11-year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms

Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella

PURPOSE

Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms.

MATERIALS AND METHODS

The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed.

RESULTS

Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak.

CONCLUSION

EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms.

CLINICAL IMPACT

Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Analysis of antibiotic strategies to prevent vascular graft or endograft infection after surgical treatment for infective native aortic aneurysms: a systematic review

INTRODUCTION

Some patients with an infective native aortic aneurysm (INAA) develop an aortic vascular graft or endograft infection (VGEI) even after successful open surgical repair or endovascular intervention. The aim of the systematic review and meta-analysis performed herein was to compare the clinical outcomes of different surgical and antibiotic treatment strategies.

METHODS

We systematically searched PubMed, MEDLINE, EMBASE and Web of Science. The keywords used for the search were "mycotic aortic aneurysm", "infected aortic aneurysm", "infective native aortic aneurysm", "antibiotics", "surgery", and "endovascular". The search was limited to articles written in English and to studies involving humans. Articles published before 2000 were excluded. Case reports and review articles were excluded.

RESULTS

Of the 524 studies retrieved from our search of the databases, 47 articles were included in this study. Among the 47 articles (1546 patients, 72.8% of whom were male) retrieved, five articles were excluded from the subgroup analysis because the data concerning open surgical repair and endovascular intervention could not be separated. The remaining 42 articles included a total of 1179 patients who underwent open surgical repair (622 patients) or endovascular intervention (557 patients) for INAA. There was a statistically significant difference (p = 0.001) in the pooled in-hospital mortality rate between the open surgical repair group (13.2%, 82/622) and the endovascular intervention group (7.2%, 40/557). However, there was a statistically significant difference (p < 0.001) in the aortic VGEI rate between the open surgical repair group (5.4%). 29/540) and endovascular intervention (13.3%, 69/517) group. For patients who underwent open surgical repair, a lower rate of aortic vascular graft infection was associated with long-term antibiotic use (p = 0.005). For patients who underwent endovascular intervention, there was a trend of association (p = 0.071) between the lower rate of aortic endograft infection and lifelong antibiotic use.

CONCLUSION

Infective native aortic aneurysms are life-threatening. The pooled in-hospital mortality rate of the open surgical repair group was significantly higher than that of the endovascular intervention group, whereas the rate of the aortic VGEI in the open surgical repair group was significantly lower than that in the endovascular intervention group. Regardless of whether open surgical repair or endovascular intervention is performed, better long-term outcomes can be achieved with aggressive antibiotic treatment, which is especially important for patients who undergo endovascular intervention.

Outcomes Following Different Management of Mycotic Infrarenal Abdominal Aortic Aneurysms

OBJECTIVE

The objective was to present our experience on managing mycotic infrarenal abdominal aortic aneurysm (MIAAA) through a retrospective cohort study.

METHODS

Data of patients with MIAAA managed in our center from July 2016 to October 2022 were retrospectively analyzed. The diagnosis of MIAAA was made based on: (1) preoperative clinical signs of infection; (2) elevated serologic infection parameters; (3) para-aneurysmal infection features on enhanced computed tomography; and (4) positive blood or tissue cultures. All the patients received standard antibiotic therapy. Surgical management including endovascular aneurysm repair (EVAR), initial EVAR followed by open re-operation, and initial open surgical repair (OSR) were conducted according to disease seriosity, physical condition, and patient's will. Infection index and clinical outcome were evaluated during the follow-up time.

RESULTS

A total of 23 patients (21 men; averaged=66.3 years, range=49-79 years) were included, with a mean follow-up time of 19.9 months (range=1-75 months). Bacteria culture from blood or tissue specimen was positive in 15 patients (Salmonella, n=8; Escherichia coli, n=3; methicillin-sensitive Staphylococcus aureus [MSSA], n=1; Klebsiella pneumoniae, n=1; Staphylococcus epidermidis, n=1; Mycobacterium tuberculosis, n=1). Seven patients received OSR as the initial surgical intervention, whereas 14 patients chose EVAR instead. The 2 conservatively managed patients (refused surgery) died within 30 days. The 7 patients who received initial OSR survived till now. Among the 14 patients who underwent initial EVAR, infection deteriorated without exception (14/14, 100%). Three of these patients refused re-operation and died within 6 months. Eleven patients received secondary surgical intervention (10 cases of aneurysm and endograft resection, thorough debridement, subclavian to bi-femoral artery bypass, or in situ aorta reconstruction; 1 case of laparoscopic debridement) and 7 survived the follow-up time. The overall mortality rate was 39.1% (9/23). The mortality rates differed greatly following different intervention methods (merely antibiotic management, 100%; initial open operation, 0%; initial EVAR without secondary operation, 100%; initial EVAR plus secondary operation, 36.4%).

CONCLUSIONS

Open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely EVAR is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary OSR.

CLINICAL IMPACT

The management of mycotic or primary-infected aortic aneurysm is challenging; treatment remains controversial. Our center has reviewed our experience over the past 6 years and found that open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely endovascular aneurysm repair (EVAR) is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary open surgical repair.

Midterm outcomes of endovascular treatment for infected aortic aneurysms: Single center experience

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.

Brucellosis involving the aorta and iliac arteries: a systematic review of 130 cases

Objective: Brucellosis, the most common bacterial zoonosis, poses a serious threat to public health in endemic regions. Cardiovascular complications of brucellosis, mostly pericarditis or endocarditis, are the leading cause of brucellosis-related death. Complications involving the aorta and iliac arteries are extremely rare but can be life-threatening. Our objective was to identify and review all reported cases of aortic and iliac involvement in brucellosis to provide a deep, up-to-date understanding of the clinical characteristics and management of the disease. Methods: Online searches in PubMed, Web of Science, China National Knowledge Infrastructure, and the Chinese Wanfang database were conducted to collect articles reporting cases of brucellosis with aortic and iliac artery involvement. All data in terms of patient demographics, diagnostic methods, clinical manifestations, and treatment regimens and outcomes were extracted and analyzed in this systematic review. Results: A total of 79 articles were identified, reporting a total of 130 cases of brucellosis with aortic and iliac artery involvement. Of the 130 cases, 110 (84.5%) were male individuals and 100 (76.9%) were over 50 years old. The patients had an overall mortality rate of 12.3%. The abdominal aorta was most commonly involved, followed by the ascending aorta, iliac artery, and descending thoracic aorta. Arteriosclerosis, hypertension, and smoking were the most common comorbidities. There were 71 patients (54.6%) who presented with systemic symptoms of infection at the time of admission. Endovascular therapy was performed in 56 patients (43.1%), with an overall mortality rate of 3.6%. Open surgery was performed in 52 patients (40.0%), with an overall mortality rate of 15.4%. Conclusion: Aortic and iliac involvement in brucellosis is extremely rare but can be life-threatening. Its occurrence appears to be associated with the male gender, an older age, arteriosclerosis, and smoking. Although the number of reported cases in developing countries has increased significantly in recent years, its incidence in these countries may still be underestimated. Early diagnosis and therapeutic intervention are critical in improving patient outcomes. Endovascular therapy has become a preferred surgical treatment in recent years, and yet, its long-term complications remain to be assessed.

Mycotic Thoracic Aortic Aneurysm: Epidemiology, Pathophysiology, Diagnosis, and Management

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.

Outcomes of patients with aortic vascular graft and endograft infections initially contra-indicated for complete graft explantation

OBJECTIVE

Complete excision in patients with aortic vascular graft and endograft infections (VGEIs) is a significant undertaking, and many patients never undergo definitive treatment. Knowing their fate is important to be able to assess the risks of graft excision vs alternative strategies. This study analyzed their life expectancy and sepsis-free survival.

METHODS

VGEIs were diagnosed according to the Aortic Graft Infection (MAGIC) criteria, and patients turned down for graft removal from November 2006 to December 2020 were included. Primary endpoints were aortic-related and sepsis-free survival estimated using the Kaplan-Meier method. A Cox proportional hazards regression analysis was used to compute the hazard ratio (HR) and 95% confidence interval (CI) as estimates of survival without sepsis.

RESULTS

Seventy-four patients were included, with a median age of 71 years (range, 63-79 years). The index aortic repair was either open (n = 33; 44.6%), endovascular (n = 19; 25.7%), or hybrid (n = 22; 29.7%). Causative organisms were identified in 56 patients (75.7%). At presentation, 26 patients (35.1%) required salvage surgery, open (n = 22; 29.7%) or endovascular (n = 8; 10.8%), and 17 radiological drainage (23.0%). During follow-up, eight required drainage and 11 (14.9%) graft removal (five complete). Infectious complications included pseudoaneurysms (n = 14; 18.9%), rupture (n = 9; 12.2%), gastro-intestinal bleeding (n = 13; 17.6%), septic embolisms (n = 4; 5.4%), and thrombosis (n = 12; 16.2%). In-hospital mortality was 20.3% (n = 15), freedom from aortic-related death and overall survival was 77.1% (95% CI, 65.2%-85.3%) and 70.4% (95% CI, 58.3%-79.7%) at 1 year, and 61.7% (95% CI, 46.1%-74.0%) and 43.1% (95% CI, 29.2%-56.3%) at 5 years. Sepsis recurrence occurred in 37 patients (50.0%). Seven (16.3%) developed acquired antimicrobial resistance. Malnutrition (HR, 3.3; 95% CI, 1.4-7.6; P = .005), hemorrhagic shock at presentation (HR, 2.9; 95% CI, 1.0-8.2; P = .048), aorto-enteric fistulae (HR, 3.3; 95% CI, 1.3-8.4; P = .011), fungal coinfection (HR, 3.5; 95% CI, 1.2-11.5; P = .030), and infection with resistant micro-organisms (HR, 3.1; 95% CI, 1.1-8.3; P = .023) were significantly associated with worse survival without sepsis.

CONCLUSIONS

In-hospital and aortic-related mortality were significant, but with salvage surgery and antibiotic therapy, the median survival was 3 years. Sepsis recurrence remained frequent, and further procedures were needed. These outcomes should be considered when graft excision is proposed. Known predictors of adverse outcomes should become important points for discussion in multidisciplinary team meetings.

Mycotic Aortic Aneurysm: A Rare Etiology of Septic Shock

Mycotic aneurysm of the aorta is a rare disease with a high mortality rate due to its likelihood of aneurysmal rupture. This syndrome is predominantly seen in patients over age 65 with the most common presenting symptoms being fever and back pain. Our case illustrates a mycotic aneurysm of the aorta presenting in an elderly female with vague abdominal pain, flank pain, and generalized weakness. We review the investigative approach, diagnostic modalities, and treatment options in patient management. This case emphasizes the need for a high index of suspicion of mycotic aneurysms of the aorta in critically ill elderly patients as early antibiotic therapy can be crucial for source control.

Mycotic/Infective Native Aortic Aneurysms: Results After Preferential Use of Open Surgery and Arterial Allografts

OBJECTIVE

Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards.

METHODS

A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses.

RESULTS

Seventy patients (60 men [86%], median age 68 years [range 59 - 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan-Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 - 93.0) and 71.7% (95% CI 59.2 - 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 - 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0-66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 - 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 - 33.9), 4 (OR 14.9, 95% CI 1.7 - 129.3), and CKD (OR 32.0, 95% CI 1.2 - 821.5) were related to 90 day mortality.

CONCLUSION

Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn.

Systematic Review and Meta-Analysis of Outcomes Following Endovascular and Open Repair for Infective Native Aortic Aneurysms

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.

Fifteen-year, single-center experience with in situ reconstruction for infected native aortic aneurysms

OBJECTIVE

The purpose of the present study was to evaluate the survival and freedom from reinfection for patients with infected native aortic aneurysms (INAAs) treated with in situ revascularization (ISR), using either open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and to identify the predictors of outcome.

METHODS

Patients with INAAs who had undergone ISR from January 2005 to December 2020 were included in the present retrospective single-center study. The diagnosis of INAAs required a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging findings, and (4) intraoperative findings. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. The predictive factors for adverse outcomes were evaluated using the Mann-Whitney U test or the Fisher exact test and multivariate regression analysis.

RESULTS

A total of 65 patients (53 men [81.5%]; median age, 69.0 years; interquartile range, 61.5-75.0 years) were included, 31 (47.7%) were immunocompromised, 60 were symptomatic (92.3%), and 32 (49.2%) had presented with rupture, including 3 aortocaval fistulas (4.6%) and 12 aortoenteric fistulas (18.5%). The most common location was infrarenal (n = 39; 60.0%). Of the 65 patients, 55 (84.6%) had undergone primary OSR with ISR, 3 (4.6%) had required EVAR as a bridge to OSR, and 8 (12.3%) had undergone EVAR as definitive treatment. The approach was a midline laparotomy for 44 patients (67.7%), mostly followed by reconstruction and aortic-aortic bypass (n = 28; 40.6%) and the use of a silver and triclosan Dacron graft (n = 30; 43.5%). Causative organisms were identified in 55 patients (84.6%). The 30-day and in-hospital mortality rates were 6.2% (n = 4) and 10.8% (n = 7). The median follow-up was 33.5 months (interquartile range, 13.6-62.3 months). The estimated 1- and 5-year survival rates were 79.7% (95% confidence interval [CI], 67.6%-87.7%) and 67.4% (95% CI, 51.2%-79.3%). The corresponding freedom from reinfection rates were 92.5% (95% CI, 81.1%-97.1%) and 79.4% (95% CI, 59.1%-90.3%). On multivariate analysis, in-hospital mortality increased with uncontrolled sepsis (P < .0001), rapidly expanding aneurysms (P = .008), and fusiform aneurysms (P = .03). The incidence of reinfection increased with longer operating times (P = .009).

CONCLUSIONS

The selective use of ISR and OSR combined with targeted antimicrobial therapy functioned reasonably well in the treatment of INAAs, although larger, prospective, multicenter studies with appropriately powered comparative cohorts are necessary to confirm our findings and to determine the best vascular substitute and precise role of EVAR as a bridge to OSR or definitive treatment.

Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections

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.

Emergent repair of infected aortic aneurysm with contained rupture using a femoral vein neoaortoiliac system

Infected aortic aneurysms are rare but are associated with high morbidity and mortality. Management involves surgical resection and debridement of the infected aorta and surrounding tissues, arterial reconstruction or bypass, and flap coverage, followed by long-term antibiotic therapy. Autogenous reconstruction using a neoaortoiliac system (NAIS) is a durable form of repair with a decreased risk of reinfection. However, NAIS reconstruction is generally thought to be contraindicated for emergent, but not impending, rupture settings. We present the successful application of NAIS for a contained rupture of an infected infrarenal aneurysm. Use of the NAIS can provide a more durable option for select patients.

Imaging features of mycotic aortic aneurysms

Infectious aortitis (IA) is a rare and life-threatening cardiovascular disease. Early diagnosis and timely intervention are crucial for reducing mortality associated with mycotic aortic aneurysms (MAAs); however, early diagnosis is challenging due to the nonspecific symptoms. Some cases are diagnosed at an advanced stage or after developing complications, such as rupture or aortic fistula. Current state-of-the-art imaging modalities-including computed tomography (CT), magnetic resonance imaging (MRI), and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT-can detect infected aneurysms in clinically suspicious cases. MAA features on imaging include lobulated pseudoaneurysm, indistinct irregular arterial wall, perianeurysmal gas, perianeurysmal edema, perianeurysmal soft tissue mass, aneurysmal thrombosis, and high metabolic activity with increased uptake of FDG. Enlarged lymph nodes are often found adjacent to the aneurysm, while iliopsoas abscess (IPA), spondylitis, and aortic fistulas are commonly associated complications. After surgery or endovascular repair, radiological features-including ectopic gas, peri-graft fluid, thickening of adjacent bowel, pseudoaneurysm formed at the graft anastomosis, and increased uptake of FDG-may indicate an infection of aortic graft. This article provides an overview of the clinical and imaging features of MAAs. Thus, familiarity with the imaging appearances of MAAs may assist radiologists in the diagnosis and facilitation of timely treatment.

Prostatic abscess with infected aneurysms and spondylodiscitis after transrectal ultrasound-guided prostate biopsy: a case report and literature review

Background

Transrectal ultrasonography (TRUS)-guided prostate biopsy is the conventional method of diagnosing prostate cancer. TRUS-guided prostate biopsy can occasionally be associated with severe complications. Here, we report the first case of a prostate abscess with aneurysms and spondylodiscitis as a complication of TRUS-guided prostate biopsy, and we review the relevant literature.

Case presentation

A 78-year-old man presented with back pain, sepsis, and prostate abscesses. Twenty days after TRUS-guided prostate biopsy, he was found to have a 20-mm diameter abdominal aortic aneurysm that expanded to 28.2 mm in the space of a week, despite antibiotic therapy. Therefore, he underwent transurethral resection of the prostate to control prostatic abscesses. Although his aneurysm decreased to 23 mm in size after surgery, he continued to experience back pain. He was diagnosed as having pyogenic spondylitis and this was managed using a lumbar corset. Sixty-four days after the prostate biopsy, the aneurysm had re-expanded to 30 mm; therefore, we performed endovascular aneurysm repair (EVAR) using a microcore stent graft 82 days after the biopsy. Four days after the EVAR, the patient developed acute cholecystitis, and he underwent endoscopic retrograde biliary drainage. One hundred and sixty days after the prostate biopsy, all the complications had improved, and he was discharged. A literature review identified a further six cases of spondylodiscitis that had occurred after transrectal ultrasound-guided prostate biopsy.

Conclusions

We have reported the first case of a complication of TRUS-guided prostate biopsy that involved prostatic abscesses, aneurysms, and spondylodiscitis. Although such complications are uncommon, clinicians should be aware of the potential for such severe complications of this procedure to develop.

Methicillin-resistant Staphylococcus aureus portends a poor prognosis after endovascular repair of mycotic aortic aneurysms and aortic graft infections

OBJECTIVE

Mycotic aortic aneurysms and aortic graft infections (aortic infections [AIs]) are rare but highly morbid conditions. Open surgical repair is the "gold standard" treatment, but endovascular repair (EVR) is increasingly being used in the management of AI because of the lower operative morbidity. Multiple organisms are associated with AI, and bacteriology may be an important indication of mortality. We describe the bacteriology and associated outcomes of a group of patients treated with an EVR-first approach for AI.

METHODS

All patients who underwent EVR for native aortic or aortic graft infections between 2005 and 2016 were retrospectively reviewed. Primary end points were 30-day mortality and overall mortality. The primary exposure variable was bacteria species. Logistic regression analysis was used to determine association with mortality. Kaplan-Meier survival analysis was used to estimate survival.

RESULTS

A total of 2038 EVRs were performed in 1989 unique and consecutive patients. Of those, 27 patients had undergone EVR for AI. Thirteen presented ruptured (48%). Eighteen (67%) were hemodynamically unstable. Ten had a gastrointestinal bleed (37%), whereas others presented with abdominal pain (33%), fever (22%), chest or back pain (18.5%), and hemothorax (3.7%). Twenty patients had a positive blood culture (74%), with the most common organism being methicillin-resistant Staphylococcus aureus (MRSA) isolated in 37% (10). Other organisms were Escherichia coli (3), Staphylococcus epidermidis (2), Streptococcus (2), Enterococcus faecalis (1), vancomycin-resistant Enterococcus (1), and Klebsiella (1). Thirteen patients had 4 to 6 weeks of postoperative antibiotic therapy, six of whom died after therapy. Fourteen were prescribed lifelong therapy; 10 died while receiving antibiotics. On univariate analysis for mortality, smoking history (P = .061) and aerodigestive bleeding on presentation (P = .109) approached significance, whereas MRSA infection (P = .001) was strongly associated with increased mortality. On multivariate analysis, MRSA remained a strong, independent predictor of mortality (adjusted odds ratio, 93.2; 95% confidence interval, 1.9-4643; P = .023). Overall 30-day mortality was 11%, all MRSA positive. At mean follow-up of 17.4 ± 28 months, overall mortality was 59%. Overall survival at 1 year, 3 years, and 5 years was 49%, 31%, and 23%. Kaplan-Meier survival analysis demonstrated that MRSA-positive patients had a significantly lower survival compared with other pathogens (1-year, 20% vs 71%; 5-year, 0% vs 44%; P = .0009).

CONCLUSIONS

In our series of AI, the most commonly isolated organism was MRSA. MRSA is highly virulent and is associated with increased mortality compared with all other organisms, regardless of treatment. Given our results, EVR for MRSA-positive AI was not a durable treatment option.

Iliohepatic artery bypass for hepatic ischemia after repair of mycotic celiac artery aneurysm

An 81-year-old woman presented to our institution with a contained ruptured mycotic aortic aneurysm involving the takeoff of the celiac artery that required ligation of the celiac trunk, resulting in foregut ischemia and the need for revascularization. The technique of aortic reconstruction with delayed hepatic artery revascularization by a common iliac artery to hepatic artery bypass is described.

Infection-relapse and a potentially surgical stratification model for the treatment of mycotic aortic aneurysms: A propensity-matched pilot study

Objective

This study evaluates the overall survival and the infection-relapse after endovascular repair (Endo) vs. open surgery (Open) for mycotic aortic aneurysms and the potential influence of perioperative severity of infection to the decision-making on the long-term survival.

Design

A multicenter, retrospective analysis of 5247 consecutive aortic aneurysm repair performed from January 2003 to December 2017 at five tertiary medical centers was conducted. Among the study population, 257 patients with mycotic aortic aneurysms s were identified. Methods: Finally, 73 patients were enrolled in the cohort after exclusion and a 1:1 propensity-matched analysis. The study cohort drawn from matched data included 37 patients in the Endo group and 36 patients in the Open group. The primary endpoint was overall survival. Secondary endpoints included infection-relapse during the follow-up. Univariate and multivariate Cox regression analyses were used to assess predictors for late mortality.

Results

The mean follow-up time for the entire cohort was 41 months (range, 1 to 135 months). Among propensity-matched patients, there was no significant difference in baseline characteristics. There was no difference in overall survival ( P = 0.083) between the groups at five years, but Open group was associated with a lower infection-relapse incidence during the follow-up ( P = 0.011). Subgroup analysis revealed a better survival rate for Open in patients with severe infection ( P = 0.003) or small periaortic abscess ( P = 0.049).

Conclusion

There were no significant differences between Endo and Open in overall survival. However, Open was a more definite option with less infection-relapse and had potential advantages for patients with severe infection or with a small periaortic abscess.

Mycotic aortic aneurysms post-Intravesical BCG treatment for early-stage bladder carcinoma

Background

Intravesicular Bacillus Calmette-Guérin (BCG) is an effective adjunctive therapy for superficial bladder cancer that has been shown to delay recurrence and progression of disease. Serious side effects are relatively rare but are difficult to diagnose and are often overlooked. Vascular complications are particularly rare.

Case presentation

We report two cases of mycotic aortic aneurysms secondary to BCG treatment, one managed with endovascular stent-graft placement and the other with open surgical repair. The present understanding of disseminated BCGosis, including a literature review, will be discussed.

Conclusion

The incidence of mycotic aneurysms from BCG treatment is rare and very few cases have been reported in the literature. These cases further expand the current knowledge on vascular complications related to BCG treatment. In the absence of formal guidelines, we recommend a multidisciplinary approach involving vascular surgery, diagnostic and interventional radiology, and infectious disease to manage these patients.

Open Repair of Mycotic Abdominal Aortic Aneurysms With Biological Grafts: An International Multicenter Study

BACKGROUND

The treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm.

METHODS AND RESULTS

All patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30- and 90-day survival, treatment-related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty-six patients (46 males) with median age of 69 years (range 35-85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In-situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube-grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow-up of 26 months (range 3 weeks-172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty-day survival was 95% (n=53) and 90-day survival was 91% (n=51). Treatment-related mortality was 9% (n=5). Kaplan-Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%-94%) and at 5 years was 71% (52%-89%).

CONCLUSIONS

Mycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

Endovascular Repair of Three Concurrent Mycotic Pseudoaneurysms

INTRODUCTION

Mycotic pseudoaneurysm has traditionally been repaired surgically with excision of the infected artery and revascularization via extra-anatomical or in situ bypass. There have been reports of endovascular repair for high-risk patients for formal surgical repair. We present a case of a patient with 3 large pseudoaneurysms arising from the right subclavian artery, descending thoracic aorta, and right popliteal artery treated with endovascular and hybrid intervention.

CASE

A 74-year-old male with remote history of coronary artery bypass graft and recent sternoclavicular joint abscess developed 3 concurrent pseudoaneurysms arising from the right subclavian artery, distal descending thoracic aorta, and right popliteal artery. He underwent right axillary to common carotid bypass with endovascular stent graft placement in the distal innominate and proximal subclavian artery, and subsequently had thoracic endovascular aortic repair and right popliteal stent graft. Four months later, he presented with hemoptysis due to compression of the lung secondary to the pseudoaneurysm. He underwent right anterior thoracotomy and debridement of the pseudoaneurysm. Patient recovered from the procedure and discharged.

CONCLUSION

Endovascular repair of mycotic pseudoaneurysm is an acceptable alternative for high-risk patients. Even when open approach became necessarily, endovascular stent graft decreased blood loss and morbidity.

On the Diagnosis of Mycotic Aortic Aneurysms

Objective:

There is striking paucity in consensus on the terminology, definition, and diagnostic criteria of mycotic aortic aneurysms. This literature study aims to elucidate this scientific omission, discuss its consequences, and present a proposition for reporting items on this disease.

Methods:

A systematic literature review on PubMed and Medline using mycotic and infected aortic aneurysms between 1850 and 2017 was performed. Articles were assessed according to a protocol regarding terminology, definition, and diagnostic criteria. Case series with less than 5 patients were excluded.

Results:

A total of 49 articles were included. The most prevalent term was mycotic aortic aneurysm but there was no widely accepted definition. Most modern publications used a diagnostic workup based on a combination on clinical presentation, laboratory results, imaging findings, and intraoperative findings. How these protean variables should be balanced was unclear. A proposition of reporting items was framed and consisted of definition of disease used, basis of diagnostic workup, exclusion criteria, patient characteristics, laboratory and imaging findings, aneurysm anatomy, details on treatment, pre/postoperative antibiotic treatment, and details on follow-up.

Conclusions:

This article emphasizes the need to standardize definition, terminology, and diagnostic criteria for mycotic aortic aneurysms and proposes reporting items enhancing comparability between studies.

An Uncommon Cause of Deep Vein Thrombosis: Mycotic Aneurysm Secondary to Salmonella Arteritis

Mycotic aneurysm is an uncommon surgical emergency with high mortality. Endovascular infection due to salmonella is the commonest cause of intra-abdominal mycotic aneurysm. We report a rare presentation of mycotic aneurysm in a 78-year-old man who presented to the accident and emergency department with deep vein thrombosis due to compression of the iliac vein by a mycotic aneurysm arising from the internal iliac artery and an adjacent abscess. A comprehensive review of the aetiology, clinical presentation and management of mycotic aneurysm secondary to salmonella arteritis is presented.

Mycotic Abdominal Aortic Aneurysm Secondary to Septic Embolism of a Thoracic Aorta Graft Infection

Mycotic aneurysms account for 1% of abdominal aortic aneurysms. There are very few cases published that describe the formation of mycotic aneurysms after septic embolism due to graft infection. We present the first case to our knowledge to be described in the literature of a mycotic aneurysm caused by septic embolism derived from a thoracic aorta graft infection, treated with conventional surgery leading to a successful outcome and evolution.

Surgical Treatment of Infected Aortoiliac Aneurysm

Purpose:

Infected aneurysms of the abdominal aorta or iliac artery (IAAA) are rare but fatal and difficult to treat. The purpose of this study was to review the clinical presentations and outcomes of IAAA and to establish a treatment strategy for optimal treatment of IAAA.

Materials and Methods:

Electronic medical records of 13 patients treated for IAAA at Seoul National University Hospital between March 2004 and December 2012 were retrospectively reviewed.

Results:

Mean age was 64.2 (median 70, range 20–79) years. Aneurysms were located in the infrarenal aorta (n=7), iliac arteries (n=5), and suprarenal aorta (n=1). Seven patients underwent excision and in situ interposition graft, 3 underwent extra-anatomical bypass, and 1 underwent endovascular repair. One patient with endovascular repair in an outside hospital refused resection, and only debridement was done, which revealed tuberculosis infection. One staphylococcal infection was caused by iliac stenting. Mycobacterium was the most common pathogen, followed by Klebsiella, Salmonella, and Staphylococcus. There were 3 in-hospital mortalities and the causes were sepsis in 2 and aneurysm rupture in 1. The 3 extra-anatomic bypasses were all patent after 5-year follow-up.

Conclusion:

IAAA develops from various causes and various organisms. IAAA cases with gross pus were treated with extra-anatomic bypass, which was durable. In situ reconstruction is favorable for long term-safety and efficacy, but extensive debridement is essential.

Mycotic aneurysm in a turtle hunter: brief review and a case report

Salmonella-associated mycotic aneurysm is a rare, but dreaded, complication of salmonellosis. Immunocompromised and elderly populations are more susceptible to develop this extra-intestinal complication. Salmonella is spread via fecal–oral and vehicle-borne routes. Reptiles, especially small pet turtles, have been linked with an increased risk of Salmonella infection. Diagnosis of mycotic aneurysm is a challenge due to atypical presentations. Recently, widespread use of CT scan imaging to evaluate for unexplained abdominal pain and sepsis has led to early identification of mycotic aneurysms. Antibiotic therapy and surgical intervention are the cornerstones of management. Open surgery has been the gold standard of treatment but is associated with increased morbidity and mortality. A relatively new alternative to open surgery is endovascular aneurysm repair (EVAR). It is comparatively less invasive and is associated with reduced early morbidity and mortality in the setting of mycotic aneurysm. However, there is a risk of late infection. Here, we present a patient with Salmonella mycotic aneurysm initially treated conservatively with antibiotic therapy who later underwent successful interval EVAR with no complications to date. Also included is a brief review of Salmonella-associated mycotic aneurysms.

Clinical, microbiologic, and outcome analysis of mycotic aortic aneurysm: the role of endovascular repair

BACKGROUND

Mycotic aortic aneurysm (MAA) is an infrequent but devastating form of vascular disease.

METHODS

We conducted a retrospective cohort study at a major medical center to identify independent risk factors for MAA and to provide opinions about treating it. The study population consisted of 43 patients who had had 44 MAAs over a period of 15 y.

RESULTS

All of the patients had positive blood cultures, radiologic findings typical of MAA, and clinical signs of infection (leukocytosis, fever, and elevated C-reactive protein). The mean age of the patients was 63.8±10.6 y and the mean period of their follow up was 35.7±39.3 mo. Twenty-nine patients with MAAs underwent traditional open surgery, 11 others received endovascular stent grafts, and four MAAs were managed conservatively. The most frequent causative pathogens were Salmonella (36/44 patients [81.8%]), in whom organisms of Salmonella serogroup C (consisting mainly of S. choleraesuis) were identified in 14 patients, organisms of Salmonella serogroup D were identified in 13 patients, and species without serogroup information were identified in nine patients. The overall mortality in the study population was 43.2% (with an aneurysm-related mortality of 18.2%, surgically related mortality of 13.6%, and in-hospital mortality of 22.7%).

CONCLUSIONS

Shock is a risk factor for operative mortality. Misdiagnosis and treatment of MAA as low back pain, co-existing connective-tissue disease such as systemic lupus erythematosus and rheumatoid arthritis, and Salmonella serogroup C-associated bacteremia are risk factors for aneurysm-related death. Endovascular repair should be considered as an alternative option to the open repair of MAA.

Treatment of infected abdominal aortic aneurysm caused by Salmonella

BACKGROUND

We reviewed the outcomes of patients treated for nontyphoidal Salmonella-infected abdominal aortic aneurysm (AAA) treatment at a single center.

METHODS

This was a retrospective chart review of 26 patients with nontyphoidal Salmonella-infected AAA. Four patients underwent medical therapy alone, while 22 patients underwent surgical therapy. Revascularization method selection was dependent on preoperative antibiotic response in the surgical therapy group.

RESULTS

The in-hospital mortality rate for the surgical therapy group was 14%, while the rate for the medical therapy group was 100%. Overall survival for the surgical therapy group was 82%, while the reinfection rate was 9%. In the surgical therapy group, 2 patients had periaortic abscesses and underwent in situ prosthetic graft replacement; none developed graft-related complications or died in the hospital. Kaplan-Meier analysis and log-rank testing revealed no significant differences in graft-related complication and overall survival rates between in situ prosthetic graft group and extra-anatomic bypass group. Salmonella choleraesuis had a higher antimicrobial resistance rate than other isolates. The predictors of survival were clinical presentation of abdominal pain and receiving surgical therapy.

CONCLUSIONS

If patients with Salmonella-infected AAAs have good responses to preoperative antibiotic therapy, in situ prosthetic graft replacement is a viable revascularization method, even in the situation of periaortic abscess presentation formation.

Stent-graft implantation for clinically diagnosed syphilitic aortic aneurysm in an HIV-infected patient

We describe our experience with stent-graft placement in a patient with a clinically diagnosed syphilitic aortic aneurysm.The patient was a 43-year-old man with syphilitic and human immunodeficiency virus (HIV) co-infection. Computed tomography (CT) revealed an aortic aneurysm with 89 mm in maximum size which was located at distal aortic arch and was considered syphilis derived saccular aneurysm. The aneurysm was judged at high risk of rupture from its shape. We decided to perform stent-graft implantation. Before surgery, the patient was given antibacterial and anti-HIV agents. Hand-made fenestrated stent graft by Tokyo Medical University was implanted. The graft was placed from the ascending aorta to Th 9 level in the descending aorta. The aneurysm completely disappeared during follow-up, with no flare-up of syphilitic infection up to 2 years after surgery.The number of patients with syphilis and human immunodeficiency virus co-infection is now increasing. Stent-graft implantation may be an effective treatment in such immunocompromised patients.