Stent-Graft Treatment of Infected Aortic and Arterial Aneurysms

Tuberculous aneurysm diagnosed by CT-Guided biopsy after stent graft replacement: A case report

A tuberculous aneurysm is an uncommon extrapulmonary tuberculosis and is usually fatal. The best way to treat it involves a combination of open surgery and medical treatment. However, it can be challenging to diagnose a tuberculous aneurysm. In this report, we describe a patient with a tuberculous aneurysm who was treated with stent-graft replacement and CT-guided biopsy for diagnosis, followed by nine months of anti-tuberculosis therapy. Despite one week of anti-tuberculous therapy, her fever persisted. A CT scan revealed new, well-defined nodules measuring 1-2mm in the lungs and hepatomegaly, indicating complications of miliary tuberculosis. After three weeks after the CT-guided biopsy, Mycobacterium tuberculosis grew from the arterial wall tissue, leading to the diagnosis of a tuberculous aneurysm complicated by miliary tuberculosis. The patient's aneurysm disappeared on follow-up CT scans, and the patient has been under observation for five years without a relapse. This rare case of tuberculous aneurysm can provide lessons for countries with a low prevalence of tuberculosis. This suggests the possibility of treatment with stent-graft replacement and anti-tuberculous medication and the usefulness of CT-guided biopsy for microbiological and pathological diagnosis.

Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella

PURPOSE

Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms.

MATERIALS AND METHODS

The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed.

RESULTS

Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak.

CONCLUSION

EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms.

CLINICAL IMPACT

Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

[Tuberculosis aneurysm of descending thoracic aorta treated by covered stent graft : A case report]

Tuberculous aneurysm is a rare but lethal disease. It preferentially affects the aorta. The contamination occurs either secondarily to a tuberculosis site in contact with the aorta or by blood contamination. It presents an increased and unpredictable risk of rupture, hence the interest of urgent diagnostic and therapeutic management. His treatment was long based on surgery, but currently the endovascular approach is increasingly used. The treatment, whatever its type, will always be associated with a medical treatment for tuberculosis. We report the case of a patient with a descending thoracic aortic aneurysm considered tuberculous on the basis of epidemiological, clinical and biological arguments; who was treated by deployment of an endoprosthesis with good clinical and radiological evolution.

Human descending aorta injury caused by brucellosis: A case report

BACKGROUND

Brucellosis is one of the most common zoonotic diseases in the world. Although cardiovascular complications of human brucellosis account for only 3% of morbidity, they are the leading cause of death. Peripheral vascular disease due to brucellosis is rare and under-reported in the literature.

CASE PRESENTATION

Two patients with previous brucellosis, both of whom had been treated with anti-brucellosis, were admitted to vascular surgery for thoracic aortic ulcer and abdominal aortic pseudoaneurysm, respectively, with positive IgG antibody to brucellosis and negative IgM antibody to brucellosis, tube agglutination test, and blood culture. These 2 patients were successfully treated with aortic stent-graft implantation and followed up for 8 and 10 weeks without complications.

CONCLUSIONS

Chronic damage to human blood vessels by brucellosis may not disappear with brucellosis treatment, and peripheral blood vessels should be examined annually in people previously diagnosed with brucellosis. Clinicians in related departments should pay attention to peripheral vascular complications of brucellosis.

Treatment of abdominal aortic pseudoaneurysm caused by brucellosis with endovascular aneurysm repair

Peripheral vascular disease caused by brucellosis is rarely seen around the world; thus, it is easily ignored by patients and doctors, leading to a lack of corresponding screening and delayed comprehensive treatment. Currently, there is no standard or guideline for diagnosing and treating peripheral arterial disease caused by brucellosis. From June 2021 to December 2022, four cases of abdominal aortic pseudoaneurysm caused by brucellosis disease were treated with endovascular aneurysm repair This study reported treatment results as follows and reviewed the incidence, treatment, and prognosis of abdominal aortic pseudoaneurysm caused by brucellosis.

Isolated Mycotic Internal Iliac Artery Aneurysm Treated With a Combined Endovascular Stenting and Percutaneous Drainage Approach: A Case Report and Review of Current Literature

Background

Isolated mycotic internal iliac artery aneurysms are rare and management of these patients can be complex.

Case summary

We present a rare case of isolated mycotic right internal iliac artery aneurysm caused by Salmonella enteritides. This was managed in stages – with intravenous antibiotics, followed by endovascular stenting and embolization, and subsequent percutaneous drainage of the remnant collection. The patient had no perioperative complications, and has remained well at more than 18 months post-operatively with no evidence of stent infection.

Conclusion

A minimally-invasive approach combining endovascular aneurysm repair and percutaneous drainage is a viable option in the management of a mycotic internal iliac artery aneurysm.

Emergent repair of infected aortic aneurysm with contained rupture using a femoral vein neoaortoiliac system

Infected aortic aneurysms are rare but are associated with high morbidity and mortality. Management involves surgical resection and debridement of the infected aorta and surrounding tissues, arterial reconstruction or bypass, and flap coverage, followed by long-term antibiotic therapy. Autogenous reconstruction using a neoaortoiliac system (NAIS) is a durable form of repair with a decreased risk of reinfection. However, NAIS reconstruction is generally thought to be contraindicated for emergent, but not impending, rupture settings. We present the successful application of NAIS for a contained rupture of an infected infrarenal aneurysm. Use of the NAIS can provide a more durable option for select patients.

Aortoenteric fistula after endovascular mycotic aortic aneurysm exclusion: lessons learned during the COVID-19 era

We report a case of aortoenteric fistula 2 years following endovascular aortic aneurysm repair (EVAR) for mycotic aneurysm presenting as upper gastrointestinal bleeding. Initial CT angiogram did not reveal the bleeding or connection to bowel, but endoscopy was suspicious of endograft in the duodenum. Management required a multidisciplinary approach. To stabilise the patient and to control bleeding, a 'bridging' endograft extension was performed. This was followed by open surgical removal of the EVAR endograft and lower limb in situ revascularisation. During postoperative recovery, the patient developed atypical, staged multisystemic symptoms (cardiac, pulmonary and neurological). With increasing awareness of the COVID-19 pandemic, the patient was found SARS-CoV-2-positive, which explained the progression of his symptoms. This was also reflected on other case reports in literature later.

Endovascular repair of a Clostridium perfringens infected pseudoaneurysm presenting as an intramural air pocket

An infected aneurysm (IA) is a relatively rare but complex and life-threatening disease. We report a 78-year-old man with an IA in the common iliac artery (CIA) due to Clostridium perfringens. An initial computed tomography (CT) revealed an air pocket in the left CIA, and a pseudoaneurysm was seen on the CT taken the next day, in the area where the air pocket was initially observed. Due to the patient’s high surgical risk, emergent endovascular aneurysm repair (EVAR) was performed. No indolent infection was found 1.5 years after the surgery. Because of its high risk of expansion and rupture, accurate diagnosis and immediate treatment is required for managing IAs. The case emphasizes that air density in an arterial wall could be an early radiologic feature of an IA, and EVAR could be a treatment option for IA.

Mycotic aortic aneurysms treated by endovascular repair: initial experience in a single center

INTRODUCTION

Mycotic aortic aneurysm (MAA) is an uncommon cause of aneurysmal aortic disease. However, it may have an aggressive presentation and a complicated early outcome. Endovascular aneurysm repair (EVAR) of MAA is emerging as an alternative to open repair (OR) for the treatment of these aneurysms, particularly in high-risk surgical patients. We report a single-center experience with the endovascular management of mycotic aortic aneurysms.

MATERIAL AND METHODS

Two mycotic abdominal aortic aneurysms were treated with an endovascular stent graft at Centre Hospitalier Régional du Val de Sambre, Belgium. The mean follow-up was 15 months. Technical success was achieved in all two patients. CT-scan follow up showed shrinkage of the aneurysm sac, with no evidence of infection along the stent graft and no signs of endoleakage in all patients. One patient died during the follow-up period from a cause unrelated to the aneurysm.

CONCLUSION

EVAR is an effective and safe option and might be a suitable alternative to OR in the absence of predictors of poor prognosis for the treatment of non-complicated forms of MAA.

Conservative treatment of non-aneurysmal infectious aortitis: a case report and review of the literature

BACKGROUND

 Non-aneurysmal infectious aortitis is a rare clinical entity with most often lethal complications when surgical intervention is delayed.

OBJECTIVES

 This report describes the case of a non-aneurysmal infectious aortitis complicated with a penetrating aortic ulcer in an elderly woman, caused by a methicillin-sensitive Staphylococcus aureus. Surgery was deemed contra-indicated and treatment was limited to the administration of intravenous vancomycin (2 grams daily), followed by flucloxacillin (6 times 2 grams daily). She remains well after one year.

METHODS

The Internet databases Medline and Embase were searched. Articles were selected based on relevanceof abstract, article type and impact of the journal.

RESULTS

 A literature review addresses current insights in the pathogenesis, diagnosis, and treatment of non-aneurysmal infectious aortitis.

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.

Thoracic Endovascular Aortic Repair for Aortoesophageal Fistula after Covered Rupture of Aortic Homograft: A Durable Option?

A 63-year-old woman underwent replacement of the aortic root, ascending aorta, and partial arch due to Type A aortic dissection. Shortly thereafter, a replacement of the distal aortic arch and descending aorta was performed. Three years later, the patient developed an aortoesophageal fistula (AEF) resulting in re-replacement of the distal aortic arch and proximal descending aorta with a cryopreserved aortic homograft. Six weeks post-discharge, the patient was readmitted due to recurrent AEF. A thoracic endovascular stent graft was implanted to cover the aortic rupture, followed by correction of an esophageal lesion. The patient was monitored closely over time.

Treatment of Infected Aneurysms of the Abdominal Aorta and Iliac Artery with Endovascular Aneurysm Repair and Percutaneous Drainage

Infected aneurysm remains one of the most challenging diseases for vascular surgeons. We describe the successful treatment of 2 cases of infected aneurysms with endovascular aneurysm repair and percutaneous computed tomography-guided drainage. This strategy may be an effective alternative to open surgical repair in selected patients.

Successful Endovascular Repair of a Penetrating Aortic Ulcer in Bacterial Aortitis

Infective aortitis (IA) and penetrating aortic ulcer (PAU) impending for rupture represent 2 hostile life-threatening conditions. Simultaneous presentations of these rare entities can be considered an exception. The pleomorphic clinical presentation and the multifactorial etiology require a multidisciplinary approach to reach a correct diagnosis and an urgent treatment. We report the case of a 65-year-old patient presented with acute abdominal pain and septic shock secondary to a bacterial aortitis and penetrating ulcer of abdominal aorta. Unfit for surgery due to severe comorbidities, he was treated by means of a tubular endograft and long-term antibiotic therapy. A rapid improvement of clinical conditions was observed during the subsequent hospital stay. Complete regression of aortic involvement was demonstrated after 1 year. In conclusion, for selected patients affected by IA and PAU an endovascular approach associated to long-term antibiotic therapy may be safe and effective.

Renal colic caused by mycotic iliac artery aneurysm

A 33-year-old female presented with acute colicky left loin-to-groin pain and microscopic haematuria, with a background of 6 months of muscle and joint pains and diplopia. A CT kidneys/ureters/bladder demonstrated fat stranding surrounding the left ureter, as it passed over the left common iliac vessels. Arterial and delayed phase imaging revealed an obstructed ureter secondary to a left common iliac artery aneurysm, later found to be mycotic. No previous descriptions of a mycotic aneurysm presenting as renal colic have been found in the literature. The diagnosis and management of infective endocarditis and mycotic aneurysm are discussed, with a review of the literature. This serves as a good example of a common presenting complaint occurring secondary to a rare and serious pathology.

Open stent grafting with a trifurcated graft for an infected aortic arch aneurysm concomitant with severe calcified aorta

An infected aortic arch aneurysm is a rare but life-threatening condition. Moreover, surgical treatment for patients with severe calcified aorta is challenging and needs a well-planned strategy. We report a patient with an infected aortic arch aneurysm concomitant with severe calcification of the aorta in whom good results were obtained with open stent grafting in combination with a trifurcated graft.

Endovascular Repair of a Streptococcus pneumonia-Induced Aortitis Complicated by an Iliacocaval Fistula

Purpose: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. Case report: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptoccocus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral–femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-d-glucose positron emission tomography/computed tomography. Conclusion: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.

Endovascular Management of Mycotic Aortic Aneurysms

Purpose: We report a single-center experience with the endovascular management of mycotic aortic aneurysms. Case reports: Four cases of mycotic aortic aneurysms are described; all treated with endovascular stent graft with variable configurations. All patients underwent successful placement of stent grafts for their aneurysms. No 30-day perioperative mortality was observed. One patient died during the follow-up period from a cause unrelated to the aneurysm. Conclusion: Repair of mycotic aneurysms can be accomplished with endovascular repair. This may be a valid alternative to open repair particularly in patients who are not candidates for conventional open repair.

Infected (mycotic) aneurysms: spectrum of imaging appearances and management

Infected aneurysms are uncommon. The aorta, peripheral arteries, cerebral arteries, and visceral arteries are involved in descending order of frequency. Staphylococcus and Streptococcus species are the most common causative pathogens. Early clinical diagnosis of infected aneurysms is challenging owing to their protean manifestations. Clinically apparent infected aneurysms are often at an advanced stage of development or are associated with complications, such as rupture. Nontreatment or delayed treatment of infected aneurysms often has a poor outcome, with high morbidity and mortality from fulminant sepsis or hemorrhage. Current state-of-the-art imaging modalities, such as multidetector computed tomography and magnetic resonance imaging, have replaced conventional angiography as minimally invasive techniques for detection of infected aneurysms in clinically suspected cases, as well as characterization of infected aneurysms and vascular mapping for treatment planning in confirmed cases. Doppler ultrasonography allows noninvasive assessment for infected aneurysms in the peripheral arteries. Imaging features of infected aneurysms include a lobulated vascular mass, an indistinct irregular arterial wall, perianeurysmal edema, and a perianeurysmal soft-tissue mass. Perianeurysmal gas, aneurysmal thrombosis, aneurysmal wall calcification, and disrupted arterial calcification at the site of the infected aneurysm are uncommon findings. Imaging-guided endovascular stent-graft repair and embolotherapy can be performed in select cases instead of open surgery. Familiarity with the imaging appearances of infected aneurysms should alert the radiologist to the diagnosis and permit timely treatment, which may include endovascular techniques.

Aortitis and Bacterial Endocarditis

Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.

Ischemic colitis complicating major vascular surgery

Ischemic colitis is a well-described complication of major vascular surgery, especially following open abdominal aortic aneurysm repair and endovascular aneurysm repair, but also with aortoiliac surgery, aortic dissection, and thoracic aneurysm repair. Following its onset, mortality remains high, highlighting the need for rapidly identifying the onset of symptoms and, perhaps more importantly, those patients at risk, in an attempt to prevent its onset. In this article, the authors review the causes, presentation, and diagnostic strategies of colonic ischemia. They also cover the operative management and outcomes for bowel resection and vascular repair. Finally, they evaluate some of the newer options for diagnosing this condition.

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.

A diagnostic dilemma: does peri stent-graft air after thoracic aortic endografting necessarily imply infection?

The radiographic finding of air bubbles around a surgically placed prosthetic graft is traditionally assumed to be a sign of infection until proven otherwise. Direct delivery of atmospheric air bubbles, shown in an imaging study performed very soon after a surgical intervention, or percutaneously introduced during an endovascular procedure could be possible causes of air bubble presence and not necessarily infection. However, if air around a prosthetic aortic graft is identified in an imaging study after a previous one did not document its presence, or if the amount of air is increasing on serial imaging studies, the suspicion level should increase. The case presented here is of a 49-year-old male who underwent an endovascular repair of a possible symptomatic penetrating aortic ulcer, who was found to have peri stent-graft air 3 weeks after intervention. Previous imaging postoperative studies did not reveal air around the aortic prosthesis. The diagnosis of endovascular stent-graft infection was very difficult due to several challenging factors that are herein presented.

Endovascular treatment of a tuberculous infected aneurysm of the descending thoracic aorta: A word of caution

An infected aneurysm of the thoracic aorta due to mycobacterium tuberculosis is an unusual entity for which the classical treatment is antituberculosis chemotherapy and open-chest surgery. Recent improvements in endovascular treatments have led to their proposed use for infected aneurysms in patients for whom open surgery poses too high a risk. We report on a 68-year-old man with a tuberculous aortic aneurysm who had been treated with an endoprosthesis and antituberculosis chemotherapy. His clinical and radiological follow-up was uneventful and led to the discontinuation of pharmacological treatment after 16 months. However, a recurrence of the infection led to a fatal aortic rupture 4 months after discontinuation of therapy.

Stent-Graft Repair of a Mycotic Ascending Aortic Pseudoaneurysm

A 75-year-old woman with a history of coronary artery bypass surgery complicated by mediastinitis presented with hemoptysis and fever. An enlarging pseudoaneurysm of the ascending aorta was found on computed tomography (CT) and magnetic resonance imaging. After a bypass graft procedure for cerebral and cardiac protection, two endoprosthetic cuffs, which are normally used for proximal abdominal aortic stent-graft extension, were positioned over the pseudoaneurysm neck via right carotid artery access. Blood cultures revealed methicillin-sensitive Staphylococcus aureus, and antibiotic therapy was continued for 6 weeks. Follow-up CT images demonstrated exclusion of the pseudoaneurysm with decrease in size over time. Endovascular stent-graft placement combined with antibiotic therapy may offer an alternative to surgery for the management of mycotic ascending aortic pseudoaneurysm.