Mycotic aneurysm of the thoracoabdominal aorta in a child with end-stage renal disease

Retrospective Multicenter Study Comparing Infectious and Noninfectious Aortitis

BACKGROUND

Determining the etiology of aortitis is often challenging, in particular to distinguish infectious aortitis (IA) and noninfectious aortitis (NIA). This study aims to describe and compare the clinical, biological, and radiological characteristics of IA and NIA and their outcomes.

METHODS

A multicenter retrospective study was performed in 10 French centers, including patients with aortitis between 1 January 2014 and 31 December 2019.

RESULTS

One hundred eighty-three patients were included. Of these, 66 had IA (36.1%); the causative organism was Enterobacterales and streptococci in 18.2% each, Staphylococcus aureus in 13.6%, and Coxiella burnetii in 10.6%. NIA was diagnosed in 117 patients (63.9%), mainly due to vasculitides (49.6%), followed by idiopathic aortitis (39.3%). IA was more frequently associated with aortic aneurysms compared with NIA (78.8% vs 17.6%, P < .001), especially located in the abdominal aorta (69.7% vs 23.1%, P < .001). Crude and adjusted survival were significantly lower in IA compared to NIA (P < .001 and P = .006, respectively). In the IA cohort, high American Society of Anesthesiologists score (hazard ratio [HR], 2.47 [95% confidence interval {CI}, 1.08-5.66]; P = .033) and free aneurysm rupture (HR, 9.54 [95% CI, 1.04-87.11]; P = .046) were significantly associated with mortality after adjusting for age, sex, and Charlson comorbidity score. Effective empiric antimicrobial therapy, initiated before any microbial documentation, was associated with a decreased mortality (HR, 0.23, 95% CI, .08-.71]; P = .01).

CONCLUSIONS

IA was complicated by significantly higher mortality rates compared with NIA. An appropriate initial antibiotic therapy appeared as a protective factor in IA.

Repair of idiopathic ascending aortic aneurysm in a 7-year-old child

Ascending aortic aneurysm is uncommon in the paediatric population, and because of the rarity the aetiology, natural progression, and prognosis of the disease remain unknown. A 7-year-old boy with ascending thoracic aortic aneurysm (60×67 mm) underwent graft anastomosis from the sinotubular junction to the undersurface of the arch. Analytical determinations including karyotyping and genetic mapping were all normal. To our knowledge, idiopathic aneurysm of the ascending aorta in children is very rare.

Acute Conditions Caused by Infectious Aortitis

Infection of the aorta is rare but potentially very dangerous. Under normal circumstances the aorta is very resistant to infections. Following some afflictions, the infection can pass to the aorta from blood or the surrounding tissues. The authors present their 5-year experience with therapy of various types of infections of the abdominal aorta.

METHODS

In the 5-year period between January 2008 and December 2012, the Surgical Clinic of the University Hospital in Pilsen treated 17 patients with acute infection of the abdominal aorta. They included 9 males and 8 females. The mean age was 73.05 years (58-90). The most common pathogens were Salmonella (7), Staphylococcus aureus (2), Klebsiella pneumoniae (1), Listeria monocytogenes (1), and Candida albicans (1). Two cases included mixed bacteria and no infectious agent was cultured in three cases. In 14 cases (82.6%) we decided on an open surgical solution, i.e., resection of the affected abdominal aorta, extensive debridement, and vascular reconstruction. In all of these 14 cases we decided on in situ reconstruction. Twelve cases were treated using silver-impregnated prostheses. An antibiotic impregnated graft was used in one case and fresh aortic allograft in one case. In one case (5.9%) we decided on an endovascular solution, i.e., insertion of a bifurcation stent graft and prolonged antibiotic therapy. In two cases (11.8%) we decided on conservative treatment, as both patients refused any surgical therapy.

RESULTS

Morbidity was 47.2% (8 patients). In one case we had to perform reoperation of a patient on the 15th postoperative day to evacuate the postoperative hematoma. The 30-day mortality was 5.9% (1 patient). The hospital mortality was 11.8% (2 patients). One patient died on the 42nd postoperative day due to multiorgan failure following resection of perforated aortitis. During follow-up (average 3.5 years), we had no case of infection or thrombosis of the vascular prosthesis.

CONCLUSION

Patients with mycotic aneurysms or acute aortitides face a high risk of death. One can legitimately expect an increase of "aortic infections" to parallel the increase of immunocompromised individuals. Surgical procedures for infectious aortitis are always demanding and require excellent interdisciplinary cooperation, but, as this experience shows, can lead to midterm survival.