Endovascular treatment and complete regression of an infected abdominal aortic aneurysm

Endovascular repair combined with adjunctive procedures in the treatment of tuberculous infected native aortic aneurysms

OBJECTIVE

The present study aimed to analyze the experience of a single center and assess the efficacy and durability of endovascular aortic repair (EVAR) in patients with tuberculous infected native aortic aneurysms (INAAs).

METHODS

All patients who underwent EVAR for INAAs between September 2014 and August 2021 were retrospectively reviewed. The primary endpoints were 30-day and overall mortality rates; the secondary outcomes included major complications, endoleak, recurrence, re-intervention rate, and thrombosis of the pseudoaneurysmal sac.

RESULTS

A total of 18 patients (average age 61.3 years; 10 female [55.6%]) were identified. Fifteen patients (83.3%) had adjunctive procedures in addition to EVAR. Both the in-hospital and 30-day mortality rates were 0%. The overall cumulative survival rates estimated by Kaplan-Meier were 100% at 1 and 6 months, and 92.3% at 12, 24, and 80.8% at 36 and 48 months. Type Ib and II endoleak each occurred in 1 (5.6%) patient and resolved without treatment after 1 month. No graft infections, strokes, paraplegia, ischemic abdominal complications, or other major complications occurred. The overall rates of cumulative freedom from recurrence of aneurysm and re-intervention were 83.9% and 81.8%, respectively, during the median follow-up period of 28.5 (1-72) months. The median time of administering anti-tuberculosis drugs was 10.5 (2-44) months.

CONCLUSIONS

EVAR combined with oral anti-tuberculosis medication is effective and may be an appealing treatment option for high risk INAAs patients. Adjunctive procedures, including targeted drug delivery to the site of infection, could be a solution to further controlling the infection but still needs further evaluation.

Mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection causing a diagnostic dilemma

Mycotic pseudoaneurysms usually arise from an infectious arteritis or mycotic aneurysms secondary to weakening and destruction of the arterial wall resulting in a contained rupture. We report a case of a mycotic pseudoaneurysm affecting the aortic isthmus of the thoracic aorta which is an extremely rare infection. To our knowledge no case report of mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection has thus far been described. The specific case we present is also unique in that it posed a diagnostic imaging dilemma where the initial imaging revealed a periaortic mass which could not be accurately characterized and only on subsequent imaging reveal itself to be a thrombosed mycotic pseudoaneurysm. We hope that our case report highlights to the medical community the high degree of suspicion one should have regarding pseudoaneurysms when dealing with a complex mass intimately related to a vascular structure.

Hybrid repair for a complex infection aortic pseudoaneurysm with continued antibiotic therapy: A case report and literature review

INTRODUCTION

Treatment of infection aortic pseudoaneurysm (PSA) is a great challenge to surgeons for 3 reasons: high mortality for rupture or threatened rupture; potential risk for infection of prosthetic material which probably bring a devastating result for patients; and long-term antibiotic therapy requirement. Endovascular repair is an alternative to open surgery for a less invasive, which is a trouble procedure for aortic PSA with complex aortic anatomy. The purpose of this article is to report the novel hybrid repair of an infection aortic PSA and antibiotics therapy.

CLINICAL FINDING

A 61-year-old man with complaints of repeated abdominal pain and fever for 3 months was admitted. He had a fever of 39.0°C and normal blood pressure. The blood leukocyte count was 14.9 × 10/L, C-reactive protein was 132 mg/L. There was no evidence for urinary tract infection. The small effusion was identified in bilateral thoracic cavity and pelvis cavity, and the severe lung function impairment was detected. Klebsiella pneumoniae was identified in blood cultures. Computer tomographic (CT) angiography showed a 6 cm × 6 cm aortic PSA involving bilateral renal arteries and a subhepatic inflammatory mass (identified by percutaneous puncture).

DIAGNOSIS

According to the symptoms, CT and lab test, the main diagnosis for this patient were: infective aortic PSA involving bilateral renal arteries, and Bacteremia with K pneumoniae.

INTERVENTION AND OUTCOMES

A hybrid procedure combined open surgical and endovascular was performed for managing the paravisceral infection aortic PSA in a 61-year-old man with high risk. To decrease the risk of graft infection, autologous saphenous vein graft was adopted, and long-term antibiotic therapy was used. At 2 years follow-up, the patient was in good clinical condition with continued antibiotic therapy.

CONCLUSION

Hybrid procedure is an alternative approach according to high risk patients with complex anatomy for open repair of infection aortic PSA. The postoperative long-time continued antibiotic therapy must be emphasized for infection PSA.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

Clinical Case Discussion: Mycotic Aortic Aneurysm and Psoas Abscess as a Complication of Bacillus Calmette-Guérin Instillations

After an infectious complication caused by bacillus Calmette-Guérin (BCG), consider a dose reduction. Treatment of a mycotic aneurysm with an endostent seems safe; however, continuation of BCG after mycotic aneurysm treatment is not advised.

Stent-graft for Recurrent Melioidosis Mycotic Aortic Aneurysm

Melioidosis is a tropical disease caused by Burkholderia pseudomallei and is prevalent in South East Asia and Northern Australia. It can infect any organ system and is potentially deadly. Melioidosis causing a mycotic aneurysm of the aorta is rare. We present a patient with a melioidosis mycotic aneurysm of the descending aorta presenting with fever and right pleural effusion, managed successfully with initial Dacron graft repair with staged omental reinforcement, and subsequent endovascular stent grafting of a late anastomotic leak.

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.

A real mycotic aneurysm-mycotic aneurysm of the abdominal aorta due to fungal infection

A 53-year-old male who was being followed up by a nephrology department because of type V crescentic glomerulonephritis was admitted with abdominal pain to our clinic. He was diagnosed with abdominal aortic aneurysm after the examinations. Aortic repair with a tubular graft was performed. Pathological examination of the aneurysm tissue showed fungal hyphae. We started antifungal chemotherapy with amphotericin B. A separation of the graft body occurred, and the patient was reoperated on. An excision of the graft, ligation of the aorta, and axillobifemoral graft by-pass was performed. At the 15(th) month of his discharge, the patient was readmitted to the emergency room of our clinic suffering from hematemesis. According to the examinations, an aortoduodenal fistula was diagnosed, and we performed a partial duodenal resection and end-to-end duodenoduodenostomy. We want to share this unusual, interesting, and complicated case, operated on several times because of a mycotic aneurysm due to a fungal infection.

Treatment of Primary Infected Juxtarenal Aortic Aneurysm With the Multilayer Stent

Purpose:

To report the use of multilayer uncovered stent to treat primary infected juxtarenal aortic aneurysm.

Case Report:

A 50-year-old man was admitted to hospital for rapid onset of intractable abdominal pain and high fever. Computed tomographic scan showed 2 juxtarenal saccular aneurysms of abdominal aorta with morphologic and clinical changes compatible with infectious etiology. Patient was treated with multilayer flow-modulating stent. Follow-up imaging showed persistent aneurysm exclusion and continuous aneurysm shrinkage of the sac until complete regression to a normal aortic configuration was seen at 1 year. During follow-up (24 months), patient continued to do well, and there was no recurrence of infection.

Conclusion:

Multilayer stent appeared to be an acceptable treatment option for primary infected juxtarenal aortic aneurysms. Aneurysmal sac completely disappeared and visceral branches remained patent at 2-year follow-up. However, longer follow-up is necessary to evaluate the long-term patency of involved visceral arteries.

Endovascular abdominal aortic stent grafting in unrecognized Salmonella aortitis

Abdominal endovascular graft infection is a rare but life-threatening complication of endovascular repair that can be challenging to manage. This report delineates the progression of a unique set of events leading to Salmonella graft infection and investigates current treatment options.

Management of the infected aortoiliac aneurysms

PURPOSE

We have reviewed ruptured and nonruptured infected aortoiliac aneurysms to study the clinical presentation, management and eventual outcome of patients managed with in situ prostheses, axillofemoral prostheses grafts and endovascular reconstruction.

DESIGN

A retrospective chart review of 16 cases treated at a single institution.

METHODS

From January 2007 to March 2008, a total of 93 patients with aortoiliac aneurysms underwent surgical repair at our institution. Among these, 16 patients (17.2%) were shown to be infected aneurysms of the infrarenal (n = 6), juxtarenal (n = 2), and pararenal aorta (n = 1); the others were 5 common, 1 external, and 1 internal iliac arteries. Fourteen patients were male and 2 were female with the mean age of 66 years (range, 45-79). In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered at least 1 week, unless in patients need emergency operations. At the time of an operation, all were saccular and were classified as primary infected aortoiliac aneurysms. Thirteen patients had surgical debridement with in situ graft interposition and omental wrapping, 2 underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass, 1 underwent aneurysmectomy of left external iliac artery and polytetrafluoroethylene (PTFE) graft interposition, and 1 underwent endovascular exclusion. The parenteral antibiotics were continued in the postoperative period for 4-6 weeks. Chronic renal disease was present in 37.5% (6/16), with diabetes mellitus present in 31.25% (5/16). The most common pathogen was Salmonella sp. (n = 6) and E. coli (n = 5). Thirty-seven percent (6/16) of the patients presented late, with a 37.5% (6/16) incidence of ruptured (4 contained, 2 free ruptured) that needed emergency surgery.

RESULTS

Disease-specific mortality was 31.25% (5/16). The 30-day mortality rate of ruptured cases is high 67% (4/6), because patients present late in the course of the disease. One patient who underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass died 6 months later from burst aortic stump. Salmonella and E. coli are the most common pathogens.

CONCLUSIONS

Early diagnosis followed by surgical intervention with proper antibiotic coverage provides the best results. Mortality rate was still high in patients with sepsis and rupture. An in situ graft interposition and omental wrapping is a safe option for revascularization of infected aneurysms of the iliac arteries and infrarenal aorta.

Primary infected, ruptured abdominal aortic aneurysms: what we learned in 10 years

Primary infected, ruptured aortic aneurysms remain a rare and challenging clinical problem. Surgical treatment includes a range of options such as extra-anatomic bypass grafting and debridement with secutive in situ graft placement with autologous, bovine, and prosthetic grafts. Recently, endovascular treatment for infected abdominal aortic aneurysms has been reported with acceptable short-term survival. However, conclusive evidence based on randomized data with regard to optimal treatment is unavailable. We present 3 patients with a primary infected, ruptured abdominal aortic aneurysm that was treated with in situ graft placement and long-term antibiotic therapy. Our results, combined with a review of the literature, support in situ grafting as the treatment of choice.

A Case Report of Endovascular Stenting in Salmonella Mycotic Aneurysm: A Successful Procedure in an Immunocompromised Patient

Introduction: Mycotic aneurysms are associated with high mortality rates and are managed in the local setting with extra-anatomical bypass followed by ligation, exclusion and debridement of the aneurysm. This is the first case of successful endovascular stenting in an immunocompromised patient with Salmonella mycotic aneurysm. Clinical Picture: A middle-aged man who was HIV positive had Salmonella septicaemia. He developed abdominal pain 5 days after admission and a computed tomography (CT) scan of the abdomen revealed infrarenal aortitis. He developed a mycotic aneurysm 3 weeks later. Treatment: He opted for endovascular stenting and after prolonged antibiotic therapy and negative blood cultures, he underwent the procedure using a TalentTM stent, with an iliac extension. Outcome: He was discharged 1 week after stenting and maintained on oral bactrim based on sensitivity. At 1-year follow-up, he remains well symptomatically and CT scan showed no endoleak or collection. Conclusion: Endovascular stenting, though a fairly new procedure, can be successfully deployed even in a mycotic aneurysm in the right setting. Key words: Aortitis, Aortic aneurysm, Endovascular stenting, Salmonella enteriditis

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.

Infected splenic artery aneurysm with associated splenic abscess formation secondary to bacterial endocarditis: case report and review of the literature

Infected aneurysms are rare and may present with rupture or sepsis. Surgical treatment is often required to prevent catastrophic sequelae. Bacterial endocarditis is one of the classic causes of infected aneurysm. We present a case of a 6.1-cm infected splenic artery aneurysm secondary to endocarditis. Surgical treatment consisted of aortic and mitral valve replacements, splenic artery aneurysm resection, and splenectomy. We reviewed five other reported infected splenic artery aneurysms in which documented ruptured had occurred in three patients. Because the rate of rupture in these patients appears to be quite high, infected splenic artery aneurysms require prompt treatment.

Endovascular stent graft repair for infected thoracic aortic pseudoaneurysms—a durable option?

OBJECTIVE

Open surgical repair for infected thoracic aortic pseudoaneurysms carries significant mortality and morbidity. Endovascular stent graft repair has been our preferred approach, although its role remains controversial because persistent infection is always a concern. We aimed to assess the efficacy and durability of endovascular stent graft repair in these patients.

METHODS

Between August 2000 and November 2005, seven consecutive patients with eight infected pseudoaneurysms of the thoracic aorta were treated with endovascular stent graft repair. Patients were diagnosed based on a typical appearance of an infected pseudoaneurysm on imaging together with a positive bacteriology culture or clinical evidence of sepsis. The follow-up protocol included regular clinical examination, hematologic tests, and computed tomography scans.

RESULTS

There were six men and one woman with a median age of 68 years at operation. Three patients presented with an aortoenteric fistula. The operations were performed in the operating room with the image guidance of a mobile C-arm. Endovascular stent grafts were deployed successfully in all patients, with complete exclusion of the pseudoaneurysms. Intravenous antibiotics were continued for 1 to 6 weeks and followed by lifelong maintenance oral antibiotics. The median hospital stay was 27 days, with no hospital deaths. No paraplegia or other major complications occurred. Two patients with aortoesophageal fistula where the fistula tracts were persistent died during follow-up. The other five patients remained well, with no evidence of graft infection at a median follow-up of 34 months. A significant reduction in the diameter of the pseudoaneurysm (>5 mm) was noted on computed tomography scans after 12 months.

CONCLUSION

Endovascular stent graft repair is effective and may be a durable option for infected pseudoaneurysms of the thoracic aorta.

Endovascular repair of a saccular infrarenal aortic aneurysm in a liver transplant patient

Saccular infrarenal aortic aneurysms are rare lesions that usually require prompt surgical repair. In clinical situations where morbidity and mortality associated with open aortic surgery appear to be prohibitively high, an endovascular approach may serve as a life-saving alternative. We report successful endovascular repair of a symptomatic saccular infrarenal aortic aneurysm in a complicated liver transplant patient.

Endovascular Management of Ruptured, Mycotic Abdominal Aortic Aneurysm

Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.

Infectious Aortitis

Infection of the aorta usually results from septic embolization to the vasa vasorum, hematogenous seeding of an existing aneurysm, or extension from a contiguous site of infection. The diagnosis should be considered in patients, often men over the age of 50 years with atherosclerosis, who present with fever, abdominal pain, palpable abdominal mass, and leukocytosis, with or without positive blood cultures. In the pre-antibiotic area, infectious aortitis was largely a complication of infective endocarditis, and was usually caused by group A streptococci, Streptococcus pneumoniae, or Haemophilus influenzae. Now a diverse array of bacteria and fungi has been associated, most commonly Salmonella species, which comprise nearly one third of the abdominal aortic infections and Staphylococcus aureus. Computed tomography is the most useful imaging modality. Medical treatment alone carries a high mortality, whereas the mortality with surgery combined with antimicrobial treatment is lower. Empiric antibiotics effective against S. aureus and gram-negative rods, such as Salmonella, should be initiated in cases identified before microbiologic diagnosis. Surgical debridement and revascularization should be completed early because delay may lead to aneurysm rupture, which increases mortality. The intent of surgery is to 1) control hemorrhage, if the aneurysm has ruptured; 2) confirm the diagnosis; 3) control sepsis; and 4) reconstruct the arterial vasculature. The patient should remain on parenteral or oral antibiotics for at least 6 weeks, perhaps longer, to assure full eradication of the pathogen and prevent recurrent infection. Close medical follow-up is indicated and includes serial blood cultures and computed tomography scans.

Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta

BACKGROUND

To review the outcome of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta treated in a major teaching hospital.

METHODS

Between December 1994 and January 2003, 13 infected aortic aneurysms and pseudoaneurysms (5 thoracic, 4 paravisceral, 4 infrarenal) in 10 consecutive patients were treated surgically. Aortic debridement with in situ reconstruction is our standard practice. Endovascular repair was offered to suitable patients with thoracic aortic involvement.

RESULTS

There were six men and four women with a mean age of 63 years. The commonest pathogen was Salmonella species, accounting for 50% of the cases. Aortic debridement with in situ revascularization was performed for six patients with visceral reconstruction in four of them. One patient with aortic bifurcation involvement and gross purulent infection had ligation and debridement followed by right axillobifemoral bypass. Four infected thoracic aortic pseudoaneurysms in three other patients underwent endovascular repair. There was no hospital death, limb loss, renal failure, or intestinal ischemia. There were two late deaths from sepsis and pneumonia at 3 months and 77 months after operation. Eight patients were alive after a mean follow-up of 36 months and no late graft infection was evident.

CONCLUSIONS

Surgical treatment for infected aortic aneurysms with in situ reconstruction is associated with favorable outcome and good long-term result. Endovascular repair has a potential role.

Mycotic aneurysm of the abdominal aorta with retroperitoneal abscess: Successful endovascular repair

Mycotic aortic aneurysms are rare. Improved diagnostic procedures, appropriate antibiotic treatment, and safe surgical techniques have reduced the high mortality associated with bacterial aortitis. However, definite evidence-based conclusions with regard to the surgical strategy cannot be drawn from the data available in the published literature. We report successful endovascular repair of a mycotic abdominal aortic aneurysm. Endovascular treatment may offer a benefit, especially in critically ill patients.

The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome

Cardiovascular infections due to Salmonella enterica are infrequently reported, so their clinical features, prognosis, and optimal treatment are not completely known. Mortality associated with aortitis and endocarditis caused by nontyphoidal Salmonella remains exceedingly high. In this review of cases of cardiovascular infections due to Salmonella enterica studied in 2 hospitals in Madrid, we tried to assess the clinical manifestations and the procedures leading to diagnosis in addition to treatment and outcome. To complete the spectrum of infections related to cardiovascular surgery, cases of postoperative mediastinitis, pericarditis, and infections associated with cardiac devices were also included.Twenty-three patients were reviewed: 11 had mycotic aneurysms; 7 had endocarditis; 2 had device-related infections; and 3 had pericarditis, mediastinitis, and infection of an arteriovenous fistula, respectively. The risk of endovascular infection in patients older than 60 years with bacteremia due to nontyphoidal Salmonella was 23%. Most patients with aortitis had risk factors for atherosclerosis, and 6 had preexisting atherosclerotic aortic aneurysms. All except 1 patient with endocarditis had underlying cardiac disorders. Acquired immunodeficiency disease (AIDS) was a major risk factor for salmonella bacteremia in 1 patient with aortitis and 1 with endocarditis. Fever, unremitting sepsis, "breakthrough" and relapsing bacteremia were the most common clinical findings. In addition, abdominal or thoracic pain and cardiac failure and pericarditis were common features in patients with aortitis and endocarditis respectively. Computed tomography (CT) scan, arteriography, and echocardiography were the main diagnostic tools. Mortality associated with mycotic aneurysms and endocarditis due to S. enterica was 45% and 28%, respectively. Thoracic aneurysms, rupture, and shock at the time of diagnosis were associated with increased mortality in patients with aortitis. In situ bypass grafting was successfully performed in most cases. After surgery, antimicrobial therapy was continued for 4-9 weeks. No relapses were observed after a mean follow-up of 64 months. Antimicrobial therapy alone or combined with valve replacement or excision of a ventricular aneurysm was successful treatment for most patients with salmonella endocarditis. Combined medical and surgical treatment was required for patients with mediastinitis and pericarditis, and patients with device-related infections needed removal of the complete device. Diagnosis of aortitis due to nontyphoidal Salmonella should be established as early as possible to reduce mortality. Patients older than 60 years who have positive blood cultures for Salmonella along with fever and back, abdominal, or chest pain should have an extensive workup for infective aortitis. Immediate bactericidal antimicrobial therapy should be started and a CT scan should be performed on an emergency basis. If a mycotic aneurysm is found, surgical resection should follow as soon as possible. Resection of the aneurysm with in situ bypass grafting is the procedure of choice. Postoperative antimicrobial therapy for 6-8 weeks seems enough to avoid relapses. Optimal treatment of patients with endocarditis occurring on ventricular aneurysms must include resection of the aneurysmal sac. Salmonella endocarditis can be successfully treated with antimicrobials alone. Valve replacement should be reserved for patients with cardiac failure or persisting sepsis, and for those who relapse after discontinuation of antimicrobial therapy.

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.