 10.7759/cureus.31010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/30/2022] Open
Abstract
Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.
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17
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Choinski KN, Harris JD, Cooke PV, Tadros RO. Treatment of a descending thoracic mycotic aneurysm secondary to disseminated aspergillosis infection with thoracic endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:319-322. [PMID: 35812126 PMCID: PMC9259443 DOI: 10.1016/j.jvscit.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Mycotic aortic aneurysms are a rare and potentially fatal aortic pathology. Advancements in vascular technology have allowed endovascular repair to be a durable and less invasive option for the treatment of mycotic aortic aneurysms. We have presented the case of a 51-year-old man with a mycotic aneurysm of the descending thoracic aorta secondary to chronic, disseminated aspergillosis infection after liver transplantation. The aneurysm was successfully treated with thoracic aortic stent graft deployment. No perioperative complications occurred, and follow-up computed tomography angiography showed no signs of an endoleak. The patient will continue with lifelong antifungal therapy and close follow-up with vascular surgery.
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18
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Ruwisch J, Fischer B, Häbel L, Laenger F, Bollmann BA. A Case Report and Review of the Literature: Infectious Aneurysm Formation in the Pulmonary Arteries-A Rare but Perilous Sequela of Persisting Infection With Klebsiella pneumoniae. Front Microbiol 2022; 13:893737. [PMID: 35656000 PMCID: PMC9152446 DOI: 10.3389/fmicb.2022.893737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/19/2022] [Indexed: 12/03/2022] Open
Abstract
Septic aneurysms of the pulmonary artery are rare conditions, with few cases having been reported worldwide. They are assumed to result from septic emboli that cause a local inflammatory reaction of the arterial wall, ultimately leading to degenerative changes. We report the case of a 63-year-old female patient presenting with Klebsiella pneumoniae urosepsis and first diagnosis of diabetes mellitus, who developed a life-threatening infectious pulmonary artery aneurysm secondary to bacteremia with Klebsiella pneumoniae. The patient required a lobectomy due to pulmonary hemorrhage. We review the clinical hallmarks of Klebsiella pneumoniae related septic pulmonary embolic disease and summarize currently known risk factors for the development of infectious aneurysmatic disease including diabetes mellitus and other states of immunosuppression. The featured case aims to increase the awareness for this seldom but life-threatening complication of infectious diseases such as Klebsiella pneumoniae urosepsis.
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Affiliation(s)
- Jannik Ruwisch
- Clinic for Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End Stage and Obstructive Lung Disease, German Center for Lung Research, Hannover, Germany
| | - Bettina Fischer
- Clinic for Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End Stage and Obstructive Lung Disease, German Center for Lung Research, Hannover, Germany
| | - Lea Häbel
- Clinic for Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Florian Laenger
- Biomedical Research in End Stage and Obstructive Lung Disease, German Center for Lung Research, Hannover, Germany.,Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Benjamin-Alexander Bollmann
- Clinic for Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End Stage and Obstructive Lung Disease, German Center for Lung Research, Hannover, Germany
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19
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Hakkenbrak NAG, Truijers M, Thomassen I. Thoracic Endovascular Aneurysm Repair and Tracheal Stenting for Respiratory Failure due to a Thoracic Aortic Aneurysm: A Case Report. Vasc Endovascular Surg 2022; 56:514-516. [PMID: 35363099 PMCID: PMC9163772 DOI: 10.1177/15385744221085814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An 82-year-old male was referred to the emergency department for severe respiratory distress. Computed tomography angiography showed tracheal compression due to a large ruptured saccular aneurysm of the descending thoracic aorta. Emergency Thoracic Endovascular Aneurysm Repair (TEVAR) was performed. To reduce tracheal compression, an endotracheal stent was placed (silicone Dumon©). Following surgery, respiratory function improved. Two days after the surgery, the patient refused further invasive treatment, including mechanical mucus aspiration from the endotracheal stent, and palliative sedation was initiated. Conventional treatment to reduce tracheal compression by a saccular aortic aneurysm is open surgical aneurysm repair. If open repair is contraindicated because of patient age, comorbidity, or in case of severe hemodynamic instability following aneurysm rupture, TEVAR with endotracheal stent placement may serve as a bridge to definite surgery to reduce tracheal compression.
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Affiliation(s)
- Nadia A G Hakkenbrak
- Department of vascular surgery, Amsterdam UMC, 1209Location VU Medical Centre, Amsterdam, The Netherlands.,Department of vascular surgery, 1140Northwest Clinics, Alkmaar, The Netherlands
| | - Maarten Truijers
- Department of vascular surgery, Amsterdam UMC, 1209Location VU Medical Centre, Amsterdam, The Netherlands.,Department of vascular surgery, 3670Spaarne Gasthuis, Haarlem, The Netherlands
| | - Irene Thomassen
- Department of vascular surgery, Amsterdam UMC, 1209Location VU Medical Centre, Amsterdam, The Netherlands.,Department of vascular surgery, 1140Northwest Clinics, Alkmaar, The Netherlands
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20
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Systematic Review and Meta-Analysis of Outcomes Following Endovascular and Open Repair for Infective Native Aortic Aneurysms. Ann Vasc Surg 2021; 79:348-358. [PMID: 34644648 DOI: 10.1016/j.avsg.2021.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/02/2021] [Accepted: 07/04/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of our systematic review and meta-analysis was to demonstrate the clinical outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infective native aortic aneurysms (INAAs). METHODS MEDLINE, Embase, and Cochrane Databases were searched for articles reporting OSR and/or EVAR repair of INAA. The methodological quality of included studies was assessed by the Newcastle-Ottawa scale and Moga-Score. Random-effects models were used to calculate the pooled measures. RESULTS A total of 34 studies were included, with 22 studies reporting OSR alone, 6 studies reporting EVAR alone and 6 comparative studies for INAAs. The pooled estimates of infection-related complications (IRCs) were 8.2% (95% CI 4.9%-12.2%) in OSR cohort and 23.2% (95% CI 16.1%-31.0%) in EVAR cohort. EVAR was associated with a significantly increased risk of IRCs compared with OSR during follow-up (OR 1.9, 95% CI 1.0-3.7). As for survival outcomes, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality in OSR cohort were 11.7% (95% CI 7.7%-16.1%), 21.6% (95%CI 16.3%-27.4%) and 28.3% (95% CI 20.5%-36.7%; I2=50.47%), respectively. For EVAR cohort, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality were 4.9% (95% CI 1.1%-10.4%), 9.4% (95% CI 2.7%-18.7%) and 22.2% (95% CI 12.4%-33.7%), respectively. EVAR was associated with a significantly decreased of 30-day mortality (OR 0.2, 95% CI 0.1-0.6). However, no difference was found between EVAR and OSR in 3-month (OR 0.2, 95% CI 0-1.1), 1-year all-cause mortality (OR 0.4, 95% CI 0.1-1.1) or aneurysm-related mortality (OR 1.4, 95% CI 0.5-3.9). Moreover, no difference of incidence of reintervention was observed (OR 2.6, 95% CI 0.9-7.7; I2=53.7%) between two groups. CONCLUSIONS EVAR could provide better short-term survival than OSR in patients with INAAs. However, patients undergoing EVAR suffered from higher risks of IRCs. EVAR could be considered as an alternative for low-risk patients with well-controlled infections or patients considered high-risk for open reconstruction.
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21
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Couture T, Gaudric J, Davaine JM, Jayet J, Chiche L, Jarraya M, Koskas F. Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections. J Vasc Surg 2021; 73:626-634. [PMID: 33485491 DOI: 10.1016/j.jvs.2020.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts. METHODS Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity. RESULTS Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively. CONCLUSIONS Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.
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Affiliation(s)
- Thibault Couture
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France.
| | - Julien Gaudric
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jean-Michel Davaine
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jérémie Jayet
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France
| | - Laurent Chiche
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France
| | | | - Fabien Koskas
- Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France
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Shchetynska-Marinova T, Amendt K, Sadick M, Keese M, Sigl M. Aortitis - An Interdisciplinary Challenge. In Vivo 2021; 35:41-52. [PMID: 33402448 DOI: 10.21873/invivo.12230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/24/2022]
Abstract
The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.
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Affiliation(s)
- Tetyana Shchetynska-Marinova
- First Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Klaus Amendt
- Vascular Center Oberrhein, Internal Medicine I, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Maliha Sadick
- Clinic for Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Keese
- Department of Vascular Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Sigl
- First Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany;
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23
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Blinick R, Chaya N, Zalta B, Haramati LB, Shmukler A. Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse. J Thorac Imaging 2021; 36:W16-W31. [PMID: 32102017 DOI: 10.1097/rti.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.
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Affiliation(s)
| | - Nathan Chaya
- Montefiore Medical Center, Bronx
- Staten Island University Hospital, Staten Island, NY
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24
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Yamashita T, Yamanaka K, Izumi A, Matsui J, Kurimoto M, Aoki H, Tamura J. Endovascular repair using a covered stent for a ruptured infected aneurysm of the superior mesenteric artery after pancreaticoduodenectomy: a case report. Surg Case Rep 2020; 6:270. [PMID: 33074371 PMCID: PMC7573079 DOI: 10.1186/s40792-020-01047-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/11/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Delayed arterial hemorrhage after pancreaticoduodenectomy is a life-threatening complication. There are no reports about infected aneurysms of the superior mesenteric artery after pancreaticoduodenectomy without clinically relevant pancreatic fistula. CASE PRESENTATION A 78-year-old woman with borderline resectable pancreatic ductal adenocarcinoma involving the superior mesenteric arterial nerve plexus underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the superior mesenteric arterial nerve plexus after neoadjuvant chemotherapy. On postoperative day 14, she had bacteremia and sudden fever with chills. During the postoperative course, macroscopic abscesses or distinct infectious signs, including pancreatic fistula or bile fistula, were not present, but pylephlebitis was observed. After the antimicrobial treatment course, the patient was discharged. After 17 days, she was hospitalized for melena. Contrast-enhanced computed tomography showed a ruptured aneurysm of the superior mesenteric artery into the small intestine without a major intraabdominal abscess. E. coli was isolated from blood cultures. The patient was diagnosed with a ruptured infected aneurysm of the superior mesenteric artery. She was treated successfully with a covered stent by the cardiology team. There was no recurrence of bleeding at the 4-month follow-up, and the stent was patent in all subsequent computed tomography scans. CONCLUSIONS Endovascular repair using a covered stent was effective in palliating acute bleeding from an infected aneurysm of the superior mesenteric artery.
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Affiliation(s)
- Tokuyuki Yamashita
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Kenya Yamanaka
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan.
| | - Ai Izumi
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Jun Matsui
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Makoto Kurimoto
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Hikaru Aoki
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
| | - Jun Tamura
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77, Higashinaniwa, Amagasaki, Hyogo, Japan
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25
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Zeng L, Shu W, Ma H, Hu J. Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review. Medicine (Baltimore) 2020; 99:e20849. [PMID: 32590781 PMCID: PMC7328905 DOI: 10.1097/md.0000000000020849] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Ingestion of a foreign body can cause different degrees of damage to esophagus, and several complications are potentially life-threatening if not properly handled. The aortic injury caused by a perforating esophageal foreign body is rare but lethal. The optimal management still remains controversial. The purpose of this report is to describe our experience in the management of the aortic injury caused by esophageal foreign body ingestion. METHODS Between January 2015 and December 2015, we retrospectively enrolled cases of esophageal perforation involving the aorta by foreign body. The general parameters, esophageal foreign body, types of aortic injury, treatment, and outcome were analyzed. Additionally, we reviewed the literature of the management of esophageal perforation involving the aorta caused by foreign bodies. The study was approved by the ethics committee of the First Affiliated Hospital, College of Medicine, Zhejiang University, and the need for informed consent was waived (Quick review 2019, No. 609). RESULTS Three cases of esophageal perforation involving the aorta by foreign body was selected in the study. Two male and 1 female patients (range, 51-58 years old) with the aorta involvement caused by a perforating foreign body in the esophagus in 3 forms were identified, including 1 patient with mycotic aortic pseudoaneurysm, 1 patient with aortoesophageal fistula and 1 patient with the aortic intramural hematoma. One patient died of the rupture of the pseudoaneurysm during the preparation of the surgery. The other 2 patients were cured with a multidisciplinary approach, which is an urgent thoracic endovascular aortic repair followed by mediastinal debridement/drainage or endoscopic retrieval. Two of 3 patients were survived until now. CONCLUSION The management of the aortic injury caused by esophageal foreign body injury is challenging. Early diagnosis and multidisciplinary management is crucial.
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Denny KJ, Kumar A, Timsit JF, Laupland KB. Extra-cardiac endovascular infections in the critically ill. Intensive Care Med 2019; 46:173-181. [PMID: 31745594 DOI: 10.1007/s00134-019-05855-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/04/2019] [Indexed: 01/16/2023]
Abstract
Vascular infections are associated with high complication rates and mortality. While there is an extensive body of literature surrounding cardiac infections including endocarditis, this is less so the case for other endovascular infections. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe vascular infections exclusive of those involving the heart. Endovascular infections may involve either the arterial or venous vasculature and may arise in native vessels or secondary to implanted devices. Management is complex and requires multi-disciplinary involvement from the outset. Infective arteritis or device-related arterial infection involves removal of the infected tissue or device. In cases where complete excision is not possible, prolonged courses of antimicrobials are required. Serious infections associated with the venous system include septic thrombophlebitis of the internal jugular and other deep veins, and intracranial/venous sinuses. Source control is of paramount importance in these cases with adjunctive antimicrobial therapy. The role of anticoagulation is controversial although recommended in the absence of contraindications. An improved understanding of the management of these infections, and thus improved patient outcomes, requires multi-center, international collaboration.
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Affiliation(s)
- Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queensland, Herston, QLD, Australia
| | - Anand Kumar
- Sections of Critical Care Medicine and Infectious Diseases, Health Sciences Centre, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jean-Francois Timsit
- AP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018, Paris, France.,University of Paris, IAME, INSERM, 75018, Paris, France
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Queensland University of Technology, Brisbane, QLD, Australia.
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27
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Takigawa T, Baba H, Hisahara M, Ando Y, Ochiai Y, Tokunaga S. Use of computed tomography-guided biopsy to detect Peptostreptococcus micros-induced mycotic abdominal aortic aneurysm after endovascular repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:477-480. [PMID: 31763502 PMCID: PMC6859297 DOI: 10.1016/j.jvscit.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/09/2019] [Indexed: 11/28/2022]
Abstract
Mycotic aortic aneurysm (MAA) is rare but lethal. Detection of the causative bacteria is important for successful treatment. In some cases, however, no micro-organisms are detected by repeated blood cultures. Open surgery is the standard procedure for MAA, but endovascular intervention is also performed. An aneurysm specimen cannot be taken for culture when using an endovascular approach, decreasing the opportunity to detect the causative organism. We performed successful endovascular repair in a rare case of a Peptostreptococcus micros-induced MAA as detected by postoperative computed tomography-guided biopsy. This case may help to establish appropriate medical treatment for MAAs.
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Affiliation(s)
- Tomoya Takigawa
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
| | - Hironori Baba
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
| | - Manabu Hisahara
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
| | - Yusuke Ando
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
| | - Yoshie Ochiai
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
| | - Shigehiko Tokunaga
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, Fukuoka, Japan
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28
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Sörelius K, Budtz-Lilly J, Mani K, Wanhainen A. Systematic Review of the Management of Mycotic Aortic Aneurysms. Eur J Vasc Endovasc Surg 2019; 58:426-435. [DOI: 10.1016/j.ejvs.2019.05.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 12/21/2022]
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29
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Botianu PVH. Current indications for the intrathoracic transposition of the omentum. J Cardiothorac Surg 2019; 14:103. [PMID: 31182112 PMCID: PMC6558767 DOI: 10.1186/s13019-019-0924-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 05/28/2019] [Indexed: 12/30/2022] Open
Abstract
Background The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications. Methodology and review This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery. Conclusions OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.
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Affiliation(s)
- Petre V H Botianu
- Surgery IV Discipline, M5 Department, University of Medicine and Pharmacy from Tirgu-Mures, 540091 Bujorului 2A, Tirgu-Mures, Romania.
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30
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Repair of Thoracic and Thoracoabdominal Mycotic Aneurysms and Infected Aortic Grafts Using Allograft. Ann Thorac Surg 2018; 106:1129-1135. [DOI: 10.1016/j.athoracsur.2018.04.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/16/2018] [Accepted: 04/17/2018] [Indexed: 12/25/2022]
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31
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Lau C, Leonard JR, Iannacone E, Gaudino M, Girardi LN. Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Semin Thorac Cardiovasc Surg 2018; 31:11-16. [PMID: 30071280 DOI: 10.1053/j.semtcvs.2018.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/24/2018] [Indexed: 01/16/2023]
Abstract
Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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Shahi N, Arosemena M, Kwon J, DiMuzio P, Abai B, Salvatore DM. A rare case of Clostridium septicum aortitis with colon adenocarcinoma. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:87-90. [PMID: 29707691 PMCID: PMC5918140 DOI: 10.1016/j.jvscit.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 12/16/2017] [Indexed: 11/26/2022]
Abstract
Clostridium septicum aortitis is a rare, highly morbid condition typically accompanied by malignant disease, such as hematologic cancer or colon adenocarcinoma. Presenting symptoms commonly described include acute onset of abdominal pain, nausea, and fevers. Prompt diagnosis of infectious aortitis is critical to prevent deadly complications, such as sepsis and vascular catastrophe. The described management largely involves surgical resection of the infected aorta, débridement, and arterial revascularization through extra-anatomic bypass or aortic graft placement.
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Affiliation(s)
- Niti Shahi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Mariano Arosemena
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Jeontaik Kwon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Paul DiMuzio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Dawn M Salvatore
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
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Deipolyi AR, Czaplicki CD, Oklu R. Inflammatory and infectious aortic diseases. Cardiovasc Diagn Ther 2018; 8:S61-S70. [PMID: 29850419 PMCID: PMC5949581 DOI: 10.21037/cdt.2017.09.03] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 09/01/2017] [Indexed: 12/15/2022]
Abstract
Aortitis is aortic inflammation, which can be due to inflammatory or infectious diseases. Left undiagnosed, aortitis can lead to aneurysm formation and rupture, in addition to ischemic compromise of major organs. Infectious aortic diseases include mycotic aneurysm and graft infection; the most common inflammatory diseases are Takayasu's and giant cell arteritis. We review the epidemiology, etiology, presentation and diagnosis, and treatment of these entities.
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Affiliation(s)
- Amy R. Deipolyi
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Kim HH, Kim DJ, Joo HC. Outcomes of Open Repair of Mycotic Aortic Aneurysms with In Situ Replacement. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:430-435. [PMID: 29234609 PMCID: PMC5716645 DOI: 10.5090/kjtcs.2017.50.6.430] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 11/16/2022]
Abstract
Background Mycotic aortic aneurysms are rare and life-threatening. Unfortunately, no established guidelines exist for the treatment of patients with mycotic aortic aneurysms. The purpose of this study was to evaluate the midterm outcomes of the open repair of mycotic thoracic and thoracoabdominal aneurysms and suggest a therapeutic strategy. Methods From 2006 to 2016, 19 patients underwent open repair for an aortic aneurysm. All infected tissue was extensively debrided and covered with soft tissue. We recorded the clinical findings, anatomic location of the aneurysm, bacteriology results, antibiotic therapy, morbidity, and mortality for these cases. Results The median age was 62±7.2 years (range, 16 to 78 years), 13 patients (68%) were men, and the mean aneurysm size was 44.5±4.9 mm. The mean time from onset of illness to surgery was 14.5±2.4 days. Aortic continuity was restored in situ with a Dacron prosthesis (79%), homograft (16%), or Gore-Tex graft (5%). Soft-tissue coverage of the prosthesis was performed in 8 patients. The mean follow-up time was 43.2±11.7 months. The early mortality rate was 10.5%, and the 5-year survival rate was 74.9%±11.5%. Conclusion This study showed acceptable early and midterm outcomes of open repair of mycotic aneurysms. We emphasize that aggressive intraoperative debridement with soft-tissue coverage results in a high rate of success in these high-risk patients.
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Affiliation(s)
- Hyo-Hyun Kim
- Department of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Do Jung Kim
- Department of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Hyun-Chel Joo
- Department of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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35
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Lau C, Girardi LN. Staged endovascular followed by open repair of mycotic thoracic aneurysms: A bridge to success? J Thorac Cardiovasc Surg 2017; 155:e91-e92. [PMID: 29157928 DOI: 10.1016/j.jtcvs.2017.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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36
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Girardi LN, Lau C, Munjal M, Elsayed M, Gambardella I, Ohmes LB, Gaudino M. Impact of preoperative pulmonary function on outcomes after open repair of descending and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2017; 153:S22-S29.e2. [DOI: 10.1016/j.jtcvs.2016.10.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/17/2016] [Accepted: 10/31/2016] [Indexed: 12/25/2022]
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Cepeda González C, García Benedito P, Rodríguez Maya B, Culebras Requena J. Aortitis bacteriana aguda por Yersinia enterocolitica. Enferm Infecc Microbiol Clin 2016; 34:604-605. [DOI: 10.1016/j.eimc.2015.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
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Chen SL, Kuo IJ, Fujitani RM, Kabutey NK. Endovascular Management of Concomitant Thoracic and Abdominal Aortic Ruptures Resulting from Brucellosis Aortitis. Ann Vasc Surg 2016; 38:190.e1-190.e4. [PMID: 27554701 DOI: 10.1016/j.avsg.2016.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/29/2016] [Accepted: 08/06/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute aortic symptomatology is an unusual manifestation of Brucella melitensis infection. We present a rare case of acute multifocal thoracic and abdominal aortic ruptures arising from Brucellosis aortitis managed exclusively with endovascular surgery. METHODS A 71-year-old Hispanic male with a history of atrial fibrillation and prior stroke on chronic anticoagulation presented with shortness of breath and malaise. In addition, he had been treated approximately 1 year previously in Mexico for B. melitensis bacteremia after eating fresh unpasteurized cheese. Computed tomography (CT) angiography demonstrated an acute rupture of the descending thoracic aorta just proximal to the celiac trunk and synchronous rupture at the abdominal aortic bifurctation. RESULTS The patient was taken emergently to the hybrid operating room, where synchronous supraceliac thoracic aorta and abdominal aortoiliac stent grafts were deployed under local anesthesia. Completion angiography demonstrated total exclusion of the thoracic and abdominal extravasation with no evidence of endoleak. Twenty hours postoperatively, the patient became acutely obtunded and hypotensive. Repeat CT angiography demonstrated contrast extravasation at the level of the excluded aortic bifurcation. Emergent angiography confirmed a type II endoleak with free extraluminal rupture. Multiple coils were placed at the level of the aortic bifurcation between the left limb of the stent graft and the aortic wall to tamponade the endoleak. No further extravasation was noted on final aortography. Postoperatively, blood cultures confirmed the diagnosis of B. melitensis. The patient was treated with systemic doxycycline, gentamicin, and rifampin. Resolution of the acute event occurred without additional sequelae and he was discharged from the hospital to a rehabilitation facility. CONCLUSIONS Concomitant multifocal aortic ruptures arising from Brucellosis aortic infection is a very rare event. In this case, the patient was successfully treated with thoracic and abdominal endovascular stent-graft exclusion, coiling, and long-term targeted antibiotics.
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Affiliation(s)
- Samuel L Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Isabella J Kuo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Roy M Fujitani
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA.
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Deipolyi AR, Rho J, Khademhosseini A, Oklu R. Diagnosis and management of mycotic aneurysms. Clin Imaging 2016; 40:256-62. [DOI: 10.1016/j.clinimag.2015.11.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/04/2015] [Accepted: 11/23/2015] [Indexed: 02/06/2023]
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