Treatment of primary infected aortic aneurysm without aortic resection

Infected Aortic Aneurysm Secondary to Pyogenic Flexor Tenosynovitis from Streptococcus pyogenes

Infected aortic aneurysms are rare, and have a high mortality rate. Although not a major pathogen, Streptococcus pyogenes has been reported to cause infected aortic aneurysms. In the present case, the patient was hospitalized for pyogenic flexor tenosynovitis with S. pyogenes bacteremia. Despite drainage of the abscess around the flexor tendon and effective antimicrobial therapy, infected aneurysms developed in the abdomen and ascending aorta. Because of their rapid enlargement, these aneurysms were treated with in situ reconstruction. Although rare, the possibility that S. pyogenes is the causative pathogen of infected aortic aneurysms should be considered.

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.

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.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Isolated Mycotic Internal Iliac Artery Aneurysm Treated With a Combined Endovascular Stenting and Percutaneous Drainage Approach: A Case Report and Review of Current Literature

Background

Isolated mycotic internal iliac artery aneurysms are rare and management of these patients can be complex.

Case summary

We present a rare case of isolated mycotic right internal iliac artery aneurysm caused by Salmonella enteritides. This was managed in stages – with intravenous antibiotics, followed by endovascular stenting and embolization, and subsequent percutaneous drainage of the remnant collection. The patient had no perioperative complications, and has remained well at more than 18 months post-operatively with no evidence of stent infection.

Conclusion

A minimally-invasive approach combining endovascular aneurysm repair and percutaneous drainage is a viable option in the management of a mycotic internal iliac artery aneurysm.

Invasive Non-typhoidal Salmonella (iNTS) Infections

Salmonella enterica invade the host via the intestinal tract. There are ~ 2 thousand distinct serovars of non-typhoidal Salmonella (NTS) that can cause gastroenteritis in normal hosts, but bacteremia is an uncommon complication of gastroenteritis except at the extremes of age [1]. In contrast, enteric fever and invasive NTS infections (iNTS) are each caused by only a few serovars of S. enterica (Table 1), and bacteremia not gastroenteritis is their principal manifestation.

Listeria monocytogenes infectious abdominal aortic aneurysm: Case report and review of the literature

Listeria monocytogenes-caused primary infected abdominal aortic aneurysm is a very rare disease. Aortic wall tissue sampling is essential for confirmation of diagnosis. Surgical repair and long-term antibacterial treatment are crucial for management.

A complicated course for an infected endovascular stent graft

The management of an infected endovascular aortic stent graft can be complex and morbid. Therefore, caution should be exercised before an endovascular approach is considered in patients presenting with a saccular aneurysm who are younger than 65 years and without risk factors for this may indicate a mycotic aneurysm. An open approach with consideration of aneurysm excision should be entertained to prevent an endovascular implantation in the setting of an infected aorta. We report a case of endovascular aortic stent graft infection that led to complex surgical management and prolonged postoperative care.

Long-term outcome of endovascular aortic repair for mycotic abdominal aortic aneurysm

BACKGROUND

This study aimed to evaluate the feasibility and efficacy of endovascular treatment for mycotic abdominal aortic aneurysm (AAA) with long-term follow-up time period.

METHODS

Patients with mycotic AAA treated with endovascular aortic repair between January 2009 and December 2017 were included in this study. The preoperative and long-term outcomes during follow-up were reviewed and analysed.

RESULTS

Sixteen patients (12 males and four females with a mean age of 57.6 ± 14.1 years) were included in this study. The technical success rate was 100%. There were no preoperative mortalities, and one instance of deep venous thrombosis during hospitalization was recorded. The median follow-up time period was 41.2 (interquartile range 24.8-69.7) months, and the late mortality rate was 12.5%. Three (18.8%) patients presented with reinfection during follow-up. One patient presented with abdominal abscess and recurrent juxtarenal aortic aneurysm at 40 months post-operatively, and he received hybrid surgery and abdominal debridement and drainage. One patient developed staphylococcal bloodstream sepsis at 3 months post-operatively and the other patient developed Salmonella bloodstream sepsis at 9 months post-operatively. Pathogenic bacteria were consistent with the previous results. They both recovered after 2 months of intravenous antibiotic treatment. At present, all three patients are still alive without endograft infection and receiving outpatient follow-up. The aneurysm diameter decreased by more than 5 mm among five patients and remained stable in 10 patients at 1 year post-operatively.

CONCLUSION

Endovascular aortic repair is a feasible and effective method of treating mycotic AAA with an acceptable reinfection rate from our single-centre experience.

Multilevel Mycotic Aneurysms Due to Salmonella Infection: Case Report and Review of the Literature

Infected or mycotic aneurysms (MAs) of the aorta and adjacent arteries are rare and difficult to treat. We report a unique case of a Salmonella serotype enteritidis-induced rapidly expanding aortic and iliac pseudoaneurysm during preoperative workup. Based on the presented case, we postulate that the agressive nature of Salmonella enteritidis MAs should not be underestimated. If postponed intervention is chosen and the patient is managed conservatively with antibiotic therapy to create a window of definitive diagnosis, one should consider close follow-up imaging to observe progression of the pseudoaneurysm. This may prevent the need of acute intervention.

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.

Aneurisma de aorta abdominal infectado por Salmonella species

Resumo Os aneurismas de aorta abdominal infecciosos (AAAIs) são raros e apresentam uma alta mortalidade devido à septicemia e ao risco de ruptura. A opção terapêutica consagrada consiste na correção aberta com ressecção do aneurisma, debridamento e reconstrução com veia autóloga. Mais recentemente, alguns grupos vêm relatando séries de casos nas quais se realizou tratamento endovascular. Em ambas as opções, a antibioticoterapia adjuvante é imperativa. Relatamos um caso ilustrativo em que o tratamento de escolha foi a cirurgia aberta com reconstrução utilizando-se veia autóloga.