Successful endoluminal repair of an infected thoracic pseudoaneurysm caused by methicillin-resistant Staphylococcus aureus

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.

А Rare Case of an Infected, Ruptured Popliteal Artery Aneurysm Occurring Following Surgical Treatment for Panaritium

We present a successful case of treating an infected popliteal aneurysm in a 71-year-old man who arrived at the emergency department in a septic state, reporting a three-week history of fever, lethargy, general malaise, and pain and swelling in the right popliteal fossa. Previously diagnosed with a sizable right popliteal aneurysm, the patient had undergone endovascular treatment using a Viabahn (WL Gore & Associates, Flagstaff, USA) endoprosthesis two months earlier. His fever and malaise emerged a week following minor surgery for a toe infection (panaritium) on the right foot, leading to subsequent necrotic lymphangitis on the dorsum of the same foot. A PET/CT scan strongly indicated an infection within the aneurysmal sac, while a CT angiography confirmed the integrity of the stent graft without any leaks but revealed a ruptured aneurysm. Urgent surgical intervention was necessary. An extra-anatomical autovenous bypass was conducted, followed by an aneurysm and endograft removal. Subsequently, a vacuum-assisted closure (VAC) system was employed to manage the infected wound post sac extraction. The surgical procedure went smoothly without complications, and following a course of antibiotics, the patient recovered well, eventually being discharged after 50 days.

Endovascular treatment for mycotic aneurysm using pyoktanin- applied devices

Background

Mycotic thoracic aortic aneurysm is an extremely rare but serious disease because it can easily rupture and has a high mortality rate. The standard therapy for it comprises graft replacement and debridement using systemic antibiotics; nonetheless, this has a high mortality rate and complications. Endovascular aortic repair is considered a bridging therapy before open surgery. However, we have used it at our institution for the radical treatment of mycotic thoracic aortic aneurysm utilizing pyoktanin (methylrosanilide chloride)-applied devices. Thus, the aim of this study was to report our clinical experience with pyoktanin-applied thoracic endovascular aortic repair for the treatment of mycotic thoracic aortic aneurysm, including its effects.

Methods

From April 2017 to July 2019, we performed thoracic endovascular aortic repair using pyoktanin for eight cases of mycotic thoracic aortic aneurysm using Valiant®. During device preparation before insertion, pyoktanin was flushed from the side port instead of saline containing heparin.

Results

There were no operative deaths, recurrences of infection, or major complications. Two cases died from pneumonia and cancer; the other six cases were alive during the follow-up period.

Conclusions

Pyoktanin-applied thoracic endovascular aortic repair for mycotic thoracic aortic aneurysm treatment is effective. However, the appropriate use of antibiotics and bundled therapy is necessary at present.

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 Stent Exclusion of a Hepatic Artery Pseudoaneurysm

Presented is a patient with an iatrogenic hepatic artery pseudoaneurysm that was treated by endovascular stent grafting. Endovascular stent grafting of a hepatic artery pseudoaneurysm offers a safe and potentially less morbid alternative to an open repair. The report stresses the necessity of careful preoperative evaluation with angiography to determine the feasibility of the procedure. An aggressive approach to treating hepatic artery pseudoaneurysms is advocated because of the poor correlation between size and their tendency to rupture. With an increasing rate of diagnosis of visceral artery aneurysms in elderly, debilitated patients, endovascular repair is anticipated to have an increasing role and should be considered a first-line therapy in anatomically suitable candidates.

Endovascular management of ruptured infected popliteal artery aneurysm

Infected popliteal aneurysm is a rare high-risk condition that can present as an emergency with acute rupture and sepsis. Management of acute ischemia in the presence of local and systemic sepsis is challenging. Open surgery is not always possible and carries a high risk of morbidity and death. An endovascular approach has been advocated in infected aneurysms elsewhere in the body, with good short-term and medium-term outcomes encouraging such approach in the popliteal artery. We report a case of successful endovascular treatment of an infected ruptured popliteal aneurysm with favorable outcome after 2-year follow-up and a related review of the literature.

Gram-negative groin sepsis treated with covered stents and systemic antibiotics

Prosthetic graft infections are hazardous conditions. Those due to Gram-negative bacteria are particularly serious. When Gram-negative microorganisms are present, entire graft excision is recommended, with revascularization if needed, preferably with autogenous tissues or with prosthetic grafts via non-infected planes if autogenous options are not available. We herein report the case of a diabetic man with critical limb ischemia, who after lower-extremity revascularization with a prosthetic graft, developed an early graft infection due to Gram-negative and fungal organisms, and who was successfully treated with a covered stent placed across grossly infected tissues. A discussion on the pertinent literature is also offered.

Endovascular treatment of an aortobronchial fistula caused by a distal aortic arch mycotic aneurysm: report of a case

We report a case of an aortobronchial fistula causing massive hemoptysis, which was managed by emergency stent grafting. Although this procedure was successful initially, the aortobronchial fistula appeared again 7 months later. Aneurysmectomy, followed by rifampicin-soaked gelatin sealed polyester graft replacement and omentopexy, was performed under cardiopulmonary bypass. The patient, a 73-year-old woman, had an uneventful postoperative course and the infection was eradicated.

Mycotic aneurysm of the femoral artery complicating Staphylococcus aureus bacteremia: a case report

Introduction

Staphylococcus aureus is the major cause of bacteremia, with the potential for some complications, namely mycotic aneurysms, defined as irreversible dilatation of an artery due to destruction of the vessel wall by infection.

Case presentation

The authors present the case of a 52 year-old-Caucasian male, admitted with Staphylococcus aureus bacteremia and mycotic aneurysm of the right superficial femoral artery, associated with advanced atherosclerotic process.

Conclusion

Mycotic aneurysms are rare, and a high index of suspicion is needed, because appropriate treatment will certainly affect the outcome, as they are associated with high morbidity and mortality.

Endovascular repair of mycotic aneurysms of the aorta: An alternative to conventional bypass surgery in patients with acute sepsis

Treatment of mycotic aneurysms of the aorta includes excision of infected tissue followed by anatomic or extra-anatomic bypass. However, operative mortality remains high particularly in elderly patients with comorbidities. We describe here 2 patients with mycotic aneurysms of the descending aorta in whom endovascular repair was successfully performed. In 1 of these patients, stent grafting was attained during the acute, bacteraemic phase of infection. After 12 and 20 months, respectively, of diagnosis, both patients are doing well.

Endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm in an intravenous drug abuser

An interesting case of an intravenous drug abuser who had endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm, resulting from recurrent puncture of the femoral artery is reported in this study.

Endovascular repair of a ruptured mycotic aneurysm of the common iliac artery

This report describes the case of a ruptured mycotic aneurysm of the left common iliac artery, successfully treated with endovascular stent-grafting. A 64-year-old woman underwent diagnostic coronary angiography complicated by an infected hematoma of the left groin. Seven days later, she developed methicillin-resistant Staphylococcus aureus septicemia and CT scan evidence of perivascular inflammation around the left common iliac artery. This was followed by rupture of a mycotic aneurysm of the left common iliac artery. The lesion was successfully treated with a stent-graft and prolonged antibiotic therapy, and the patient remains free of infection 10 months later. Accumulating evidence suggests that endovascular repair can be used safely for the repair of ruptured infected aneurysms.

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.

Combined endovascular and open treatment for infected pseudoaneurysm of the thoracic aortic arch

Infected pseudoaneurysm of the aortic arch is a rare but life-threatening condition. The conventional treatment involves cardiopulmonary bypass, prolonged vascular clamping, and an extensive bypass procedure. We report a case of infected pseudoaneurysm involving the aortic arch. The patient underwent debranching of the supra-aortic arteries and bypass surgery, followed by stent grafting the next day. The patient had good recovery, and the 1-year follow-up computed tomography scan showed resolution of the infected pseudoaneurysm.

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 management of hepatic artery pseudoaneurysm hemorrhage complicating pancreaticoduodenectomy

Gastrointestinal bleeding is a morbid complication of pancreaticoduodenectomy. Determining its etiology is often a daunting challenge in that both common and unusual mechanisms may be operative. Visceral artery pseudoaneurysms, although rare, must be considered in that minimally invasive means are available for effective therapy. Our recent experience with two cases highlights the importance for both general and vascular surgeons to be aware of the diagnostic and therapeutic role for early angiography and deployment of endovascular techniques to achieve a successful outcome.

Mycotic Common Iliac Artery Aneurysm Complicating Methicillin-Resistant Staphylococcus aureus Bacteremia: An Unusual Cause of Ureteric Obstruction

A 60-year-old man presented with ureteric obstruction secondary to a mycotic right common iliac artery aneurysm complicating methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The diagnosis of MRSA was not known at the time of surgery, and in situ replacement of the aneurysm using a rifampicin-bonded prosthesis was performed. The patient made a full recovery, and to date there is no evidence of residual or recurrent infection. To our knowledge, this is the first reported case of mycotic iliac aneurysm infected with MRSA in the literature. We discuss the consequences and the considerable diagnostic and therapeutic problems that arise.

MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.

Endovascular Repair of the Thoracic Aorta: Lessons Learned

BACKGROUND

Available information on outcome and best strategies for thoracic endovascular repair is somewhat limited and unclear. We sought to gain a better understanding of these issues through a retrospective review of our 8-year clinical experience in the treatment of thoracic aortic aneurysms and dissections.

METHODS

A retrospective chart review of 186 patients undergoing stent-graft repair of thoracic aortic lesions at our institution during the 92-month period ending on December 31, 2004 was performed. Patients were divided into two groups based on the indication for treatment; group A had thoracic aortic aneurysms (TAA) and group B had type B aortic dissections (TBAD). Both groups were analyzed for outcome variables including technical success, mortality, major morbidity, endoleak rate and type, secondary endovascular interventions, and long-term survival. Mean follow-up was 40 months (range, 1 to 92 months).

RESULTS

Compared to group B, group A patients were older and had a higher incidence of peripheral vascular disease and chronic obstructive pulmonary disease. Sixty percent of all patients were American Society of Anesthesiologists class III and the remainder were class IV (38.3%) and V (1.7%). The procedure was completed in 180 patients (96.7%), with all 6 failures being access-related. The average procedure time was 149 minutes (range, 72 to 405). The 30-day mortality was 4.7% (9 patients), and serious morbidity was 19.9% (37 patients). Eight patients (4.3%) developed spinal cord ischemia, 4 immediately after the procedure and 4 delayed (1 to 3 days). Total hospital length of stay averaged 6.7 days. Secondary endovascular interventions were successful in 17 patients with angiographically confirmed endoleaks (type I and III). At an average follow-up of 40 months, freedom from all-cause mortality was 62.5% in group A and 58.1% in group B.

CONCLUSIONS

Stent-graft repair for TAA and TBAD can be achieved with high technical success and comparatively low rates of morbidity and mortality. Midterm survival appears to be favorable. Further refinements in device technology and procedural techniques are needed.

Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm

A 72-year-old man was admitted because of progressive right upper-abdominal distension and pain as well as concurrent remittent fever for 5 months. He had undergone a radical gastrectomy and catheter intubation in the common hepatic artery for chemotherapy 12 months before admission. The diagnosis of giant infected hepatic-celiac artery pseudoaneurysm was established. Coils embolotherapy was given in another hospital, but it failed. After admission, a computed tomographic aortogram showed a mass 10.3 x 8.5 x 8.1 cm in size in the right upper abdomen that originated from the common hepatic artery and the celiac artery. A celiac-super mesenteric artery (SMA) double catheter simultaneous digital subtraction angiography (DSA) further revealed that the entrance of the aneurysm opened directly from the abdominal aorta, the distance between the orifice of SMA and celiac axis was only 0.5 cm, and the diameter of the celiac trunk had been aneurysmally enlarged to 2.0 cm. A blood culture was positive for Bacillus pyocyaneus. After detailed discussion and preparation, a stent-graft complex was negotiated through the left femoral artery and deployed successfully into the abdominal aorta to seal the orifice of celiac trunk under the dynamic supervision of DSA. Completion angiography revealed that the hepatic-celiac pseudoaneurysm was completely excluded from aortic flow by the endoluminal stent-graft complex, while the SMA and renal arteries remained perfectly patent. The patient recovered uneventfully and was discharged without any residual symptoms. At a 5-year follow-up, the patient remained asymptomatic and was leading a normal life.

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.