Stent-graft repair of a mycotic left subclavian artery pseudoaneurysm

Open repair of a proximal left subclavian artery mycotic aneurysm with median claviculectomy

Surgical repair of a subclavian artery mycotic aneurysm is dependent on aneurysm-specific characteristics and anatomic exposures could require sternotomy, thoracotomy, or supraclavicular incisions. Alternatively, a median claviculectomy can be used. We successfully performed a subclavian artery to axillary artery bypass with median claviculectomy in a 23-year-old man with multiple comorbidities. Postoperative Doppler ultrasound showed a patent left axillary artery with a palpable left radial artery, and the patient demonstrated full left shoulder range of motion without any significant deformities. This case suggests that a median claviculectomy can produce satisfactory outcomes in patients with subclavian artery mycotic aneurysms.

Infected femoral pseudoaneurysms in intravenous drug abusers: a decade of experience from a Singapore tertiary centre

INTRODUCTION

A pseudoaneurysm (or false aneurysm) is a haematoma that communicates with an artery through a disruption in the arterial wall. The femoral artery is the most common injection site among drug users, and infected femoral pseudoaneurysms are the most common vascular complications.

METHODS

A retrospective review of medical records of intravenous drug abusers (IVDAs) who presented with infected femoral pseudoaneurysms from January 2006 to December 2016 was carried out. Patients who had pseudoaneurysms due to other aetiologies or trauma were excluded.

RESULTS

A total of 27 patients with infected femoral pseudoaneurysms were identified. The majority were male (92.6%) and of Malay ethnicity (55.6%). Median age was 50 (range 31-62) years. Commonly abused drugs were buprenorphine (or Subutex; 59.3%) and midazolam (or Dormicum; 51.9%). Groin pain and swelling (100.0%), fever (66.7%) and presence of a pulsatile mass (51.9%) were the most common presenting symptoms. Diagnosis was confirmed via computed tomography angiography in all patients. 25 patients underwent upfront arterial ligation with debridement, among whom three patients required concurrent surgical revascularisation. Only two patients underwent ultrasonography-guided thrombin injection - one eventually required surgery and the other was lost to follow-up. Postoperative complications included wound infection (42.3%), bleeding (11.5%) and necrotising fasciitis eventually resulting in limb loss (3.8%). There were no associated mortalities.

CONCLUSION

Infected pseudoaneurysms in IVDAs pose a unique challenge to vascular surgeons. We found that simple ligation and debridement was a safe and effective option for such patients.

Stent graft exclusion of a mycotic profunda femoris artery pseudoaneurysm with 2-year follow-up

Mycotic pseudoaneurysms develop at sites of intimal disruption where bacterial invasion occurs. The conventional treatment involves arterial ligation, excision and debridement, followed by a bypass procedure at a later point. Recently, covered stent grafts have been used to treat mycotic arterial aneurysms either as temporary or definitive procedures. However, this is associated with a risk of stent graft infection, recurrence and rupture. There is a paucity of long-term results on the durability of such endovascular stent graft procedures in mycotic arterial pseudoaneurysms. We describe a successful endovascular covered stent repair of a mycotic profunda femoris artery pseudoaneurysm and follow-up of this repair at 2 years.

Endovascular treatment of multiple tuberculous mycotic aneurysm: A case report

RATIONALE

We present a rare case of multiple tuberculous mycotic aneurysm. Multiple aneurysms caused by tuberculosis (TB) are difficult to treat. Here, we discuss a treatment modality using a microcore stent graft.

PATIENT CONCERNS

A 73-year-old man with pain in the back and on the right side of the chest associated with dry cough, presented with an inability to walk since 1-month.

DIAGNOSES

A diagnosis of multiple aneurysms caused by TB was made, based on computed tomography (CT) scan and positive T-spot and Xpert tests.

INTERVENTIONS

We administered the empirical anti-TB regimen (pyrazinamide, isoniazid, rifampicin, and ethambutol) and performed endovascular repair using microcore stent graft.

OUTCOMES

The post-operative hemodynamic analysis indicated that the patient's aneurysms no longer had a risk of rupture, and blood flow in the major branches of the aorta had been maintained. However, the patient could not survive due to a pulmonary infection acquired during recuperation at a local hospital.

LESSONS

For multiple tuberculous mycotic aneurysms, anti-TB therapy is inadequate and the microcore stent graft is a feasible option that can improve the hemodynamics in the aneurysms.

Emergency Endovascular Management of a Symptomatic Pseudoaneurysm of the Left Subclavian Artery Ostium Using a Combination of an Abdominal Aortic Stent-Graft Extension Cuff and a Periscope Stent Graft

A pseudoaneurysm located at the subclavian artery ostium is an infrequent but life-threatening pathology that usually requires major thoracic surgery with a high risk of mortality and morbidity. Endovascular therapy applied to the aortic arch branches is a recent alternative technique, which is still in its early stages because dedicated endovascular devices for the aortic arch are lacking. In this article, we present the emergency endovascular management of a symptomatic pseudoaneurysm of the left subclavian artery ostium which was presumably secondary to an atherosclerotic plaque rupture. Endovascular exclusion required a combination of an abdominal aortic stent-graft extension cuff, which was placed via a retroperitoneal iliac access, and a subclavian artery periscope stent graft.

Endovascular Repair of Three Concurrent Mycotic Pseudoaneurysms

INTRODUCTION

Mycotic pseudoaneurysm has traditionally been repaired surgically with excision of the infected artery and revascularization via extra-anatomical or in situ bypass. There have been reports of endovascular repair for high-risk patients for formal surgical repair. We present a case of a patient with 3 large pseudoaneurysms arising from the right subclavian artery, descending thoracic aorta, and right popliteal artery treated with endovascular and hybrid intervention.

CASE

A 74-year-old male with remote history of coronary artery bypass graft and recent sternoclavicular joint abscess developed 3 concurrent pseudoaneurysms arising from the right subclavian artery, distal descending thoracic aorta, and right popliteal artery. He underwent right axillary to common carotid bypass with endovascular stent graft placement in the distal innominate and proximal subclavian artery, and subsequently had thoracic endovascular aortic repair and right popliteal stent graft. Four months later, he presented with hemoptysis due to compression of the lung secondary to the pseudoaneurysm. He underwent right anterior thoracotomy and debridement of the pseudoaneurysm. Patient recovered from the procedure and discharged.

CONCLUSION

Endovascular repair of mycotic pseudoaneurysm is an acceptable alternative for high-risk patients. Even when open approach became necessarily, endovascular stent graft decreased blood loss and morbidity.

Management options in the treatment of femoral pseudoaneurysms secondary to intravenous drug abuse: A case series

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Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to their optimum management.

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Excision and ligation of the femoral artery without revascularisation is the most common operative intervention.

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With the identification and optimisation of suitable patients, revascularisation can be performed in the emergency setting.

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Current endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure.

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Ligation of the common femoral artery without revascularisation is both safe and effective as most patients will avoid critical ischaemia.

Introduction

Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to the optimum management of these patients. Whilst emergency revascularisation options are available, excision and ligation of the femoral artery remains the most common operative intervention but risks leaving the patient with critical ischaemia or intermittent claudication. This case series reviewed the outcomes of 4 patients who underwent excision-ligation without revascularisation of an infected femoral pseudoaneurysm at a district general hospital.

Presentation

Four patients (2 male, 2 female) with infected femoral pseudoaneurysms presented via the emergency room with diagnosis confirmed with contrast cross-sectional imaging. All patients underwent emergency excision and ligation of the pseudoaneurysm without revascularisation. One patient returned to theatre with critical ischaemia necessitating a hindquarter amputation. The remaining 3 patients were discharged without claudication symptoms.

Conclusion

With the identification of suitable patients and pre-operative optimisation, revascularisation can be performed in the emergency setting with an extra-anatomical bypass appearing to confer the best results. Currently endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure, however, there are several case reports documenting successful outcomes when using a stent graft alongside a prolonged course of antibiotics. For the majority of patients, excision-ligation without revascularisation is both safe and effective as few are left with symptoms of limb ischaemia.

Endoprosthetic Treatment of a Mycotic Superficial Femoral Artery Aneurysm

Purpose:

To describe the successful stent-graft exclusion of a mycotic aneurysm of the superficial femoral artery.

Case Report:

A 78-year-old man presented with Salmonella arteritis and the formation of a mycotic false aneurysm of the superficial femoral artery. Antibiotics were administered; the aneurysm was excluded using 2 Hemobahn stent-grafts, and the surrounding hematoma was drained. One year postoperatively, there are no clinical or biochemical signs of infection. Ultrasound examination does not show any fluid around the patent stent-graft.

Conclusions:

Stent-graft placement might be an alternative to traditional surgery in selected cases of mycotic aneurysm.

Emergent rescue operation for expanding mycotic pseudoaneurysm causing hemoptysis, originating from right subclavian artery

Mycotic pseudoaneurysm of the subclavian artery is uncommon and its therapeutic strategy has not been established. We report a case of 81-year-old woman with mycotic pseudoaneurysm in the right subclavian artery. Blood culture showed Enterobacter cloacae. Because of hemoptysis and acute expansion of the pseudoaneurysm, emergent coil embolization was performed, but failed. The patient underwent urgent operation for an en-bloc resection of the pseudoaneurysm after aorto-right common carotid artery bypass followed by omentum packing. The patient underwent continuous wound irrigation for 3 weeks. The postoperative course was uneventful and without recurrence of infection.

Subclavian aneurysm presenting with massive hemoptysis: a case report and review of the literature

We present a case of a 70-year-old male with a past medical history of coronary artery bypass grafting and end stage renal disease who presented with massive hemoptysis. He had a history of methicillin-resistant Staphylococcus aureus endocarditis, with infection and removal of endocardial pacing leads. His work-up revealed a 2.9-cm proximal left subclavian artery aneurysm. Bronchoscopy confirmed bright red blood in the left upper lobe bronchus and coronary angiography confirmed a patent left internal mammary artery (LIMA) to left anterior descending bypass. Because of the consideration of maintaining coronary perfusion via the LIMA while excluding the subclavian aneurysm, he underwent a left carotid to left axillary artery bypass graft followed by deployment of an Amplatzer II vascular plug just distal to the aneurysm. A thoracic endograft was then deployed to exclude the origin of the subclavian. A review of the literature reveals hemoptysis as a rare presentation of a subclavian aneurysm. We discuss approaches to this challenging clinical problem, ranging from open repair to hybrid approaches.

Coil occlusion of a subclavian mycotic aneurysm

We report the first successful application of nonferromagnetic embolization coils for endovascular exclusion of a mycotic right subclavian artery aneurysm. A 58-year-old woman presented with acute cervical pain and a pulsatile mass in the right supraclavicular fossa under antibiotic medication for subacute infectious endocarditis. Diagnostic work-up including duplex sonography, digital subtraction angiography, and magnetic resonance imaging demonstrated a saccular aneurysm of the extrathoracic right subclavian artery. As an alternative to open surgery or stent-graft repair, this pathology was electively treated by transcatheter coil embolization. No neurological deficit or ischemic symptoms were noted during 9 months clinical follow-up. Multislice computed tomography scan revealed complete occlusion of the mycotic aneurysm 6 months after the interventional procedure. Transcatheter closure with Inconel embolization coils is a cost-effective and safe therapeutic option in patients with mycotic aneurysm originating from the subclavian artery.

Covered stent application of a repeatedly regrowing iatrogenic subclavian artery pseudoaneurysm at the origin of the vertebral artery

SUMMARY

Formation of an iatrogenic subclavian artery pseudoaneurysm while attempting central venous access through the internal jugular vein is relatively uncommon. However, management of a subclavian artery pseudoaneurysm remains a challenge because of its growing tendency and its relation to the origin of the vertebral artery (VA). We report a strategy for using a covered stent as for the endovascular treatment of a patient with a repeatedly regrowing subclavian artery pseudoaneurysm at the origin of the VA.

Combined surgery for the treatment of bilateral subclavian artery aneurysm in Marfan syndrome

Large bilateral aneurysm of the subclavian artery is an infrequent entity that can progress to thrombosis, embolization, or rupture if left untreated. Treatment consists of exclusion of the aneurysm by an endovascular procedure or open surgery. We present a case of large bilateral subclavian artery aneurysm in a patient with Marfan syndrome that was treated by a combination of endovascular and conventional surgery. This therapeutic approach provided good results for patency with lower morbidity and mortality.

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.