Acute Conditions Caused by Infectious Aortitis

Urgent or Emergent Endovascular Aortic Repair of Infective Aortitis

Background: Aortitis is a rare inflammation of the aorta. It can be classified as infective, non-infective, or idiopathic. Infective aortitis can debut as an acute aortic syndrome that needs urgent or emergent treatment. Historically, these kinds of patients have been preferably treated by open surgery, with subsequent lack of information about the endovascular repair. The aim of the present study is to report the results of our experience with the urgent or emergent endovascular repair of infective aortitis with acute presentation. Methods: All consecutive urgent or emergent endovascular repairs, performed between January 2019 and January 2024 for the treatment of infective aortitis, were included. The inclusion criteria were clinical, laboratory, and radiological findings recognized as aortitis risk factors. Patients with graft or endograft infection, aortic fistulae, and mycotic aneurysm were excluded. Primary endpoints were technical success and 30-day and follow-up survival. Early and late major adverse events, any changes in lesion morphology over time, and need for re-intervention were also assessed. Results: A total of 15 patients (14 males and 1 female) with a mean age of 74.2 ± 8.3 were included. All the subjects were treated by endovascular means in an urgent or emergent setting because of a rapidly growing aneurysm, symptomatic lesion, or contained or free aortic rupture. The diagnosis of infective aortitis was confirmed postoperatively by positive blood cultures in all the patients. A rapidly growing or symptomatic lesion was noted in all 15 subjects. Among these there were six (40%) contained and two (13%) free aneurysm ruptures. The endovascular techniques performed were as follows: four thoracic-EVAR (TEVAR), three off-the-shelf branched-EVAR (BEVAR), one Chimney-EVAR (Ch-EVAR), six EVAR with bifurcated graft, and one EVAR with straight tube graft. Technical success was achieved in 100% of the patients. Two patients (13%) died within 30 days after the index procedure. No case of early aortic-related mortality was registered. During a mean follow-up of 31.6 ± 23.1 months (range 1-71), no further death or major adverse event was registered among the remaining 13 alive patients. Re-interventions were performed in three cases (20%). Aneurysm's shrinkage > 5 mm or stability was noted in 10 of the 13 patients who survived the early period after repair. Conclusions: Despite the relative reluctance to use an endograft in an infected area, in our experience the endovascular approach resulted to be feasible, safe, and effective in the treatment of infective aortitis with acute presentation, with acceptable peri-operative and mid-term follow-up outcomes. Further studies are needed to confirm our results.

Delayed right external iliac artery disruption after radical cystectomy: A case report and literature review

A 60-year-old male patient underwent laparoscopic radical cystectomy with bilateral pelvic lymph node dissection and urinary diversion as a treatment for muscle-invasive bladder cancer and was discharged two weeks later. One month later, the patient was readmitted with septic and haemorrhagic shock, and was diagnosed with right external iliac artery disruption. The patient underwent an exploratory operation and a vessel split of the right external iliac artery was found. The artery split was covered by a vascular stent. Klebsiella pneumoniae subsp. Pneumoniae was isolated in blood culture and the patient then received adequate antibiotics based on the drug sensitivity test. The patient eventually had a good recovery and was discharged five weeks later. In summary, although iliac artery injury after successful pelvic surgery is a rare event, this life-threatening complication should be taken into full consideration, particularly in patients with high-risk factors such as diabetes mellitus.

Successful surgical treatment of Stanford type A aortic dissection due to Salmonella aortitis

BACKGROUND

Salmonella spp. cause infectious aortitis through the hematogenous spread of an intestinal Salmonella infection. Salmonella aortitis can result in extensive tissue damage in the aorta leading to complications including dissection, abscess formation, pseudoaneurysms, and rupture, which require early diagnosis and treatment with both surgery and antibiotic therapy.

CASE PRESENTATION

We report a case of Salmonella aortitis complicated by Stanford type A aortic dissection. A 62-year-old man with a history of heroin use presented with chest pain, epigastric pain and vomiting. The computed tomography scan showed Stanford type A aortic dissection without malperfusion. At the time of surgery, an aortic dissection with purulent fluid and contained rupture was noted in the ascending aorta. Fluid culture was consistent with Salmonella. A composite valve-graft conduit aortic root replacement with ascending aorta and hemiarch replacement was performed. The patient recovered well and was discharged on long-term antibiotics.

CONCLUSIONS

This rare case of a Stanford type A aortic dissection with contained rupture due to Salmonella aortitis was successfully treated with emergent surgery and antibiotic therapy.

[INFECTIOUS AORTITIS-RELATED MORTALITY AFTER ILEAL NEOBLADDER SUBSTITUTION IN A PATIENT WITH DIABETES MELLITUS]

A 78-year-old man, who underwent total cystectomy with ileal neobladder substitution for bladder cancer 5 years ago, had a fever since the beginning of May 2022. He was hospitalized in an internal medicine ward of another hospital and was diagnosed with febrile urinary tract infection (UTI). Escherichia coli with sensitivity to almost all antibiotics was cultured in urine. Computed tomography (CT) showed that the distended neobladder with bilateral hydronephrosis contained gas and the severely athelosclerotic aorta. Even after using four antibiotics, the UTI could not be controlled. After 3 weeks of hospitalization, CT showed periaortic lymphatic swelling. Therefore, he was transferred to our hospital on 6 June due to uncontrollable UTI and lymphatic metastasis of bladder cancer. However, CT revealed that the neobladder remained distended and showed thickening of the periaortic soft tissue with gas. He was diagnosed with advanced infectious aortitis. Furthermore, he had poorly controlled diabetes mellitus of HbA1c 8.4%. Immediately after admission, an exchange of the urethral catheter and antibiotics, and blood sugar control strengthening were performed. On the second day, the patient was close to defervescence. However, on the third day, abrupt onset of loss of consciousness and abdominal swelling occurred. CT showed retroperitoneal hematoma caused by the rupture of the aorta. Then, bradycardia and respiratory arrest occurred, ventilator management and blood transfusion were performed, and the patient survived. However, his condition worsened, and he died 2 days later. The patient had undergone ileal neobladder substitution, but had infectious aortitis and died of an aortic rupture due to distended neobladder-induced UTI, poorly controlled diabetes mellitus and the severely athelosclerotic aorta.

Contemporary management of infective native aortic aneurysms

PURPOSE OF REVIEW

Infective native aortic aneurysms (INAAs) are challenging and complex with both bacteraemia and an aneurysm prone to rupture. They are fatal unless recognized and treated promptly. The rarity of the disease makes it unfamiliar to most physicians, which might delay both diagnosis and treatment.The present review aims to outline the recently published diagnostic algorithm of INAAs, the main characteristics of the disease and present an overview of contemporary treatment strategies.

RECENT FINDINGS

New terminology, definition, diagnostic algorithm and reporting standards have recently been proposed for INAAs. Current evidence concerning the treatment of INAAs is founded on retrospective register-based multicentre studies and small single-centre studies. Recent findings encourage the use of endovascular aortic repair (EVAR) for surgical treatment of INAAs. Although EVAR, as a surgical approach, does not drain the infection, the postoperative infection-related complication rates (IRCs) are similar to the ones reported after open surgical repair (OSR) with aortic prosthetic reconstruction and extensive debridement. IRCs carry over 50% risk of being fatal. Postoperative mortality after EVAR remains considerably lower supporting the use of method for aged and comorbid group of patients. Biological grafts have the benefit of being more resistant to reinfection. OSR with biological reconstruction is a promising surgical approach for patients fit for open surgery; however, data are scarce and long-term follow-up is lacking.

SUMMARY

The treatment of INAAs should be guided by experienced multidisciplinary team and tailored individually based on patients' condition and centres' experience. An international consensus document is warranted to enable further research on this disease.

Pentadecanoic acid against Candida albicans-Klebsiella pneumoniae biofilm: towards the development of an anti-biofilm coating to prevent polymicrobial infections

The ability to form biofilms is a common feature of microorganisms, which can colonize a variety of surfaces, such as host tissues and medical devices, resulting in infections highly resistant to conventional drugs. This aspect is particularly critical in polymicrobial biofilms involving both fungi and bacteria, therefore, to eradicate such severe infections, new and effective anti-biofilm strategies are needed. The efficacy of pentadecanal and pentadecanoic acid as anti-biofilm agents has been recently reported against different bacterial strains. Their chemical similarity with diffusible signal factors (DSFs), plus the already known ability of fatty acids to act as anti-biofilm agents, suggested to explore their use against Candida albicans and Klebsiella pneumoniae mixed biofilm. In this work, we demonstrated the ability of both molecules to prevent the formation and destabilize the structure of the dual-species biofilm. Moreover, the pentadecanoic acid anti-biofilm coating, previously developed through the adsorption of the fatty acid on polydimethylsiloxane (PDMS), was proved to prevent the polymicrobial biofilm formation in dynamic conditions by confocal laser scanning microscopy analysis. Finally, the evaluation of the expression levels of some biofilm-related genes of C. albicans and K. pneumoniae treated with pentadecanoic acid provided some insights into the molecular mechanisms underpinning its anti-biofilm effect.

Recurrent infection is more common after endovascular versus open repair of infected abdominal aortic aneurysm: Systematic review and meta-analysis

OBJECTIVE

Controversy has continued regarding the use of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) for infected abdominal aortic aneurysms (AAAs). In the present study, we investigated the comparative outcomes of EVAR and OAR for the treatment of infected AAAs.

METHODS

We conducted a systematic review and meta-analysis using the MEDLINE and EMBASE databases through May 2021. We included studies that had described both EVAR and OAR for the treatment of infected AAAs. The primary endpoints were the rates of recurrent infection and related rupture and/or death. Perioperative and 1-year mortality and readmissions and reinterventions were also analyzed.

RESULTS

Fourteen observational studies describing a total of 1203 patients (EVAR, 359 [29.8%]; OAR, 844 [70.2%]) were eligible for qualitative analysis. The baseline characteristics included diabetes mellitus (33.2%), fever at presentation (71.6%), rupture at diagnosis (26.1%), and positive blood cultures (52.5%). The mean follow-up period ranged from 12 to 40 months. The use of EVAR became more prevalent in recent years (2016-2020, 32.4%) compared with the former period (2010-2015, 13.8%; P < .0001). Fenestrated, branched, or concomitant visceral debranching EVAR was performed in 6.1% of cases. In OAR, surgical debridement was consistently performed, and in situ reconstruction was applied in 82.2% and an omental flap in 51.5%. In nine studies considered for quantitative analysis, the patients' background (EVAR, n = 264; OAR, n = 274) were statistically balanced. The crude rates of recurrent infection and related rupture or death were 13.6% (95% confidence interval [CI], 8.8%-18.5%) and 4.9% (95% CI 1.8%-8.0%), respectively. The pooled analyses depicted significantly higher rates of recurrent infection after EVAR than after OAR (relative risk [RR], 2.42; 95% CI, 1.80-3.27; P < .0001; I² = 0%). Recurrent infection-related rupture or death (RR, 1.51; 95% CI, 0.70-3.23; P = .29; I² = 0%), perioperative death (RR, 0.80; 95% CI, 0.39-1.65; P = .55; I² = 35%), 1-year mortality (hazard ratio, 1.12; 95% CI, 0.97-1.28; P =.13; I² = 0%), and readmission or reintervention (RR, 1.16; 95% CI, 0.74-1.82; P =.52; I² = 0%) were not significantly different statistically between the two groups. Funnel plots showed no evidence of publication bias. Sensitivity analyses of leave-one-out meta-analysis confirmed higher rates of recurrent infection after EVAR.

CONCLUSIONS

EVAR has become more prevalent as the initial treatment of infected AAAs. Although operative and 1-year survival were similar between OAR and EVAR groups, recurrent infection was more frequent after EVAR. This limitation should be weighed in selecting patients for EVAR in infected AAAs. Postoperative graft and infection surveillance are critical, especially after EVAR.

Salmonella aortitis successfully treated with antibiotics without surgery

Aortitis is an inflammation of the aorta that is linked to large vessel vasculitis and other rheumatologic cases. Less often, an infectious etiology of aortitis is diagnosed. Aortitis is associated with high mortality and morbidity and requires a high index of suspicion. Here we present a rare case of aortitis secondary to Salmonella Septicemia treated with six weeks of antibiotics in the hospital without and remained asymptomatic and inflammatory markers normalized at 2 weeks follow up (ESR, CRP, and WBCs).

Favorable Conservative Management of a Rare Primary Aortitis Secondary to Listeria Monocytogenes: Case Report and Review of the Literature

Primary aortitis (PA) secondary to Listeria monocytogenes is extremely rare with only a few cases reported in the literature. Presently, there is no consensus concerning the best treatment when no complications are found in the thoracic computed tomography (CT) imaging. This report illustrates the clinical presentation and favorable clinical course of a rare case of PA secondary to Listeria monocytogenes in an 82-year-old diabetic woman, successfully treated with conservative management with 18 months of follow up. Included in this article, we additionally present a review of the literature of this uncommon etiology of infectious aortitis.

Listeria monocytogenes infectious abdominal aortic aneurysm: Case report and review of the literature

Listeria monocytogenes-caused primary infected abdominal aortic aneurysm is a very rare disease. Aortic wall tissue sampling is essential for confirmation of diagnosis. Surgical repair and long-term antibacterial treatment are crucial for management.

A strobe multicenter descriptive study of 55 infectious aortitis

Infectious aortitis (IA) is a rare and severe disease. The treatment classically associates open surgery with prolonged antibiotic therapy. This study aimed to describe clinical characteristics, medical and surgical supports in a large and current series of IA.We conducted a retrospective multicenter study of native aorta IA, between 2000 and 2019. Inclusion criteria were the presence of a microorganism on blood culture, aortic sample or any other validated technique and structural anomaly in imaging.We included 55 patients (85% men), with a median age of 65. Microbiology data substantially differed from previous studies with 12 Gram-negative rods IA, of which only 3 due to Salmonella spp., 24 Gram-positive cocci IA of which 12 Streptococcus spp., and 18 IA due to intracellular growth and/or fastidious microorganisms, of which 8 Coxiella burnetii, 3 Treponema pallidum, and 5 tuberculosis suspicious cases. Fifteen patients (27%) presented with thoracic IA, 31 (56%) with abdominal IA, and 9 (16%) with thoraco-abdominal IA. Eight patients had no surgery, 41 underwent open surgery, only 4 endovascular aneurysm repair, and 2 a combination of these 2 techniques. Nine patients died before 1-month follow-up. There was no difference in the mortality rate between the different types of germ or localization of IA.The variety of germs involved in IA increases. Positron emission tomography-computed tomography scan is a very useful tool for diagnosis. Surgery is still mainly done in open approach and a prospective multicenter study seems necessary to better determine the place of endovascular aneurysm repair versus open surgery.

Mucormycosis with peculiar aortic involvement in a child with acute lymphoblastic leukemia

Among fungal infection, mucormycosis is a rare but severe etiology in immunocompromised patients. Lung and sinus are the usual sites; the involvement of blood vessels is also described. The diagnosis is a real challenge, because blood tests (galactomannan, beta-D-glucan) are negative and the only diagnostic tool is usually the biopsy of the affected zone. Aortitis is rare and usually caused by bacterial infection, fungal etiology is unusual and only episodic cases are reported in literature. Medical therapy alone is usually not sufficient and debilitating surgical intervention is required. We report the case of a child affected by B precursor acute lymphoblastic leukemia, presenting a systemic fungal infection complicated by aortitis, probably due to Mucor. The patient developed fever and pneumonia during the Induction phase of chemotherapy. At the beginning, the infection was treated as bacterial and the diagnosis of Mucor infection was possible only after surgical intervention with histological analysis. Medical therapy (antifungal) was not sufficient alone to cure the infection and an urgent surgical intervention was required. This case underlines the challenge in the diagnosis of mucomycosis, that should be suspected in case of prolonged fever during aplasia, not responding to standard antibiotic and antifungal therapies. Mucor infection often require a combined intervention, both medical and surgical to cure the infection.

Aerococcus urinae Aortitis: A Case Report

Background

Aerococcus urinae is a Gram-positive coccus that is increasingly recognized as a urinary pathogen since the introduction of mass spectrometry for identification of bacteria. We report a case of abdominal aortitis (with aneurysm) caused by A urinae in a male with recurrent urinary tract infections and recently treated A urinae bacteremia. A 63-year-old gentleman with a history of A urinae urosepsis 7 weeks prior, presented to the Emergency Department with thoracolumbar back pain radiating bilaterally into the groin. Radiological and surgical findings were consistent with infective infrarenal aortitis with aneurysm.

Methods

The patient successfully underwent open surgical debridement and reconstruction of the infrarenal aorta with autologous vein graft.

Results

Aerococcus urinae was isolated from excised tissue. The patient completed a 4-week course of intravenous antimicrobial therapy.

Conclusions

Aurinae is a urinary pathogen with the ability to cause severe invasive disease including endovascular infections.

Non-typhoidal Salmonella aortitis

Non-typhoidal Salmonella (NTS) spp. causes about 40% of all infective aortitis and it is characterized by high morbidity and mortality. Human infection occurs by fecal-oral transmission through ingestion of contaminated food, milk, or water (inter-human or zoonotic transmission). Approximately 5% of patients with NTS gastroenteritis develop bacteremia and the incidence of extra-intestinal focal infection in NTS bacteremia is about 40%. The organism can reach an extra-intestinal focus through blood dissemination, direct extension from the surrounding organs and direct bacterial inoculation (e.g. invasive medical procedures). Medical and surgical interventions are both needed to successfully control the infection. Here, we report a case of abdominal sub-renal aortitis caused by Salmonella enterica serovar Enteritidis in an 80-year-old man.

Spontaneous resolution of idiopathic aortitis and pitfalls in diagnosis

Idiopathic aortitis is an inflammatory disease of the aorta that is diagnosed after the less frequent infectious and rheumatologic variants are excluded. The etiology and natural history of the disease are poorly understood, and its presentation is variable; the need for exclusion of infectious, malignant, and rheumatologic causes can make its evaluation and diagnosis challenging. Treatment is tailored to the diagnosis and may include observation, antimicrobial therapies, and immunosuppressive agents when appropriate. Operative therapy is rarely needed and reserved for symptomatic patients or instances in which infection cannot be excluded. We present a case of idiopathic aortitis that resolved spontaneously with expectant management and discuss the pitfalls in the diagnosis and care of the disease.

Listeria monocytogenes infectious periaortitis: a case report from the infectious disease standpoint

Background

Endograft infection is a rare but extremely dangerous complication of aortic repair (25–100% of mortality). We describe here the first case of Listeria monocytogenes abdominal periaortitis associated with a vascular graft. We also discuss the differential diagnosis of periaortitis and provide a literature review of L. monocytogenes infectious aortitis.

Case presentation

Nine months after endovascular treatment of an abdominal aortic aneurysm (abdominal stent graft), a 76-year-old man was admitted for severe abdominal pain radiating to the back. Laboratory tests were normal apart from elevated C-reactive protein (CRP). Injected abdominal computed tomography (CT) showed infiltration of the fat tissues around the aortic endoprosthesis and aneurysmal sac expansion; positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a hypermetabolic mass in contact with the endoprosthesis. Blood cultures were negative. At surgical revision, an infra-renal peri-aortic abscess was evident; post-operative antibiotic therapy with ciprofloxacin and doxycycline was started. Cultures of intraoperative samples were positive for L. monocytogenes. Results were further confirmed by a broad-range polymerase chain reaction (PCR) and next-generation sequencing. Antibiotic treatment was switched to intravenous amoxicillin for 6 weeks. Evolution was uneventful with decrease of inflammatory parameters and regression of the abscess.

Conclusion

An etiologic bacterial diagnosis before starting antibiotic therapy is paramount; nevertheless, culture-independent methods may provide a microbiological diagnosis in those cases where antimicrobials are empirically used and when cultures remain negative.

Mycotic aneurysm due to Salmonella species: clinical experiences and review of the literature

The mortality of patients with mycotic aneurysms is high, especially in East Asia, and infection by Salmonella species is the most common. Our study aimed to improve prognosis of adult mycotic aneurysms with early diagnosis and accurate treatment. Four adult patients with mycotic aneurysm caused by Salmonella were included and analyzed by single-center retrospective analysis. Cases reported in the literature during the past 10 years were also summarized. The average age of the 4 male patients was 61.25 years, while that of the 53 cases reported in the literature was 65.13 years. Hypertension, diabetes, and atherosclerosis were common complications. Most patients presented fever and experienced pain at the corresponding position of the aneurysm. Laboratory examination found an increased number of white blood cells accompanied by an increase in inflammatory markers. Most aneurysms were found in the abdominal aorta, while the rupture of an aneurysm was the most common complication. The mortality rates were 21.43 and 7.14% after open surgery or endovascular aneurysm repair (EVAR) intervention, respectively. The recurrence rates of infection were 0 and 17.85% for both treatments, respectively. The mortality rate of mycotic aneurysm caused by Salmonella infection was high in middle-aged males with hypertension, diabetes, and atherosclerosis. The possibility of a Salmonella-infected aneurysm should be considered in these high-risk groups presenting chills, fever, chest, and back pain. Open surgery was superior to EVAR treatment in the clearance of infected foci and the reduction of postoperative recurrence. The recurrence of postoperative infection can be prevented by intravenous antibiotic therapy for 6 weeks post-surgery.

Acute non-traumatic disease of the abdominal aorta

Acute pathology in the abdominal aorta is associated with significant morbidity and mortality. The most feared complication of abdominal aortic disease is acute rupture in the setting of atherosclerotic abdominal aortic aneurysm. Although frank rupture often is easily diagnosed on CT, other findings such as a hyperattenuating crescent, discontinuous intimal calcium, and draping of the aorta are subtle signs of aneurysm instability. A true aneurysm should be distinguished from a rapidly growing, saccular pseudoaneurysm in the setting of infectious aortitis, as treatment strategy differs. Acute aortic syndrome involving the abdominal aorta, such as dissection and intramural hematoma, often is an extension of thoracic aortic disease, whereas penetrating atherosclerotic ulcers occasionally involve only the abdominal aorta. The goal of treating acute aortic pathology is to repair and prevent rupture, as well as restore and maintain perfusion of the lower extremities, kidneys, and mesentery. However, both open and endovascular repair of the abdominal aorta may become acutely complicated, resulting in compromise of these goals. Examples include aortoenteric fistula, endoleak, anastomotic pseudoaneurysm, graft infection, and thrombosis or kinking of a stent graft resulting in ischemia of the limbs and mesentery.

A Case of Recurrent Aortic Rupture Associated with Klebsiella pneumoniae Pericarditis Treated by Two Separate Aortic Operations

A 49-year-old female presented with severe dyspnea. She was diagnosed with cardiac tamponade combined with ascending aortic pseudoaneurysm and rupture, which was caused by Klebsiella pneumoniae infection. This extremely rare condition was managed by an emergency pericardiostomy and two separate aortic operations. Antibiotics active for the K. pneumoniae isolate were used throughout. The patient was well for nine months after discharge and continues to be followed up for signs of possible reinfection.