Infected aneurysm of the thoracic aorta

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.

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

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.

Surgical Outcomes of Infective Native Aortoiliac Aneurysms in a Chilean Academic Center

BACKGROUND

Infective native aortic aneurysms (INAAs), formerly called mycotic aneurysms, remain an uncommon disease with significant heterogeneity among cases; hence, there is lack of solid evidence to opt for the best treatment strategy. The present study aims to describe a 20-year experience at a single institution treating this uncommon condition.

METHODS

Retrospective study of all patients treated for INAA at a single academic hospital in Santiago, Chile, between 2002 and 2022. Clinical characteristics are described, as well as operative outcomes per type of treatment. Nonparametric Mann-Whitney U-test or Kruskal-Wallis tests were performed when appropriate, and results were reported as median and ranges. Survival at given timeframes was determined by a Kaplan-Meier curve, with analysis performed through a Cox regression model.

RESULTS

During the study period, 1,798 patients underwent aortic procedures at our center, of which 35 (1.9%) were treated for INAA. Of them, 25 (71.4%) were male. One patient had 2 INAAs. Median age was 69.5 years (range: 34-89 years). Of the 36 INAAs, the most frequent location was the abdominal and thoracic aorta in 20 (55.5%) and 11 (30.5%) cases, respectively, followed by the iliac arteries in 4 (11.1%) cases. One (2.7%) patient presented a thoracoabdominal INAA. Overall, endovascular treatment associated with long-term antibiotics was used in 20 (57.1%) patients: 4 of them underwent hybrid treatment. Fifteen (42.8%) patients underwent direct aortic debridement followed by in situ or extra anatomic revascularization. There was a significant difference in age between both treatment strategies (a median of 76.5 years for endovascular versus a median of 57 years for open, P = 0.011). The median hospital stay was 15 days (range: 2-70 days). The early complications rate (<30 postoperative days) was 20% (n = 7). Early mortality rate (inhospital or before postoperative 30 days) was 14.2% (n = 5). Median follow-up was 33 months (range: 6-216 months). The overall survival rates at 1, 3, and 5 years were 69.9% (standard error [SE] 8.0), 61.7% (SE 9.8), and 50.9% (SE 11.8), respectively. Five-year survival rate of patients undergoing endovascular treatment compared with open approach was 45.9% (SE 15.1) versus 80.0% (SE 17.8), respectively (P = 0.431). There were no significant differences in survival between open and endovascular treatment, hazard ratio 3.58 (confidence interval 95%: 0.185-1.968, SE ± 0.45 P = 0.454).

CONCLUSIONS

Patients treated by endovascular approach were older than patients treated by open approach. Even though, the open group had a higher 5-year survival rate than the endovascular group, not statically significance differences were found between treatments.

A rare case of mycotic aortic aneurysm with Clostridium perfringens culture

Key Clinical Message

As only early diagnosis, prompt surgical intervention, and appropriate antibiotic therapy can decrease clostridial MAA mortality rate; keeping in mind a broad differential diagnosis in a patient with sepsis and unusual vascular symptoms is important.

Abstract

Mycotic aortic aneurysm (MAA) is an infrequent but very consequential condition characterized by the pathological disruption of the aorta due to infection. Clostridium perfringens is a bacterium that falls under the taxonomic classification of the genus Clostridium. Although mycotic aneurysm is often not commonly linked with this infection, there are instances when it may function as a causative agent for MAA. Timely diagnosis and thorough therapeutic techniques, including surgical intervention and quick administration of appropriate antibiotics, can potentially reduce the mortality rate associated with clostridial MAA. In this study, we presented a clinical report detailing the diagnosis of a mycotic aneurysm caused by C. perfringens in the thoracic aorta in a 66-year-old male patient with a history of diabetes mellitus and a recent prostate biopsy. Furthermore, we discussed the surgical approach and overall management strategy to address this case.

Emphysematous changes as red flag signs preceding rapidly progressive infectious aortic disease: two case reports

BACKGROUND

Infectious aortic disease is a rare and fatal disease, that requires the appropriate intervention. An accurate diagnosis should be promptly established. However, this is difficult because the clinical manifestations of this disease vary and are non-specific.

CASE PRESENTATION

(CASE 1) An 87-year-old male, presenting with generalized malaise and weight loss, was admitted for further examination. A chest computed tomography (CT) showed mediastinal emphysema. Empirical intravenous antibiotics were administered to address the non-specific infectious findings in the laboratory data. The treatment was effective, and the patient fully recovered. However, he was in shock due to aortic rupture and marked pseudo aneurysmal formation around the aortic arch day 25 of hospitalization. An emergency total aortic arch replacement was performed, and the patient was discharged. (CASE 2) An 82-year-old male who had undergone Y-graft replacement in the abdominal aorta 15 years previously was admitted due to general malaise and anorexia. Abdominal CT revealed emphysematous changes adjacent to the abdominal aorta. The patient responded favorably to empirical treatment with intravenous antibiotics and was discharged 19 days after admission. Four days after discharge, the patient went into cardiac arrest after an episode of hematemesis. Abdominal CT revealed an enlarged stomach and duodenum, filled with massive high-density contents proximal to the abdominal aorta. He died of hemorrhagic shock despite cardiopulmonary resuscitation.

CONCLUSIONS

Although emphysematous changes are rare, they are red flag signs during the early stage of infectious aortic disease. Thus, physicians should remain vigilant for this kind of critical sign.

Staphylococcus aureus sepsis and hemoptysis as messengers of a rather impractically located mycotic aneurysm

BACKGROUND

Mycotic aortic aneurysms (MAA) arise due to infection of a pre-existent aneurysm or aneurysmal degeneration of an infected vascular wall. MAA of the thoracic aorta are relatively rare. Treatment is mainly guided by clinical experience as there are no large randomized trials available.

CASE PRESENTATION

A 79-year-old patient was hospitalized with staphylococcus aureus sepsis and MAA originating from the ostium of the left common carotid artery (CCA). Initial treatment consisted of high-dose antibiotics and blood pressure control. After 48 hours, a CT-angiography revealed rapid growth of the MAA with imminent rupture. Various treatment options were considered: a covered stent in the left CCA, a carotid-subclavian bypass with ligation of the left CCA ostium or arch replacement, or an extra-anatomical transposition of the supra-aortic vessels combined with a thoracic endoprosthesis. The last option was selected and, combined with six weeks of antibiotics, proved successful in controlling the impending rupture and treating the MAA.

CONCLUSIONS

Endovascular techniques are used if open surgery is refused, when surgical risks are prohibitively high (as definitive or palliative treatment), or as an emergency temporary treatment until definitive surgical treatment is feasible. Our high-risk patient underwent endovascular treatment for MAA as a definitive treatment. Endovascular treatment is increasingly becoming the treatment of choice due to the high morbidity and mortality of open surgical repair. Although the main concern using endovascular treatment is absence of debridement, recent studies show that combining endovascular treatment and long-term antibiotic therapy represents a potentially durable treatment and viable alternative to open surgical repair.

Infectious Aortitis of Thoracic Aortic Aneurysm From Clostridium Septicum

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.).

Predicting Infection Related Complications After Endovascular Repair of Infective Native Aortic Aneurysms

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.

Emphysematous Salmonella-Infected Aneurysm of the Aortic Arch: Case Report

BACKGROUND

Infected aortic aneurysm is a relatively rare disease with significant morbidity and mortality. Because of its deeper position, patients with infected aortic arch aneurysms may present with only fever and other vague symptoms, such as weakness, fatigue, dizziness, anorexia, and functional decline. It is difficult confirm a diagnosis that is based solely on history or physical examination, and it may only be apparent on imaging studies.

CASE REPORT

We present a brief case report of a patient presenting to the emergency department with unexplained fever who was diagnosed with emphysematous salmonella-infected aneurysm of the aortic arch. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Infected aortic arch aneurysm is an extremely unusual disease entity that emergency physicians encounter. Because of the high mortality and morbidity of this catastrophic disease, an infected aortic aneurysm should be considered as a possible diagnosis in patients with persistent fever and vague symptoms without a specific infection focus. To avoid delayed diagnosis, emergency physicians should be aware of infected aortic arch aneurysm.

Thoracic and Thoracoabdominal Aneurysms: Etiology, Epidemiology, and Natural History

Thoracic aortic aneurysms and thoracoabdominal aneurysms are often found incidentally. Complications include dissection or rupture. Most of the thoracic aortic aneurysms and thoracoabdominal aneurysms develop in patients with risk factors for atherosclerosis. Younger patients without significant cardiovascular risk factors may have a genetic basis and include syndromes such as Marfan, Ehlers-Danlos, and Loeys-Dietz and bicuspid aortic valve. Most thoracic aneurysms grow slowly over time and factors that accelerate growth rate include dissection, aneurysm size, bicuspid valve disease, and Marfan syndrome. Size cutoffs where complications occur determine when surgery or intervention should be considered.

In situ repair or reconstruction of the abdominal aorta-iliac artery by autologous fascia-peritoneum with posterior rectus sheath for the treatment of the infected abdominal aortic and iliac artery aneurysms: A case series and literature review

Background

Infected abdominal aortic and iliac artery aneurysms are considered acute and severe diseases with insidious onset, rapid development, and high mortality in vascular surgery. Currently, there is no better treatment, either anatomic or extra-anatomical repair.

Case presentation

From February 2018 to April 2022, 7 patients with infected abdominal aortic and iliac artery aneurysms did not have sufficient autologous venous material for repair. With the consent of the Ethics Committee of the hospital, it uses the autologous peritoneal fascial tissue with rectus sheath to repair or reconstruct the infected vessels in situ. There were 5 cases of infected abdominal aortic aneurysm, 1 case of an infected common iliac aneurysm, and 1 case of the infected internal iliac aneurysm. Aortoduodenal fistula was found in 3 cases, all of them were given duodenal fistula repair and gastrojejunostomy and cholecystostomy. Three cases of infected abdominal aortic aneurysms were repaired with the autologous peritoneal fascial tissue patch, and 2 cases of infected abdominal aortic aneurysms were reconstructed by the autologous peritoneal fascial tissue suture to bifurcate graft in situ, the autologous peritoneal fascial tissue suture reconstructed the rest 2 cases of infected iliac aneurysm to tubular graft in situ. It was essential that Careful debridement of all infected tissue and adequate postoperative irrigation and drainage. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics based on bacterial culture and susceptibility results of infected tissues and blood. All 7 patients had underwent surgery successfully. But there were 2 cases died of anastomotic infection or massive hemorrhage after the operation, the other 5 cases survived. The follow-up time was 2–19 months. The enhanced CT of postoperation showed that the reconstructed arteries were smooth without obvious stenosis or expansion, and no abdominal wall hernia occurred.

Conclusion

In situ repair or reconstruction with autologous peritoneal fascial tissue with rectus sheath is a feasible treatment for the infected aneurysm patients without adequate autologous venous substitute, but it still needs long-term follow-up and a large sample to be further confirmed.

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.

Treatment of a descending thoracic mycotic aneurysm secondary to disseminated aspergillosis infection with thoracic endovascular aortic repair

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.

Surgical strategy for treating mycotic aneurysms of thoracic and abdominal aorta and iliac artery: analysis of long-term follow-up data

Mycotic aneurysms of the aorta and iliac arteries are rare, but life-threatening conditions. We reviewed our experience to determine the best surgical strategy. Between 2007 and 2015, we operated 14 patients with mycotic aneurysms of the aortic arch (n  =  6), descending aorta (n  =  1), thoracoabdominal aorta (n  =  2), abdominal aorta (n  =  4), and iliac artery (n  =  1). The mean age was 70.4  ±  8.8 years, and 10 males were included. Blood culture, tissue culture, or both were positive in 11 patients. Four of five patients with mycotic aneurysms of the abdominal aorta and iliac artery underwent extra-anatomical bypass. Ten underwent in-situ graft replacement for managing mycotic aneurysms of the thoracic aorta. One patient with a mycotic thoracoabdominal aortic aneurysm underwent visceral bypass of the descending aorta and extra-anatomical bypass. Omental pedicle grafting was performed in 10 patients. The mean follow-up period was 8.6  ±  3.1 years. Three patients (21.4%) died. Recurrent infection was observed in one patient with a mycotic aneurysm of iliac artery three months after the initial surgery. The patient underwent extra-anatomical bypass with omental pedicle grafting as a redo. Nine patients were discharged, and no recurrence of infection was observed. Two patients died of cancer and heart failure. The five- and seven-year survival rates were 100% ± 0.0% and 85.7% ± 13.2%, respectively. A combination of radical debridement of the infectious source and omental pedicle grafting with either in-situ graft replacement or extra-anatomical bypass is an effective strategy.

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.

In situ reconstruction of ruptured mycotic iliac artery aneurysm with autologous fascial-peritoneal tissue: a case report and literature review

Background

Infectious aneurysms are rare in clinic with poor therapeutic outcomes. When artery rupture occurs, the disease tends to progress resulting in a high mortality, and there remains no ideal treatment.

Case presentation

We report a case of rupture of infectious iliac artery pseudoaneurysm, who was assigned to receive artery reconstruction with autologous fascial-peritoneal tissue and obtained satisfied short-term outcome. The follow-up of 6 months after operation was good and long-term follow-up is continuing.

Conclusion

The posterior rectus fascia-peritoneal layer seems to be a feasible autologous biomaterial for vascular substitution in urgent setting when no other autologous material was available.

Mycotic aortic and left iliac ruptured aneurysm due to Escherichia Coli: a case report and literature overview

Mycotic aneurysm is a life-threatening disease often caused by Salmonella, Staphylococci and Streptococci species. Interestingly, Escherichia Coli (E. Coli) is described as a rare causative agent. We report the case of a patient who developed a mycotic aortic and ruptured left iliac aneurysm due to E. Coli. The patient developed a secondary aortic graft infection due to a mesenteric ischemia with fecal peritonitis. A literature overview of the current knowledge on mycotic aortic aneurysms specifically due to E. Coli is discussed including the clinical characteristics of patients, the management of the disease and the post-operative outcomes.

18F-fluorodeoxyglucose positron emission tomography/ computed tomography in the diagnosis of a rare mycotic aneurysm of the thoracic aorta in a patient with fever of unknown origin

Fever of unknown origin (FUO) is a condition with high mortality that often presents a diagnostic challenge to clinicians. We present the case of a patient with FUO who was discovered to have a rare mycotic aneurysm of the thoracic aorta by ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography imaging. Mycotic aneurysm, also known as an infected aneurysm, is a highly lethal condition due to the risk of sepsis and aneurysmal rupture. While unusual to present in this manner, it is of utmost importance to promptly recognize a mycotic aneurysm as a potential diagnosis because initiation of treatment is critical in reversing the natural history of the disease.

Mycotic aneurysm of the ascending aorta due to Escherichia coli: a case report

Ascending aorta mycotic aneurysm is a rare entity. It is a life-threatening condition because of the possibility of aortic dissection, or rupture. Escherichia coli is recognised as an uncommon cause of aortic mycotic aneurysm. An 81-year-old woman with a history of Escherichia coli pyelonephritis 4 months previously, was admitted to our centre for a mycotic aneurysm of the ascending aorta caused by Escherichia coli. She was successfully treated by urgent in situ replacement of the ascending aorta with a cryopreserved homograft, combined with antibiotics. Although infrequent, Escherichia coli mycotic aneurysm should be suspected in older patients with atherosclerosis and who developed septicaemia. Prompt treatment with a combination of appropriate antibiotics and surgery is required.

Concomitant paravisceral and thoracic mycotic aortic aneurysms in a cirrhotic patient

In the present case report, we have described concomitant, rapidly expanding, abdominal and thoracic mycotic aortic pseudoaneurysms in a patient who had originally presented for right arm superficial thrombophlebitis and a right-hand abscess in the presence of methicillin sensitive Staphylococcus aureus bacteremia. Within 12 days, the patient had developed a rapidly expanding paravisceral mycotic abdominal aortic pseudoaneurysm that required open surgical repair. After the initial operation, she developed a thoracic mycotic aortic aneurysm that ultimately required open surgical repair. Her postoperative course after the initial operation was complicated by decompensated hepatitis C cirrhosis that required convalescence before repair of the thoracic aneurysm. Follow-up data were available for ≤10 months after the initial operation.

Impending Aortic Rupture in a Patient with Syphilitic Aortitis

We report the case of a 48-year-old man, admitted for atrial fibrillation with rapid heart rate and intense chest pain. A quick evaluation revealed a giant aortic aneurysm with severe aortic regurgitation and pericardial fluid without a trace of aortic dissection. Because of high suspicion of aortic rupture, an emergency surgery was planned, and a Bentall procedure was performed. On examination of the aortic wall revealing vertical wrinkling with a tree bark aspect, suspicion of syphilitic aortitis arose. The diagnosis was confirmed through postoperative serologic testing and histological examination. Histopathologic differential diagnosis, special treatment and follow-up are presented.

Native and prosthetic graft infections of the thoracic aorta: surgical management

 

OBJECTIVES

Infection of the native aorta or after previous open or endovascular repair of the thoracic aorta is associated with high risks for morbidity and mortality. We analysed the outcome after surgical management of a native mycotic aneurysm or of prosthetic graft infection of the descending aorta.

METHODS

From June 2000 to May 2019, a total of 39 patients underwent surgery in our centre for infection of the native descending aorta (n = 19 [49%], group A) or a prosthetic descending aorta [n = 20 (51%), group B]. In the 20 patients in group B, a total of 8 patients had prior open aortic repair with a prosthesis and 12 patients had a previous endovascular graft repair.

RESULTS

The cohort patients had a mean age of 57 ± 14; 62% were men (n = 24). The most common symptoms at the time of presentation included fever, thoracic or abdominal pain and active bleeding. Emergency surgery was performed in 11 patients (28%); 3 patients had emergency endovascular stent grafts implanted during thoracic endovascular aortic repair for aortic rupture before further open repair. The 30-day mortality was 42% in group A and 35% in group B. The 90-day mortality was 47% in group A and 45% in group B. Pathogens could be identified in approximately half of the patients (46%). The most commonly identified pathogens were Staphylococcus aureus in 6 patients (15%) and Staphylococcus epidermidis in 4 patients (10%). Survival of the entire group (including patients with both native and prosthetic graft infections) was 44 ± 8%, 39 ± 8% and 39 ± 8% at 1, 2 and 3 years after surgery. The percentage of patients who survived the initial perioperative period was 81 ± 9%, 71 ± 9% and 71 ± 10% at 1, 2 and 3 years after surgery.

CONCLUSIONS

Patients with infection of the descending aorta, either native or prosthetic, are associated with both high morbidity and mortality. However, patients who survive the initial perioperative period have an acceptable long-term prognosis. In emergency situations, thoracic endovascular aortic repair may help to stabilize patients and serve as bridge to open repair.

Mycotic Abdominal Aortic Aneurysms - A Tertiary Centre Experience and Formulation of a Management Protocol

BACKGROUND

Mycotic abdominal aorta aneurysm (MAAA) is a rare and life-threatening condition. Because of its rarity, there is a lack of adequately powered studies and consensus on its treatment and follow up. This study aimed to review the outcomes following surgical intervention for MAAA in a single tertiary centre and to formulate a management protocol based on available evidence and expert opinion.

MATERIALS AND METHODS

Data were collected by retrospective review of case records of all patients who underwent repair of MAAA in a single tertiary referral centre from 2001 to 2018. Demographic, clinical and outcome data were analysed and compared with previously published series in the literature. A management protocol was formulated based on available literature which was then reviewed and modified as per expert opinion from multidisciplinary discussions.

RESULTS

Seventeen patients underwent repair of MAAA during the study period including 4 Open repairs, 4 surgeon modified fenestrated endovascular aortic aneurysm repairs (SM FEVAR) and 9 endovascular aortic aneurysm repairs (EVAR). One-year overall survival was 94.1%, 3-year survival was 81.8% and 5-year survival was 75.0%. The infection-free survival at 1, 3, and 5 years was 87.5%, 81.8% and 62.5%, respectively. The overall survival and infection-free survival curves for Open repair, EVAR and SM FEVAR when compared using Log Rank (Mantel-Cox) test and did not show any statistically significant difference.

CONCLUSIONS

Management of MAAA with selective use of open or endovascular repair, in combination with appropriate long-term antibiotic therapy, can achieve acceptable outcomes. The proposed protocol can aid as a guiding document for the management of MAAA but needs taking into consideration individual patient variability and local expertise.

An Unusual Case of Streptococcus pyogenes Causing Ruptured Aortic Mycotic Aneurysm

A 70-year-old male with a complex past medical history presents with confusion and slurred speech for 24 hours. His exam was unremarkable, and his CT head was negative. Both his C-reactive protein and white blood cell count were elevated. As part of the delirium workup, blood cultures were done which grew Streptococcus pyogenes with no obvious source. He was treated with appropriate antibiotics. To determine the source, a white blood cell scan was done, which showed increased localization within a left-sided upper mediastinum mass. Subsequently, chest CT scan with contrast showed an acute type B aortic dissection with mycotic aneurysm. Consequently, he was taken urgently for surgical management. He completed 6 weeks of penicillin G and was discharged to a rehabilitation center. This case illustrates both a rare entity, mycotic aneurysm secondary to Streptococcus pyogenes, and the importance of getting an Infectious Diseases consult in the setting of an unknown source of bacteremia.

Clinical Characteristics and Longitudinal Outcomes of Primary Mycotic Aortic Aneurysms

Medical therapy for mycotic aortic aneurysms (MAA) is almost universally fatal, while surgical and endovascular repair carry high morbidity and mortality. The purpose of this study was to compare outcomes between patients receiving treatment for MAA. Records were obtained and patients with MAA were stratified by intervention: endovascular repair, open surgery, and medical therapy. Primary outcomes were aneurysm-related mortality and survival. Risk-adjusted associations with mortality were assessed using time-to-event analysis. Thirty-eight patients were identified (median age, 67). Twenty-one underwent endovascular repair,10 had open surgery and 7 received medical therapy alone. Overall mortality was 47% (n = 18), with 94% aneurysm related. Median survival was significantly longer in the endovascular group (747.0 [161-1249]) vs open surgery and medical therapy (507.5 [34-806] and 66 [13-146] days, respectively; P = .02). The endovascular group had significantly fewer perioperative complications (43% vs 80%, P < .01). However, 4 endovascular patients experienced reinfection versus no open surgery patients. Mortality risk factors included medical therapy (hazard ratio [HR]: 5.3, P < .01) and aneurysm size (HR: 1.4 per 1-cm increase in diameter, P = .03). Endovascular repair of MAA was associated with the best long-term survival and lowest perioperative complication rate, although it is associated with greater reinfection. These tradeoffs should be considered when selecting which procedure is best for a patient.

Streptococcus pneumoniae as a Cause of Mycotic and Infected Aneurysms in Patients without Respiratory Features: Challenging Diagnoses Aided by 16S PCR

BACKGROUND

Streptococcus pneumoniae is considered a rare cause of mycotic aneurysms. The microbiological diagnosis of mycotic aneurysms can be difficult, and many patients have negative blood culture results.

METHODS

We describe a series of four consecutive cases of mycotic aneurysms caused by S. pneumoniae with no respiratory features or extravascular septic foci. In two patients with negative blood culture results, 16S PCR was used for the diagnosis of S. pneumoniae infection.

RESULTS

Four men with mycotic aneurysms affecting the aorta, axillary, and popliteal arteries caused by S. pneumoniae presented to our center between 2015 and 2016. All were treated with at least one month of intravenous antibiotics, followed by at least 4 weeks of oral antibiotics. Two were additionally managed using endovascular surgical techniques, and one underwent an open surgical repair. The fourth patient presented with bilateral popliteal aneurysms, one of which ruptured and was managed using surgical ligation and bypass, whereas the other side subsequently ruptured and was repaired endovascularly. Three of the four patients are currently off antibiotics and considered cured, while one died of an unrelated cause.

CONCLUSIONS

S. pneumoniae should be considered a potential causative agent of mycotic aneurysms. Diagnosis can be confirmed using 16S PCR, especially in patients where peripheral blood cultures are uninformative.

Hybrid endovascular exclusion of a bleeding innominate artery pseudoaneurysm in a patient with no open surgical options

Mycotic pseudoaneurysms (MPs) rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.

Unexpected source of Proteus mirabilis bacteraemia

Mycotic (infected) aneurysm involving the thoracic aorta is an exceedingly rare and life-threatening condition that is associated with high morbidity and mortality. We report an unusual source of Proteus mirabilis bacteraemia thought to be due to an infected aneurysm in the thoracic aortic arch in an elderly woman. Source of gram-negative bacteraemia is usually isolated to an intra-abdominal or a pelvic source. Proteus bacteraemia from an intrathoracic pathology is very uncommon, and in this case led to a delay in diagnosis. Although an infected aneurysm is a rare source of gram-negative bacteraemia, it must always be considered when common causes of bacteraemia have been ruled out especially in patients with vascular risk factors.

Endovascular treatment of primary mycotic aortic aneurysms: a 7-year single-center experience

Objective This study was performed to assess the efficacy and outcome of endovascular aneurysm repair (EVAR) for treatment of primary mycotic aortic aneurysms (PMAAs). Methods Fourteen consecutive patients who presented with PMAA from April 2010 to July 2017 were retrospectively reviewed. Preoperative, intraoperative, and postoperative clinical data were recorded, and late infection-related complications and long-term survival were assessed. Results The aneurysms were located in the abdominal aorta in 10 patients and in the left common iliac artery in 4 patients. Positive microbial cultures were found in 12 patients, including Salmonella species in 11 and Streptococcus in 1. The remaining two patients had negative culture results. Ten patients received preoperative antibiotics before elective EVAR for 7 ± 9 days after admission. Four patients who underwent emergent EVAR due to ruptured aneurysms were given their first dose of antibiotics before EVAR. Three patients underwent surgical drainage, and six underwent percutaneous drainage within 30 days after EVAR. No death occurred within 30 days of the initial procedure. The mean follow-up was 34.8 (range, 3-84 months). One patient underwent re-intervention to resolve obstruction of the iliac/femoral artery 5 months postoperatively. Relapse of infection occurred in six patients (42.8%) during follow-up; infection-related death occurred in three of these patients. The other patients recovered with either conversion to open radical surgery or medical therapy. The actuarial 7-year survival after EVAR was 75.7%. Conclusions EVAR and aggressive antibiotic therapy might be suitable for PMAAs. Favorable results may be typical for infection caused by Salmonella.

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.

Endovascular treatment of Brucella-infected abdominal aortic aneurysm: A case report

RATIONALE

In very rare cases, a primary infected abdominal aortic aneurysm (IAAA) is caused by a species of Brucella. In this report, we report such a case that was successfully treated with a novel approach. To the best of our knowledge, this was the first case occurring in China, in which an infection of the abdominal aortic aneurysm was caused by a Brucella species.

PATIENT CONCERNS

The clinical findings included high fever, fatigue, and abdominal pain.

DIAGNOSES

The diagnosis was confirmed by computed tomography angiography and by bacteriologic isolation from the patient's blood culture.

INTERVENTIONS

The patient was given endovascular aneurysm repair (EVAR) and Brucella-sensitive antibiotics for 6 weeks.

OUTCOMES

During the 10-month follow-up, the patient's clinical course remained uneventful.

LESSONS

Our case study supports the premise that endovascular aneurysm repair is an appropriate alternative strategy to treat an infected abdominal aortic aneurysm. Compared with conventional surgical treatment, EVAR with long-term oral antibiotics is a simpler, less traumatic, and more efficient procedure. However, this needs to be further evaluated through long-term follow-up.

Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair

Background:

No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort.

Methods:

All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score–weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time.

Results:

We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%–92%), at 1 year 79% (72%–86%), and at 5 years 59% (50%–68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994–2000 0%, 2001–2007 58%, 2008–2014 60%). Open repair was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P <0.001), with a similar trend present at 1 year (73% versus 84%, P =0.054). A propensity score–weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P =0.771), infection-related complications (18% versus 24%, P =0.439), or reoperation (21% versus 24%, P =0.650).

Conclusion:

This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations.

Mycotic aortic arch aneurysm coexistent with constrictive pericarditis: is surgery a dangerous resort?

An elderly man presented with fever and evidence of Salmonella infection, and was diagnosed to have coexisting constrictive pericarditis and mycotic aneurysm of the aortic arch. Pericardiectomy was performed under cardiopulmonary bypass with good result. To avoid deep hypothermic circulatory arrest, an aorto-brachiocephalic bypass, instead of total arch replacement, was performed. This was followed by a staged carotid-carotid bypass, thoracic endovascular stent graft placement. He was subsequently treated with prolonged antibiotics, and inflammatory marker normalized afterwards. He was last seen well 2 years after the operation. Follow-up computer tomography (CT) scan at 18 months post-op showed no evidence of endoleak or fistulation. Our case demonstrated that a hybrid treatment of open pericardiectomy and aortic debranching followed by thoracic endovascular stent graft placement is feasible and associated with satisfactory mid-term outcome.

Primary Infected Aortic Aneurysm: Clinical Presentation, Pathogen, and Outcome

PURPOSE

Infected aneurysm of the aorta and adjacent arteries is rarely occurring and can be fatal without surgical intervention. Within the medical community, the most efficacious treatment strategy to address infected aortic aneurysm remains controversial. In this study, we have reviewed our treatment experience with 109 patients.

METHODS

We included in our study all consecutive patients treated for primary infected aortic aneurysm at our facility between 1995 and 2011. Aneurysm-related mortality was defined as the presence of in-hospital and late mortality related to infection or postoperative complications.

RESULTS

The median patient age was 72 years (range, 35-88), and 87 (80%) were male. Pathogen was isolated in 101 patients, and the most common microorganism identified was non-typhoid Salmonella in 61 (60%), followed by Staphylococcus aureus in 16 (16%) and Streptococci species in 7 (7%). Eighty-five (78%) patients underwent surgical treatment. Surgery included open repair with in-situ graft replacement in 77 (71%) and endovascular repair in 8 (7%). The aneurysm-related mortality rate was 67% in medically treated and 21% in surgically treated patients, with a median follow-up duration of 31.5 months (range 1-189). Additionally, risk factors for aneurysm-related mortality included old age, chronic lung disease, psoas muscle abscess, short duration of preoperative antibiotics, no operation, and probably endovascular repair.

CONCLUSIONS

Non-typhoid Salmonella was the most common pathogen found in our study group patients with infected aortic aneurysm. It appears that prolonged preoperative antibiotic treatment followed by open in-situ graft replacement remains the preferred and most effective treatment strategy.

KEY WORDS

Infected aortic aneurysm; Outcome; Pathogen; Surgery.

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.