Early and late outcomes of surgical repair of mycotic aortic aneurysms: A 30-year experience

Endovascular Treatment for Isolated Infected Iliac Artery Aneurysms

PURPOSE

Isolated infected iliac artery aneurysms (IIIAAs) are extremely rare, life-threatening, and intractable. This study aimed to evaluate the outcomes of endovascular treatment in patients with IIIAAs.

METHODS

A retrospective study was conducted for all patients who underwent endovascular treatment for IIIAAs between June 2012 and June 2022 in 3 hospitals. The clinical data and follow-up outcomes were reviewed and assessed.

RESULTS

Fifteen patients were included in this study. The median age was 69 years, 12 patients (80%) were men, and 8 (53%) had hypertension. Most of the patients presented with abdominal or lumbar pain (87%) and fever (60%). The offending pathogen was identified in 11 patients (73%). Fifteen patients had a total of 16 IIIAAs, with 12 (75%) involving the common iliac artery. The immediate technical success rate was 100%, and the 30-day mortality was 7%. Infection-related complications occurred in 2 patients (13%) during hospitalization who were treated by open surgery at a later stage. The median follow-up was 23 months (range: 6-80 months, mean: 32 ± 25 months). Aneurysm recurrence was identified in one patient (7%) 5 months after endovascular repair. It was managed by endovascular stent-graft repair with percutaneous catheter drainage. No patients died during the follow-up period.

CONCLUSION

Endovascular treatment is feasible, safe, and effective for patients with IIIAAs, achieving acceptable clinical outcomes. Infection surveillance with essential reintervention should be considered for potential infection-related complications.

CLINICAL IMPACT

This study first reported that 15 patients underwent endovascular treatment for primary isolated infected iliac artery aneurysms (IIIAAs). It showed a good early and midterm outcomes. This is the first and largest multi-center study and the first literature review of IIIAAs. It provides an evidence that endovascular treatment is feasible, safe, and effective to treat IIIAAs. It suggests endovascular treatment is a promising alternative or a bridge to conventional open surgery for IIIAAs. This may promote endovascular therapy in the management of IIIAAs. It would help clinicians to make an appropriate treatment choice for IIIAAs.

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.

Open treatment of infected abdominal aortic aneurysm stemming from perineal infection

Infected abdominal aortic aneurysms (AAAs) make up a small minority of AAAs yet are characterized by a high fatality rate, largely attributed to their increased risk of aneurysm rupture. This case details a rare presentation of a 56-year-old man that developed Proteus mirabilis bacteremia secondary to a perineal abscess and subsequently experienced a 3 cm growth of his previously stable AAA over an 8 day period. This case underscores the importance of maintaining a heightened suspicion for infected aortic aneurysms in sick patients and highlights the critical role of surgical management in achieving source control.

Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review

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.

Management and Outcome of Non-Aneurysmal Primary Aortic Infection

INTRODUCTION

Aortic infection without prior intervention or aneurysm is exceedingly rare. We report the presentation, diagnosis, management, and outcome of patients with this unusual entity.

METHODS

Retrospective chart and imaging review of patients with primary aortic infection.

RESULTS

5 patients (3 male, mean age 71.2 years) presented between 2014 and 2022. All had abdominal, back, or flank pain. Four had constitutional symptoms. All were evaluated with a complete blood count; 3 had leukocytosis. Both serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in the 4 patients evaluated with these tests. All were studied with peripheral blood culture on the first hospital day prior to any antibiotic administration. Blood culture was positive in only 1 patient. Computed tomography (CT) scan showed periaortic inflammation without aneurysm in all. Fluorodeoxyglucose positron emission tomography (PET) was obtained in 3 and a radiolabeled leukocyte single-photon emission CT (SPECT) scan was performed in 2. All demonstrated periaortic concentration of the radioisotope consistent with inflammation or infection. Intraoperative cultures were positive in 3. One patient who had a negative intraoperative culture was examined with broad range polymerase chain reaction (PCR) and DNA sequencing which identified a causative bacterium. The other patient with a negative intraoperative culture had periaortic abscess but was on antibiotics preoperatively, potentially confounding the culture. All patients underwent in-situ repair with rifampin impregnated polyester (N = 2), cryopreserved aortic allograft (N = 2), or autogenous femoral vein (N = 1). No patient developed recurrent infection or aortic related complications following surgery with an average follow up of 31.8 months (range 8-88 months).

CONCLUSIONS

Patients with primary aortic infection present similarly with the triad of abdominal or back pain, laboratory markers of infection, and imaging demonstrating periaortic inflammation. Patients were treated successfully with in-situ repair. Preoperative identification of a causative organism was difficult, and PCR may be useful to help identify an organism.