Suprarenal mycotic aneurysm exclusion using a stent with a partial autologous covering

Sandwich EVAR occludes Celiac and Superior Mesenteric Artery for Infected Suprarenal Abdominal Aortic Aneurysm Treatment

Introduction. Infected aortoiliac aneurysms are rare, representing only 1% to 2% of all aortic aneurysms; we present a case of infected suprarenal aortic aneurysm with a nearly occluded celiac artery and superior mesenteric artery treated using an endovascular technique to preserve collateral in the retroperitoneal space from the inferior mesenteric artery for supplying visceral organs.

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.

Endovascular repair of ascending aortic pseudoaneurysm in a high-risk patient

Mycotic ascending aortic pseudoaneurysm (AAP) is an uncommon but surgically challenging problem with high morbidity and mortality rates. We describe endovascular repair of an acute mycotic AAP in a high-risk patient. A 45-year old man, HIV serum positive, chronic hepatitis HBV and HCV related, presented, after two sternotomies, with a fast growing 11 6 cm AAP that was sealed with two Gore Exluder aortic cuffs, inserted from the left axillary artery. Nine months control CT continued to show no endoleak with shrinking of the AAP.

Endovascular repair of an actively hemorrhaging stab wound injury to the abdominal aorta

Traumatic injury of the abdominal aorta is rare and potentially lethal (Yeh et al., J Vasc Surg 42(5):1007-1009, 2005; Chicos et al., Chirurgia (Bucur) 102(2):237-240, 2007) as it can result in major retroperitoneal hemorrhage, requiring an urgent open surgery. In case of concomitant bowel injury or other conditions of hostile abdomen, endovascular repair can be an alternative treatment. This case report deals with a 50-year-old man presenting at the emergency ward with three stab wounds: two in the abdomen and one in the chest. During explorative laparotomy, liver laceration and bowel perforation were repaired. One day later, abdominal CT-scan revealed an additional retroperitoneal hematoma associated with an aortic pseudoaneurysm, located anteriorly 3 cm above the aortic bifurcation. Because of the risk of graft infection, an endovascular repair of the aortic injury using a Gore excluder stent-graft was performed. Radiological and clinical follow-up revealed a gradual shrinkage of the pseudo-aneurysm and no sign of graft infection at two years' follow-up.

Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review

BACKGROUND

Surgical treatment for mycotic aortic aneurysms is not optimal. Even with a large excision, extensive debridement, in situ or extra-anatomical reconstruction, and with or without lifelong antibiotic treatment, mycotic aneurysms still carry very high mortality and morbidity. The use of endovascular aneurysm repair (EVAR) for mycotic aortic aneurysms simplifies the procedure and provides a good alternative for this critical condition. However, the question remains: if EVAR is placed in an infected bed, what is the outcome of the infection? Does it heal, become aggravated, or even cause a disastrous aortic rupture? In this study, we tried to clarify the risk factors for such an adverse response.

METHODS

A literature review was undertaken by using MEDLINE. All relevant reports on endoluminal management of mycotic aortic aneurysms were included. Logistic regressions were applied to identify predictors of persistent infection.

RESULTS

A total of 48 cases from 22 reports were included. The life-table analysis showed that the 30-day survival rate was 89.6% +/- 4.4%, and the 2-year survival rate was 82.2% +/- 5.8%. By univariate analysis, age 65 years or older, rupture of the aneurysm (including those with aortoenteric fistula and aortobronchial fistula), and fever at the time of operation were identified as significant predictors of persistent infection, and preoperative use of antibiotics for longer than 1 week and an adjunct procedure combined with EVAR were identified as significant protective factors for persistent infection. However, by multivariate logistic regression analysis, the only significant independent predictors identified were rupture of aneurysm and fever.

CONCLUSIONS

EVAR seems a possible alternative method for treating mycotic aortic aneurysms. Identification of the risk factors for persistent infection may help to decrease surgical morbidity and mortality. EVAR could be used as a temporary measure; however, a definite surgical treatment should be considered for patients present with aneurysm rupture or fever.

Endovascular repair of Salmonella-infected abdominal aortic aneurysms: a word of caution

Over the last several years, treatment modalities have changed for infected aortic aneurysms. Surgical treatment has undergone a paradigm shift from débridement and extra-anatomic bypass to direct reconstruction to, most recently, endovascular repair. Although many reports of endovascular repair of such aneurysms are favorable, the following two cases highlight some of the concerns with endografts in an infected field. Specifically, we urge caution when considering endovascular repair of Salmonella-infected arterial pathologies.

Endovascular stent-grafting for infected iliac artery pseudoaneurysms

We report two cases of acutely infected pseudoaneurysms of the iliac arteries, successfully treated with endovascular stent-grafting. Two patients underwent stent-graft treatment for erosive rupture of the iliac artery caused by surrounding infection. The first case is that of a 61-year-old man who had undergone Miles' operation for an advanced rectal cancer. Postoperatively, he developed intrapelvic abscess formation, from which methicillin-resistant Staphylococcus aureus was cultured, followed by rupture of the right external iliac artery. The second case is that of a 60-year-old man who had a pseudoaneurysm of the left common iliac artery, which was contiguous with a left psoas muscle abscess, from which Streptococcus agalactiae was cultured. Both patients were successfully treated with only a stent-graft and antibiotic therapy, and remained symptom-free 12 months and 10 months later. Although endovascular stent-grafting should not be considered standard therapy for infected aneurysms, our cases suggest that it can result in repair of infected aneurysms even in the uncontrolled active stage.

Treatment of Mycotic Aortic Aneurysms with Endoluminal Grafts

PURPOSE

To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry.

METHODS

Nine patients (five female) were identified over 5 years (1998-2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months.

RESULTS

Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival.

CONCLUSIONS

Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.

Transluminal thrombin injection and exclusion of a paramesenteric abdominal aortic aneurysm

Surgical repair of aortic aneurysms involving the visceral arteries carries high morbidity and mortality in poor surgical candidates. With current technology, visceral artery involvement generally precludes endovascular repair of aortic aneurysms. We report on a patient with a large abdominal aortic pseudoaneurysm involving the origin of the superior mesenteric artery. This aneurysm was successfully repaired by transluminal thrombin injection of the sac and exclusion with balloon expandable covered stents placed in the aorta.

Extracranial internal carotid artery Salmonella mycotic aneurysm complicated by occlusion of the internal carotid artery: depiction by color Doppler sonography, CT and DSA

Mycotic aneurysms of the extracranial carotid artery are rare. Seventy-four cases have been described in the medical literature and only eight secondary to Salmonella infection. To our knowledge, color Doppler sonography, computed tomography (CT), and digital subtraction angiography (DSA) findings relating to the diagnosis and follow-up of extracranial internal carotid artery mycotic aneurysm complicated by occlusion have not previously been described in the literature. We present a report of color Doppler sonography, CT, and DSA findings of a mycotic aneurysm of the right extracranial internal carotid artery due to Salmonella associated with occlusion of the internal carotid artery, promptly diagnosed and followed up using these imaging modalities.

Stent-graft repair of a mycotic left subclavian artery pseudoaneurysm

PURPOSE

To report successful stent-graft treatment of a mycotic pseudoaneurysm of the left subclavian artery in an immunosuppressed patient.

CASE REPORT

A 17-year-old immunosuppressed woman undergoing treatment for recurrent leukemia developed persistent fever and 2 episodes of hemoptysis. A contrast-enhanced computed tomographic (CT) scan demonstrated a saccular aneurysm of the left subclavian artery, which was considered to be a mycotic aneurysm caused by erosive fungal infection from the lung. The pseudoaneurysm was treated with a homemade stent-graft consisting of a nitinol stent and a polyester fabric. A type II endoleak present at the end of the procedure appeared to have sealed spontaneously on the CT scan at 3 days. No neurological deficit or ischemic symptoms of the left arm were noted during the follow-up, which lasted until the patient died 11 months later after rejecting a second bone marrow transplant.

CONCLUSIONS

Endovascular repair may be an alternative to open surgery for the management of mycotic aneurysms of the subclavian artery.

Percutaneous stent-graft repair of mycotic common femoral artery aneurysm

PURPOSE

To report successful percutaneous repair of a peripheral mycotic aneurysm as a bridge to standard surgical therapy.

CASE REPORT

An aneurysm of the left common femoral artery was diagnosed in a 43-year-old man with subacute infective endocarditis. A Jostent stent-graft was percutaneously deployed to exclude the mycotic lesion. Computed tomography at 8 months after the procedure documented aneurysm regression and stent-graft patency without evidence of infection. Arteriography at 18 months has confirmed continued stent-graft patency and the patient remains asymptomatic.

CONCLUSIONS

The standard management of mycotic aneurysms is usually by surgical resection and repair. However, this case suggests that percutaneous stent-graft implantation may be an option for the treatment of mycotic aneurysms.

Endovascular treatment and complete regression of an infected abdominal aortic aneurysm

PURPOSE

To report a case of successful endovascular treatment of an infected abdominal aortic aneurysm (AAA) following Salmonella septicemia.

CASE REPORT

A 60-year-old man was admitted for rapid onset of urinary frequency, fever, and suprapubic pain extending to the flanks. Blood cultures were positive for Salmonella enteritidis, and appropriate antibiotic treatment was started. After 4 weeks, fever ceased and the C-reactive protein fell to 5.8 mg/dL, but the erythrocyte sedimentation rate remained unchanged. Back pain prompted computed tomography, which showed a large AAA with a very irregular aortic wall suspicious of impending rupture. A tube stent-graft was introduced under general anesthesia from a left groin incision and deployed immediately below the renal arteries; a proximal type I endoleak was suspected but not repaired. Oral antibiotic therapy was continued for 2 months after discharge. By 6 months, the endoleak had sealed with a concomitant decrease in the maximal diameter of the aneurysm from 7.4 to 5.6 cm. At 4 years, the aneurysm sac was no longer visible.

CONCLUSIONS

Although experience is limited, endovascular grafting in combination with antibiotic therapy in selected infected aneurysms might represent an effective low-risk alternative to conventional surgery with the potential to restore normal vascular anatomy.

Endovascular grafting of traumatic aortic aneurysms in contaminated fields

PURPOSE

To evaluate the potential of endovascular stent-grafts to treat traumatic aortic lesions in contaminated areas.

METHODS

Four patients (3 women; ages 26-78 years) underwent stent-grafting to repair an aortic rupture sustained in a motorcycle accident, aortic lacerations secondary to surgical treatment of spondylitis in 2 patients, and an aortobronchial fistula following surgical thoracic aortic repair 10 years earlier. Stent-grafts (2 Corvita, 1 Talent, and 1 Vanguard) were placed endoluminally into the infected areas via a transfemoral approach. Follow-up included erythrocyte sedimentation rate, white blood count, C-reactive protein, blood cultures, and computed tomography (CT).

RESULTS

The stent-grafts were successfully placed in all cases and excluded the aortic lesion. Under supportive antibiotic therapy, inflammation parameters returned to normal. CT imaging showed no evidence of paraprosthetic infection, nor were there any other complications over a follow-up that ranged from 3 to 34 months.

CONCLUSIONS

Endovascular therapy may be an alternative in the acute management of aortic ruptures in the setting of infection. Long-term results are required for definitive evaluation of the method.