Infected (mycotic) aneurysms: spectrum of imaging appearances and management

Mycotic aortic aneurysms: characteristic macroscopic findings in a case series

Infected or mycotic aortic aneurysms (MAAs) are a rare type of aneurysms. Due to the high risk of rupture, MAAs are life-threatening conditions. Early diagnosis and treatment are necessary, yet MAAs are usually found coincidentally. We report 10 patients with MAAs in whom macroscopically, similar coined-sized lesions of the inner aortic wall were seen in all cases. When a coin-sized lesion in the inner aortic wall is seen during open surgical repair of an aortic aneurysm, the surgeon should consider an infectious cause. Microbiological tissue samples should be collected, and additional targeted antibiotic therapy should be started.

Case Report: Superior mesenteric artery vasculitis causing aneurysm following COVID-19 infection

Objective

Arteritis refers to all infectious and non-infectious conditions that lead to inflammation of the arterial wall. However, little is known about its presence in patients with coronavirus disease 2019 (COVID-19). Most patients improved with steroids along with conservative treatments in a few studies. We report our experience with superior mesenteric artery (SMA) arteritis causing an aneurysm following COVID-19 infection.

Case presentation

A 66-year-old female patient who was infected with COVID-19 1 month prior presented with abdominal pain. A computed tomography scan revealed proximal SMA arteritis. Although preliminary antibacterial treatment was initiated, the follow-up CT revealed an aggressive and fast-growing 5.7-cm SMA aneurysm. Subsequently, an open interposition bypass of the SMA aneurysm was performed successfully. As the specimens retrieved during surgery showed no bacterial colonization in the tissue or blood cultures, the patient was discharged without complications.

Conclusions

The mechanism of arteritis in patients with COVID-19 has not been elucidated. In the absence of evidence of bacterial infection in arteritis, it is necessary to consider the possibility of viral infection caused by COVID-19 during the COVID-19 pandemic era and start with high-dose steroid therapy promptly.

Transarterial embolization for an infected internal iliac artery aneurysm without recurrence for a long period: A case report

We report an 85-year-old man who underwent transarterial embolization (TAE) for an infected internal iliac artery aneurysm. The patient presented with fever and left lower abdominal pain. Computed tomography (CT) revealed the expansion of a left internal iliac artery aneurysm. We planned surgical treatment for an infected internal iliac artery aneurysm; however, the patient's age and general condition made the surgery high-risk. Therefore, we performed emergency TAE. The patient was administered antibiotics for 4 weeks and discharged on day 33 after the procedure with good progression. A 3-year follow-up CT scan showed aneurysm reduction and no recurrent infections. This case report highlights that TAE can be a treatment option for patients with an infected artery aneurysm.

Lumbar vertebral diskitis-osteomyelitis with mycotic abdominal aortic aneurysm caused by Streptococcus mitis

Vertebral osteomyelitis is a well-documented disease entity in literature with various known etiologies. However, vertebral diskitis-osteomyelitis secondary to an infected aortic aneurysm is an uncommon and life-threatening complication. We present the case of a 65-year-old male patient who presented with chronic low back pain that acutely worsened for 1 to 1.5 months and was diagnosed with vertebral diskitis-osteomyelitis secondary to a contiguous infection from an adjacent mycotic aortic aneurysm. To our knowledge, this is one of the few cases reported of vertebral diskitis-osteomyelitis secondary to mycotic aortic aneurysm. We discuss the findings on CT and MRI, as well as the value of imaging in guiding management.

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.

A review of histopathologic and radiologic features of non-atherosclerotic pathologies of the extracranial carotid arteries

Diseases of the carotid arteries can be classified into different categories based on their origin. Atherosclerotic carotid disease remains the most encountered arterial wall pathology. However, other less-common non-atherosclerotic diseases can have detrimental clinical consequences if not appropriately recognized. The underlying histological features of each disease process may result in imaging findings that possess features that are obvious of the disease. However, some carotid disease processes may have histological characteristics that manifest as non-specific radiologic findings. The purpose of this manuscript is to review various non-atherosclerotic causes of carotid artery disease as well as their histologic-radiologic characteristics to aid in the appropriate recognition of these less-commonly encountered pathologies.

Open versus endovascular repair of primary infected thoracic and abdominal aortic aneurysms

OBJECTIVE

Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms.

METHOD

A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors.

RESULT

Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67 years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24 months in the endovascular repair group and 38 months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1 year, 2 years, 5 years and 10 years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years and 10 years, respectively.

CONCLUTIONS

Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

Lethal mycotic pseudoaneurysm presenting as isolated sixth nerve palsy

Pseudoaneurysm of the internal carotid artery caused by skull base osteomyelitis (SBO) is a lethal condition seen in immunocompromised patients, predominantly those with diabetes mellitus. Cranial nerve involvement is a common complication and generally indicates a poor prognosis. We report the case of a 62-year-old diabetic patient who presented with isolated sixth cranial nerve palsy. She had uncontrolled blood sugar levels and high erythrocyte sedimentation rate, and she suffered from pyelonephritis. Neuroimaging detected SBO with multiple secondary mycotic pseudoaneurysms prominent at the petrocavernous junction. Ischemia is the most common etiology for an isolated abducens nerve palsy, but in certain cases neuroimaging is warranted to prevent life-threatening complications. This case highlights the importance and urgency of identifying and managing such conditions.

Mycotic Pulmonary Artery Aneurysm a Rare Complication of Ventricular Septal Defect With Infective Endocarditis: A Case Report

Introduction

Pulmonary artery aneurysms encompass a wide range of presentations and forms. Mycotic aneurysms represent a particular subset of focal dilatation of the vessel wall with high morbidity and mortality rates. Herein, we report the case of a 32 year old patient, with a prior history of ventricular septal defect presenting with a mycotic pulmonary artery aneurysm associated with infective endocarditis and septic emboli.

Case presentation

We present the case of a 32 year old male with known history of congenital ventricular septal defect presented to the emergency department with signs of sepsis and dyspnea. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. An echocardiogram found evidence of endocarditis with multiples intra cavitary vegetations. A CT angiogram demonstrated major right ventricular dilatation, multiple nodules and peripheral opacities, scattered throughout the lungs, indicative of septic emboli. Segmental saccular dilatation of the left lateral basal pulmonary artery consistent with a mycotic aneurysm formation was found. The patient was started on intravenous antibiotics and given the overall satisfactory evolution a conservative approach was pursued. The patient was discharged with antibiotics and scheduled for surgical repair of the ventricular septal defect.

Conclusion

To our knowledge, mycotic aneurysms associated to congenital heart malformation like ventricular septal wall defect remains a rare condition with few reported cases in the literature. Being aware of this entity is important for every practicing radiologist to allow for early diagnosis and treatment.

Mycotic Aortic Aneurysm Secondary to Salmonella enterica Infection: A Case Report and Treatment Approach

Mycotic (infected) aortic aneurysm is a severe clinical condition with high morbidity and mortality. Salmonella spp. is a Gram-negative, rod-shaped bacteria that is typically limited to the gastrointestinal tract and resolves spontaneously but can progress to invasive infections such as bacteremia. Serious complications may arise, particularly in debilitated, elderly, and neonatal patients. We describe the case of a 74-year-old female with a history of diabetes and hypertension who presented with shortness of breath, fever, chills, abdominal pain, vomiting, and diarrhea. The patient's blood culture tested positive for Salmonella enterica, and she was given ceftriaxone based on the results, but he remained symptomatic. A computed tomography scan of the chest with contrast revealed a mycotic aneurysm of the thoracic aorta. The patient was urgently transferred to a higher level of care and underwent emergency thoracic endovascular aortic repair with stenting and intravenous antibiotics. The presence of an infected aneurysm and associated abscess formation in such high-risk patients makes the endovascular approach more suitable than other options such as open surgery, aneurysmal excision and ligation without arterial reconstruction, excision with immediate reconstruction, and excision with interval reconstruction.

Ruptured Mycotic Aneurysm of the Superior Mesenteric Artery: A Case Report

An infected (mycotic) aneurysm of the visceral arteries is an uncommon entity, which may arise from a secondary infection of a preexisting aneurysm or be due to degeneration from a primary infection. Mycotic aneurysms require prompt recognition and definitive treatment; otherwise, there can be devastating morbidity and mortality. We present the case of a 51-year-old female with HIV and Crohn's disease who presented with subacute abdominal pain, nausea, and vomiting and was found to have an ultimately fatal mycotic aneurysm of the superior mesenteric artery. In addition, we discuss the characteristic imaging features of mycotic aneurysms on computed tomography and magnetic resonance imaging.

Radiological findings and endovascular management of internal carotid artery pseudoaneurysm in the setting of mucormycosis and COVID-19

The coronavirus pandemic is now a public health emergency and has spread to nearly 206 countries across the globe. This novel disease has shaken the psycho-social, economic, and medical infrastructure of India. This has become even more challenging, considering the country's huge population. With the increase in the number of coronavirus disease (COVID) cases, our country has seen an unforeseen, unprecedented rise in a potential life and organ-threatening disease-mucormycosis. Mucormycosis is a deadly, extremely morbid, possibly life-threatening, and most feared complication of the coronavirus, caused by environmental molds belonging to the order Mucorales. Here, we report 2 cases of massive epistaxis due to internal carotid artery (ICA) pseudoaneurysm secondary to mucormycosis, post-COVID-19 pneumonia, which was managed by the endovascular route. To the best of our knowledge, there is very sparse literature available describing endovascular treatment of intracranial ICA pseudoaneurysm in a patient with COVID-induced mucormycosis.

Axillary artery aneurysms in pediatric patients: A narrative review

OBJECTIVES

Axillary artery aneurysms in children are rare and multifactorial. The presenting clinical picture can range from an incidental discovery to threatening symptoms, including loss of extremity function. With the present study we aim to give a comprehensive review of the existing literature focusing on the etiology and management of this rare but threatening pathology.

METHOD

A comprehensive review was made in a multi-staged manner. All identified studies have been categorized based on the type of lesions (true or false aneurysm) and their etiologies.

RESULTS

The treatments differ from the extension of the lesions and from the etiology.

CONCLUSIONS

Open surgery repair with great saphenous vein is still the best long-term approach, but even endovascular, embolization, or conservative management can be considered.

Spontaneous Celiac Artery Pseudoaneurysm in a Patient With Viral Myocarditis: Coincidence or Consequence?

Spontaneous pseudoaneurysm formation in the celiac artery is a very infrequent occurrence in the absence of trauma or descending aortic dissection. If it continues to progress, it can lead to visceral organ infarction or life-threatening hemoperitoneum. Management is conservative in select cases; however, most patients require an endovascular or surgical approach. The definitive etiology of spontaneous celiac artery pseudoaneurysm remains unclear. We present an intriguing case of a 67-year-old female who presented to the hospital with sudden chest pain preceded by viral prodromal symptoms. She was discharged as a case of viral myocarditis and was re-admitted the same day with acute abdominal pain. Computed tomography with intravenous contrast showed an enlarging eight-millimeter celiac artery pseudoaneurysm managed with endovascular coil embolization. This case report demonstrates spontaneous celiac artery pseudoaneurysm workup and management. We are also investigating whether a unifying diagnosis exists to explain both viral myocarditis and celiac artery pseudoaneurysm or if both conditions are sporadic occurrences.

Surviving the nonsurvivable combination of a mycotic aneurysm progressing into a concomitant aorto-bronchial- and aorto-esophageal fistula, a case report

BACKGROUND

Aortic mycotic aneurysms are a rare but life-threatening condition and may be associated with aorto-bronchial- and aorto-esophageal fistulas. Although both very rare, they carry a high mortality and require (urgent) surgical intervention. Surviving all three conditions concomitantly is extraordinary. We describe a patient who underwent staged repair of such combined defects.

Isolated tricuspid valve Group B Streptococcal endocarditis with septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries

A diabetic woman in her 30s was admitted to our medical centre for persistent fever associated with worsening cough, easy fatigability and pleuritic chest pain noted after childbirth. Investigations revealed an isolated tricuspid valve endocarditis from Group B Streptococcus Despite appropriate antibiotic coverage, her symptoms persisted with worsening dyspnoea; hence, a CT pulmonary angiogram was done which showed septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries. She was treated with antibiotics and underwent tricuspid valve replacement and was discharged well with a return to her baseline functional capacity on subsequent follow-ups.

Case report: Immediate revascularization for symptomatic hepatic artery pseudoaneurysm after orthotopic liver transplantation? A case series and literature review

Introduction

Hepatic artery pseudoaneurysm (HAPA), a rare vascular complication that can develop after liver transplantation, is associated with a high mortality rate and graft loss. To salvage the liver graft, immediate revascularization, either through surgical or endovascular intervention, is required. However, currently there is no consensus on the optimal strategy. Here, we report three cases of liver transplant recipients diagnosed with HAPA and treated with immediate revascularization. In addition, we present an overview of HAPA cases described in the literature and make recommendations on how to treat this rare complication.

Methods

All adults transplanted in our center between 2005 and 2021 were retrospectively reviewed. Literature search was done in PubMed for original studies between 1980 and 2021 reporting early hepatic artery (pseudo) aneurysm after liver transplantation requiring either surgical or endovascular intervention.

Results

From a total of 1,172, 3 liver transplant patients were identified with a symptomatic HAPA and treated with immediate revascularization. HAPA occurred 73, 27, and 8 days after liver transplantation and was treated with immediate revascularization (two surgical and one endovascular intervention). Literature review identified 127 cases of HAPA. HAPA was managed with endovascular therapy in 20 cases and by surgical intervention in 89 cases. Overall reported mortality rate was 39.6%, whereas overall graft survival was 45.2%.

Conclusion

Immediate surgical or radiological interventional excision and prompt revascularization to salvage liver grafts is feasible but still associated with a high mortality.

Mycotic Aneurysm of the Thoracoabdominal Aorta: A Diagnostic Challenge

Mycotic aortic aneurysms (MAAs) are a rare form of aortic aneurysms that are associated with catastrophic outcomes if not diagnosed and treated on time. However, MAAs are a diagnostic challenge owing to their often nonspecific presentation. In this study, we present a case of a 42-year-old female with a pertinent history of intravenous drug use who presented with generalized body pain for two weeks and was found to have a mycotic thoracoabdominal aortic aneurysm (TAAA) extensively involving adjacent structures, including lungs with pleural cavity and upper renal pole. Not only does this case highlight the difficulty in early diagnosis and complex pathology of a mycotic TAAA, but it also illustrates the multidisciplinary approach required to effectively treat them.

Human descending aorta injury caused by brucellosis: A case report

BACKGROUND

Brucellosis is one of the most common zoonotic diseases in the world. Although cardiovascular complications of human brucellosis account for only 3% of morbidity, they are the leading cause of death. Peripheral vascular disease due to brucellosis is rare and under-reported in the literature.

CASE PRESENTATION

Two patients with previous brucellosis, both of whom had been treated with anti-brucellosis, were admitted to vascular surgery for thoracic aortic ulcer and abdominal aortic pseudoaneurysm, respectively, with positive IgG antibody to brucellosis and negative IgM antibody to brucellosis, tube agglutination test, and blood culture. These 2 patients were successfully treated with aortic stent-graft implantation and followed up for 8 and 10 weeks without complications.

CONCLUSIONS

Chronic damage to human blood vessels by brucellosis may not disappear with brucellosis treatment, and peripheral blood vessels should be examined annually in people previously diagnosed with brucellosis. Clinicians in related departments should pay attention to peripheral vascular complications of brucellosis.

Transcatheter arterial embolization of the subclavian and axillary artery branches for hemorrhage control

OBJECTIVE

To evaluate the effectiveness and safety of transcatheter arterial embolization (TAE) of the branches of the subclavian and axillary arteries for hemorrhage control.

METHODS

Between January 2015 and June 2022, 35 TAE procedures were performed for hemorrhage from the branches of the subclavian and axillary arteries in 34 patients (22 men, 12 women; 1 male underwent TAE twice; mean age = 76 years). Pre-TAE CT showed hematomas in the chest (n = 25) and abdominal walls (n = 3), shoulder (n = 2), and lower neck (n = 2). CT showed hemothorax in eight cases. Angiographic findings, embolization technique, and technical and clinical success of TAE were retrospectively assessed in all cases.

RESULTS

TAE was performed by transfemoral (n = 16), transradial (n = 12), and transbrachial (n = 7) approaches. Angiography revealed contrast media extravasation or pseudoaneurysms in 32 cases (91.4%). The most commonly embolized arteries were the internal thoracic (n = 12), lateral thoracic (n = 6), and thoracoacromial (n = 6) arteries. Technical and clinical success rates were 100 and 85.7%, respectively. A complication (skin necrosis after injection of the liquid embolic agent) developed in only one patient (2.9%) and was conservatively managed.

CONCLUSION

TAE is an effective and safe treatment for hemorrhage from the branches of the subclavian and axillary arteries.

ADVANCES IN KNOWLEDGE

Transfemoral approach has been used for TAE of the branches of the subclavian and axillary artery. Transradial and transbrachial approaches can also be considered.

Mycotic aneurysm by Bacteroides fragilis presenting as fever of unknown origin

A mycotic aneurysm is an infection of the vessel wall which can be bacterial, fungal, or viral in origin. It is invariably a fatal infectious disease if appropriate treatment is not done. We describe the case of a forty-six years male who presented with complaints of high-grade fever and lower back pain with worsening symptoms with the passage of the illness. An infrarenal lobulated abdominal aortic aneurysm was confirmed by CT angiography. He underwent aneurysmorrhaphy and metronidazole was started following the culture report (Bacteroides fragilis). He was discharged successfully from the hospital.

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.

Mycotic Aneurysms and Recurrent Intracranial Hemorrhages in a Patient With Infective Endocarditis

The increase in the use of IV drugs has been accompanied by an increase in the incidence of infective endocarditis (IE). The clinical picture, vitals, examination, blood cultures, laboratory tests, and imaging can help diagnose IE. The Duke criteria also play a role in the diagnosis of IE. Prolonged antibiotic use and even interventions may be needed in the management of specific cases. Rare complications such as mycotic aneurysms and intracranial hemorrhages can be fatal and must be promptly addressed to prevent loss of life and serve debilitation in these patients.

Computed tomography for aortic assessment in children

Because the aorta is the major vessel of the body, basic knowledge of aortic pathology is essential to the pediatric imager. This review divides aortic pathology into anatomical (e.g., congenital abnormalities) and acquired (e.g., vasculitis, trauma) entities, providing a brief description of pathology, technical considerations in CT acquisition and processing, and some pearls and pitfalls of interpretation. The objective of this paper is to familiarize general pediatric imagers with imaging features of common as well as high-impact aortic pathology on CT and prepare them for acquisition and reporting.

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.

Subclavian Artery: Anatomic Review and Imaging Evaluation of Abnormalities

The subclavian artery is an important structure that may be overlooked at CT of the chest and neck, in part because of its anatomic location at the periphery of the field of view but also because the clinical indication for CT examinations infrequently directs attention specifically to evaluation of the subclavian artery. As with all arteries, the subclavian artery has the potential to be involved in a variety of abnormalities, including pseudoaneurysms, dissections, stenosis or thrombosis, and vasculopathies. In addition, the subclavian artery can be secondarily involved as a collateral pathway because of an abnormality elsewhere. The subclavian artery may also be involved in surgical procedures to supply blood to other sites in the body or as an arterial access site. In these cases, recognizing the postsurgical appearance of the subclavian artery has become increasingly complex because of the use of the artery in an increasing number of procedures. Recognizing expected postoperative changes remains important to avoid mistaking them for abnormalities. The authors describe the imaging appearance of the normal anatomy of the subclavian artery and its anatomic variants, related abnormalities, and important postsurgical considerations. ^©RSNA, 2022.

MB. Salmonella Bacteremia Causing Mycotic Pseudoaneurysm of Right Common Iliac Artery Complicated by Septic Caval Thrombosis

Mycotic pseudoaneurysm (MPA) is a blind, saccular outpouching of the arterial lumen of infective origin. MPA is a rare life-threatening condition and if not treated early, has a 67% mortality rate due to sepsis and hemorrhage. Major predisposing factors are diabetes mellitus, chronic renal failure, malignancy, steroids, and intravenous drug use. Imaging modalities include Doppler ultrasound, contrast-enhanced computed tomography, and digital subtraction angiography. We report a unique case of Salmonella bacteremia-related MPA of the right common iliac artery complicated by septic inferior vena cava (IVC) thrombosis in a patient with uncontrolled diabetes. Such transcompartmental involvement of IVC has hitherto not been described in the literature and hence makes for interesting documentation. This case ponders upon the aggressiveness of the invasive nontyphoidal Salmonella infection pathogen and the need for early imaging of suspicious patients to reduce morbidity and mortality.

Celiac Trunk Mycotic Aneurysm: Diagnosis and Treatment of a Post-infective Endocarditis Complication

Pseudoaneurysms could be the dynamic evolution of an infectious break in the arterial wall; in the post-antibiotic era they are uncommon complication following infective endocarditis (IE) and are associated with high rates of morbidity and mortality especially for patients in whom a prompt diagnosis and therapeutic strategy are not performed. In this report, we describe a case of pseudoaneurysm of the celiac trunk developed as a complication of IE. Endovascular treatment is our first-line approach.

An Infected Massive Persistent Sciatic Artery Aneurysm Treated by an Aneurysmal Incision and Drainage after Angiographic Embolization

A man in his 80s undergoing chronic hemodialysis presented with a high fever. A 10-cm soft mass was palpable in his right buttock. Abdominal computed tomography and angiography showed an incomplete-type unilateral persistent sciatic artery aneurysm (PSAA) with gas patterns and a blood flow through the aneurysm. Incision drainage was performed after arterial embolization. Gram staining of the hematoma showed gram-positive cocci that had formed chains, thus leading to a diagnosis of an infected PSAA. Drainage by incision after arterial embolization was used as the therapeutic method of choice for a massive infected PSAA with a sustained blood flow in order to prevent sciatic nerve injury and bleeding associated with PSAA resection.

Mycotic and non-mycotic coronary artery aneurysms—A review of the rarity

Sir William Osler coined the term “mycotic” to identify aneurysms secondary to an infectious cause, which may not be necessarily fungal and are caused mainly by bacteria. The literature’s reported incidence of coronary artery aneurysms (CAA) is from 1.5-5%. The right coronary artery (RCA) is mainly involved, followed by the left side coronary circulation. Mycotic aneurysms are more commonly associated with infective endocarditis. More recently, coronary artery stents, particularly drug-eluting stents, are typically causing mycotic coronary aneurysms. CT angiography (CTA) has been the forefront diagnostic modality, showing both the lumen and wall of the coronary arteries. It also aids in preoperative planning. MRI is useful in diagnosing and following children with Kawasaki’s disease. Smaller mycotic coronary aneurysms may resolve with antibiotic therapy; however, aneurysms more significant than 1-2 cm diameter needs corrective surgery. Early diagnosis and appropriate management are the critical factors in the successful treatment of infective coronary artery aneurysms.

Infectious Aortitis: Case Report and Literature Review

Aortitis is the inflammation of the aorta secondary to either infectious or non-infectious etiologies. Infectious aortitis is a rare but potentially life-threatening condition. It is more common among older patients with preexisting pathology. Clinical presentation is variable, therefore, a high index of suspicion is required for timely diagnosis and management. We report a case of aortitis which was complicated with the development of a saccular abdominal aortic aneurysm. A 76-year-old male presented to the Emergency Department with two days of right lower quadrant abdominal pain. Clinical evaluation and imaging studies revealed abdominal aortitis, which progressed to a saccular abdominal aortic aneurysm. We highlight a unique presentation of infectious aortitis to raise awareness among physicians. We also reviewed the available literature on infectious aortitis to illustrate the importance of early diagnosis and appropriate treatment to improve the patients' outcomes.

Mycotic Aneurysm with Iliac Artery-Colonic Fistula

Although mycotic (infected) aneurysms are uncommon, they can affect any artery. The most frequently involved vessel is the aorta as well as femoral and cerebral arteries. A vascular-colonic fistula from infected aneurysms is even rarer, which remains a challenge for diagnosis and treatment. In this case report, we aimed to illustrate an 89-year-old man presenting initially with an aneurysm of the right common iliac artery. Forty days later, this lesion was infected and produced fresh blood in the rectum and sigmoid colon observed by colonoscopy. The final diagnosis of this case was a right common iliac artery aneurysm-colonic fistula due to infection. The patient was successfully diagnosed and treated with surgery at our hospital.

Imaging features of rhinocerebral mucormycosis: from onset to vascular complications

Rhinocerebral mucormycosis (RCM) may result in severe intracranial ischemic and hemorrhagic lesions. Both computed tomography (CT) and magnetic resonance imaging (MRI) play an essential role in the diagnosis of RCM, but whereas CT is better for assessing bone erosion, MRI is superior in evaluating soft tissue, intraorbital extension, and in assessing intracranial and vascular invasion. Specific CT and MRI techniques, such as CT angiography or enhanced MR angiography, and more advanced MRI sequences such as gadolinium-3D Black Blood imaging, contribute to the assessment of the extension of vascular invasion.In this pictorial review, we describe specific CT and MRI signs of RCM, mainly focusing on its life-threatening complications due to vascular involvement.

Patient-tailored approach for diagnostics and treatment of mycotic abdominal aortic aneurysm

OBJECTIVE

The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center.

METHODS

A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection.

RESULTS

Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 ± 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In eight patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n=4) and rupture of the mycotic abdominal aortic aneurysm (n=3). No patient characteristics could be identified as predictive for mortality.

CONCLUSION

This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic/other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist.

Emergency Department Diagnosis of Multiple Mycotic Aneurysms in an HIV-Positive Patient Using Point-of-Care Ultrasound

We report the case of a transgender woman with HIV (CD4 349), shortness of breath, and chest pain, who was found to have multiple mycotic aortic aneurysms by point-of-care ultrasound (PoCUS). This report highlights the utility of point-of-care ultrasonography in the diagnosis and management of this rare clinical entity.Multiple mycotic aortic aneurysms and purulent pericarditis are uncommon. They have high morbidity and mortality and are associated with immunocompromised states (e.g., HIV). Diagnosis of the mycotic aneurysm, and its precursor, infectious aortitis, can be challenging, and delays in care can lead to poor outcomes. Often, as described in this case report, making the diagnosis requires a high clinical suspicion, multiple imaging modalities, and laboratory studies.

Features of infective native aortic aneurysms on computed tomography

Background

Infective native aortic aneurysm (INAA) is a rare clinical diagnosis. The purpose of this study was to describe the CT findings of INAAs in detail.

Methods

This was a retrospective single-center study of INAA patients at a major referral hospital between 2005 and 2020. All images were reviewed according to a protocol consisting of aneurysm features, periaortic findings, and associated surrounding structures.

Results

One hundred and fourteen patients (mean age, 66 years [standard deviation, 11 years]; 91 men) with 132 aneurysms were included. The most common locations were infrarenal (50.8%), aortoiliac (15.2%), and juxtarenal (12.9%). The mean transaxial diameter was 6.2 cm. Most INAAs were saccular (87.9%) and multilobulated (91.7%). Calcified aortic plaque was present in 93.2% and within the aneurysm in 51.5%. INAA instability was classified as contained rupture (27.3%), impending rupture (26.5%), and free rupture (3.8%). Rapid expansion was demonstrated in 13 of 14 (92.9%) aneurysms with sequential CT studies. Periaortic inflammation was demonstrated as periaortic enhancement (94.7%), fat stranding (93.9%), soft-tissue mass (92.4%), and lymphadenopathy (62.1%). Surrounding involvement included psoas muscle (17.8%), spondylitis (11.4%), and perinephric region (2.8%). Twelve patients demonstrated thoracic and abdominal INAA complications: fistulas to the esophagus (20%), bronchus (16%), bowel (1.9%), and inferior vena cava (IVC) (0.9%).

Conclusion

The most common CT features of INAA were saccular aneurysm, multilobulation, and calcified plaques. The most frequent periaortic findings were enhancement, fat stranding, and soft-tissue mass. Surrounding involvement, including psoas muscle, IVC, gastrointestinal tract, and bronchi, was infrequent but may develop as critical INAA complications.

Periaortic air in native and post-operative aorta on computed tomography

Periaortic air can be seen in various conditions which can be a benign imaging finding or harbinger of a catastrophic event. The causes vary in native aorta and post-operative aorta. A radiologist has an important part in the management process of these patients, as the treatment varies from conservative to radical surgery based on the aetiology. The presence of periaortic air seen in the light of various clinical, laboratory and radiological findings can guide the radiologist towards a particular aetiology. Cross-sectional imaging, mainly computed tomography, is an indispensable tool in recognising ectopic periaortic air and to identify the associated findings and eventually make an accurate diagnosis. We present a pictorial review of various causes of the periaortic air in native and postoperative aorta, the salient features and management of the described conditions.

Renovascular involvement of systemic vascular disease: a pictorial review

Like many solid organs, the kidneys are susceptible to a wide variety of systemic vascular diseases. Comprising a significant subset of these diseases are the vasculitides, broadly encompassing numerous inflammatory conditions of the blood vessels. However, many of these conditions are non-vasculitic and non-inflammatory, and differentiation of these entities is crucial to guide the initiation of proper therapy. These non-vasculitic diseases include coagulopathic conditions leading to vascular complications, hemolysis, and hematogenous processes that can affect multiple organ systems. These systemic diseases can result in both macrovascular and microvascular pathology, involving the arteries, veins, and smaller vessels, and management of these conditions can differ significantly depending upon the underlying pathophysiology. Because the clinical manifestations of these disease processes can be heterogeneous, ranging from renal dysfunction to life-threatening hemorrhage, proper recognition of these entities is essential to help guide clinicians to the correct diagnosis and prevent potentially disastrous complications. Many of these systemic vascular processes can be detected by non-invasive imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), and identification of their characteristic renal manifestations by radiologists is a critical component of patient care. This review covers a variety of these diseases and their imaging manifestations, to aid in their recognition and better equip radiologists to provide vital diagnostic information that can optimize patient care.

Infected Aortic Aneurysm with Infective Spondylitis in a Patient with Pre-Aortic Confluence of the Iliac Veins: An Unusual Triple Combination

It is uncommon for infective spondylitis to coexist with an infected aneurysm of the adjacent abdominal aorta. Also, pre-aortic confluence of the iliac veins or marsupial vena cava is a rare anatomical variant, which increases the potential for venous injury and hemorrhage during an emergency operation. Herein, we report the case of a 57-year-old male with these three pathologies, who was successfully treated with emergency open surgery. During surgery, we noted this anomaly and extensive destruction of the lumbar vertebral bodies. We discuss options to treat these rare pathologies with literature review.

Mycotic Pseudoaneurysm Formation at the Cannulation Site in the Ascending Aorta

The formation of mycotic pseudoaneurysms in the ascending aorta is a rare but sometimes fatal complication after open-heart surgery, requiring cardiopulmonary bypass (CPB). There has been little cited about this rare complication. We present a case of a 51-year-old man who developed a mycotic pseudoaneurysm in the ascending aorta at a previous aortic cannulation site nine years after coronary artery bypass surgery. The patient presented to the emergency department with two weeks of worsening substernal chest pain and was found to have pseudoaneurysm in the anterior wall of the ascending aorta on chest computed tomography angiography (CTA) during his chest pain workup. The patient's blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). During the hospital course, the patient's respiratory status worsened, and repeat CTA revealed enlargement of the pseudoaneurysm arising from the anterior proximal arch of the aorta. Chest X-ray obtained because of hypoxia demonstrated widening of the upper mediastinum, which appeared increased compared with the previous exam. Because of concern for rupture of an aneurysm, the patient was taken to the operating room for redo sternotomy and repair of the pseudoaneurysm with femoral artery cannulation for cardiopulmonary bypass. The patient completed eight weeks of IV nafcillin, and rifampin was added to decrease biofilm formation.

Atypical intracranial aneurysms: spectrum of imaging findings in computed tomography and magnetic resonance imaging

We aim to describe demographics, clinical presentation, and spectrum of CT and MRI features suggestive of atypical intracranial aneurysms. The imaging protocols used for the diagnosis of intracranial aneurysms were thoroughly reviewed, including different CT and MRI protocols. We classified atypical aneurysms according to their location, size, clinical presentation, and specific imaging features. Dissecting aneurysms are one of the causes of stroke in young adults that may show intimal flap and double lumen. Traumatic intracranial aneurysms are a rare but serious complication of head injuries. Mycotic aneurysms are small and multiple at distal branch points with a high risk of rupture. Aneurysms with vasculitis are fusiform with a wide neck at a non-branch point that may be associated with vessel wall enhancement. Atherosclerotic aneurysms are usually large fusiform that affect large arteries. Oncotic aneurysms are relatively rare. They were reported to occur in patients with left atrial myxoma. Our study represented a wide spectrum of atypical intracranial aneurysms with their detailed diagnostic imaging findings on MRI and CT including newly introduced MRI sequences, which greatly influenced early diagnosis and timely management.

Differential diagnosis of a ring-enhancing brain lesion in the setting of metastatic cancer and a mycotic aneurysm

A diagnostic challenge arises when a patient presents with a ring-enhancing lesion of the brain in the setting of both metastatic cancer and a source of infection. We report a case depicting this dilemma in an 80-year-old man with a history of metastatic oral squamous cell carcinoma who presented for left-sided hemiparesis. Computed tomography and magnetic resonance imaging revealed a ring-enhancing lesion of the right parietal vertex without signs of stroke. He was also found to have an aneurysm of the right common carotid artery with abnormal surrounding soft tissue density and gas, findings suspicious for a mycotic aneurysm. The likelihood of the brain lesion being an abscess formed by septic embolization was raised, leading to the recommendation to surgically explore the brain lesion and repair the aneurysm. Nevertheless, a high index of suspicion for a brain abscess and mycotic aneurysm is necessary in this type of clinical scenario.

Computed Tomography Appearance of Unusual Nonaortic Thoracic Aneurysms and Pseudoaneurysms

Although aneurysms of the thoracic aorta are easily recognized on computed tomography (CT), nonaortic intrathoracic aneurysms and pseudoaneurysms are unusual and not often encountered by radiologists. These lesions can result in complications such as hemorrhage or symptoms from mass effect. In some cases, patients may be asymptomatic and the aneurysms may represent incidental findings. Radiologists should be familiar with the CT appearances of these rare vascular abnormalities to enable prompt diagnosis. The goals of this pictorial essay are to: (1) illustrate and describe the CT appearances of various unusual intrathoracic nonaortic aneurysms and pseudoaneurysms; (2) discuss the etiology and clinical significance of these lesions; and (3) discuss management options where appropriate.

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.

Ulnar infected pseudoaneurysm in the course of extended-spectrum beta-lactamase Escherichia coli septicemia

We describe the first case of proximal ulnar pseudoaneurysm due to extended-spectrum beta-lactamase-producing Escherichia coli. We performed an open ligation of the ulnar artery and partial excision of the aneurysmal sac. This article discusses the etiology and surgical management of ulnar-infected pseudoaneurysms according to the literature data.

CURRENT ENDOVASCULAR MANAGEMENT OF INFECTED DISTAL BRANCH INTRACRANIAL ANEURYSMS: A CASE REPORT AND INSIGHT INTO THE LITERATURE

Infected intracranial aneurysms are a rare type of inflammatory vascular lesions that occur due to infection of intracranial arterial wall. Brain aneurysms of distal arterial branches are equally rare and frequently multiple, including those situated at the peripheral middle cerebral artery segments. Although both types represent a small percentage of all intracranial aneurysms, they may bring about high mortality in case of rupture. The management of such aneurysms includes conservative treatment with broad-spectrum antibiotics, and microsurgical or endovascular treatment, which is gaining more prominence for both asymptomatic and ruptured aneurysms. Herein, we present a case of a 61-year-old male patient with a history of cardiac infective disease and multiple bilateral aneurysms of infected distal branch middle cerebral arteries, discussing the efficacy of available endovascular treatment modalities and reviewing the literature. In conclusion, selective endovascular coiling is a preferable method in the current management of distal branch infected ruptured intracranial aneurysms, which may bring a favorable outcome.

Mycotic aneurysm of the distal radial artery after cardiac catheterisation

A mycotic aneurysm of the distal radial artery following access for cardiac catheterisation is a rare complication that has not been described in the literature. We present the case of an 84-year-old man who developed bacteraemia and cellulitis over his left first dorsal webspace 2 days after undergoing cardiac catheterisation through the distal radial artery at the anatomic snuffbox. Ultrasound scanning and CT imaging were concerning for a possible pseudoaneurysm at that location. Once we confirmed that the patient had adequate flow through his hand with angiography and an Allen's test, we explored his left hand and found a mycotic aneurysm of the distal radial artery with surrounding frank purulence. We resected the aneurysm and ligated the artery. Pathology confirmed that this was a mycotic aneurysm. The patient quickly recovered from his infection after this definitive treatment.