Management of the infected aortoiliac aneurysms

Mycotic aneurysms due to Burkholderia pseudomallei in Far North Queensland, tropical Australia: A case series and review of the literature

Since 2019, Burkholderia pseudomallei has been the most common cause of mycotic aneurysm at Cairns Hospital in tropical Australia. Among 233 culture-confirmed cases of melioidosis since this time, 8 (3.4 %) were diagnosed with a mycotic aneurysm. All 8 patients had at least 1 risk factor for melioidosis, all 8 had either established vascular disease (or risk factors for it) and all 8 presented during the local wet season or shortly thereafter. Although the patients were managed in a well-resourced, high-volume melioidosis centre, the diagnosis of mycotic aneurysm was frequently delayed. The patients had a turbulent course: 6/8 (75 %) required intensive care unit admission and 7/8 (88 %) required surgical intervention. While all 8 patients survived to hospital discharge, 2 (25 %) ultimately died as a result of their B. pseudomallei infection, a high case-fatality rate by contemporary Australian standards. Adverse drug reactions were documented in 4/7 (57 %) who commenced oral trimethoprim-sulfamethoxazole (TMP-SMX) eradication therapy; an additional 2 patients were unable to adhere to their prescribed TMP-SMX, one of whom died from relapsed melioidosis. Mycotic aneurysm is an infrequent manifestation of B. pseudomallei infection, is challenging to diagnose and has a high attributable mortality. The diagnosis should be considered in older patients who reside in, or who have travelled to, endemic areas and who present with fever and abdominal or back pain and who have risk factors for melioidosis and vascular disease. Early, comprehensive imaging, thorough microbiological evaluation, prompt vascular surgery review, targeted antimicrobial therapy, close longitudinal follow-up and strategies to ensure patients' retention in care are crucial to achieve optimal outcomes.

Infective native arterial aneurysms and inflammatory abdominal aortic aneurysms: An overview with a focus on emergency settings

Infective native arterial aneurysms and inflammatory aortic aneurysms are rare but morbid pathologies seen by vascular surgeons in the emergency setting. Presentation is not always clear, and a full workup must be obtained before adopting a management strategy. Treatment is multidisciplinary and is tailored to every case based on workup findings. Imaging with computed tomography, magnetic resonance, or with fluorodeoxyglucose-positron emission tomography aids in diagnosis and in monitoring response to treatment. Open surgery is traditionally performed for definitive management. Endovascular surgery may offer an alternative treatment in select cases with acceptable outcomes. Neither technique has been proven to be superior to the other. Physicians should consider patient's anatomy, comorbidities, life expectancy, and goals of care before selecting an approach. Long-term pharmacological treatment, with antibiotics in case of infective aneurysms and immunosuppressants in case of inflammatory aneurysms, is usually required and should be managed in collaboration with infectious disease specialists and rheumatologists.

Infected Aortic Aneurysm Secondary to Pyogenic Flexor Tenosynovitis from Streptococcus pyogenes

Infected aortic aneurysms are rare, and have a high mortality rate. Although not a major pathogen, Streptococcus pyogenes has been reported to cause infected aortic aneurysms. In the present case, the patient was hospitalized for pyogenic flexor tenosynovitis with S. pyogenes bacteremia. Despite drainage of the abscess around the flexor tendon and effective antimicrobial therapy, infected aneurysms developed in the abdomen and ascending aorta. Because of their rapid enlargement, these aneurysms were treated with in situ reconstruction. Although rare, the possibility that S. pyogenes is the causative pathogen of infected aortic aneurysms should be considered.

Open versus endovascular repair of primary infected thoracic and abdominal aortic aneurysms

OBJECTIVE

Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms.

METHOD

A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors.

RESULT

Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67 years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24 months in the endovascular repair group and 38 months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1 year, 2 years, 5 years and 10 years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years and 10 years, respectively.

CONCLUTIONS

Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

In situ repair or reconstruction of the abdominal aorta-iliac artery by autologous fascia-peritoneum with posterior rectus sheath for the treatment of the infected abdominal aortic and iliac artery aneurysms: A case series and literature review

Background

Infected abdominal aortic and iliac artery aneurysms are considered acute and severe diseases with insidious onset, rapid development, and high mortality in vascular surgery. Currently, there is no better treatment, either anatomic or extra-anatomical repair.

Case presentation

From February 2018 to April 2022, 7 patients with infected abdominal aortic and iliac artery aneurysms did not have sufficient autologous venous material for repair. With the consent of the Ethics Committee of the hospital, it uses the autologous peritoneal fascial tissue with rectus sheath to repair or reconstruct the infected vessels in situ. There were 5 cases of infected abdominal aortic aneurysm, 1 case of an infected common iliac aneurysm, and 1 case of the infected internal iliac aneurysm. Aortoduodenal fistula was found in 3 cases, all of them were given duodenal fistula repair and gastrojejunostomy and cholecystostomy. Three cases of infected abdominal aortic aneurysms were repaired with the autologous peritoneal fascial tissue patch, and 2 cases of infected abdominal aortic aneurysms were reconstructed by the autologous peritoneal fascial tissue suture to bifurcate graft in situ, the autologous peritoneal fascial tissue suture reconstructed the rest 2 cases of infected iliac aneurysm to tubular graft in situ. It was essential that Careful debridement of all infected tissue and adequate postoperative irrigation and drainage. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics based on bacterial culture and susceptibility results of infected tissues and blood. All 7 patients had underwent surgery successfully. But there were 2 cases died of anastomotic infection or massive hemorrhage after the operation, the other 5 cases survived. The follow-up time was 2–19 months. The enhanced CT of postoperation showed that the reconstructed arteries were smooth without obvious stenosis or expansion, and no abdominal wall hernia occurred.

Conclusion

In situ repair or reconstruction with autologous peritoneal fascial tissue with rectus sheath is a feasible treatment for the infected aneurysm patients without adequate autologous venous substitute, but it still needs long-term follow-up and a large sample to be further confirmed.

Clinical and microbiological characteristics and challenges in diagnosing infected aneurysm: a retrospective observational study from a single center in Japan

Background

It is challenging to diagnose infected aneurysm in the early phase. This study aimed to describe the clinical and microbiological characteristics of infected aneurysm, and to elucidate the difficulties in diagnosing the disease.

Methods

Forty-one cases of infected aneurysm were diagnosed in Nagasaki University Hospital from 2005 to 2019. Information on clinical and microbiological characteristics, radiological findings, duration of onset, and type of initial computed tomography (CT) imaging conditions were collected. Factors related to diagnostic delay were analyzed by Fisher’s exact test for categorical variables or by the Wilcoxon rank-sum test for continuous variables.

Results

Pathogens were identified in 34 of 41 cases; the pathogens were Gram-positive cocci in 16 cases, Gram-negative rods in 13 cases, and others in five cases. Clinical characteristics did not differ in accordance with the identified bacteria. At the time of admission, 16 patients were given different initial diagnoses, of which acute pyelonephritis (n = 5) was the most frequent. Compared with the 22 patients with an accurate initial diagnosis, the 19 initially misdiagnosed patients were more likely to have been examined by plain CT. The sensitivities of plain CT and contrast-enhanced CT were 38.1% and 80.0%, respectively.

Conclusions

In cases of infected aneurysm, diagnostic delay is attributed to non-specific symptoms and the low sensitivity of plain CT. Clinical characteristics of infected aneurysm mimic various diseases. Contrast-enhanced CT should be considered if infected aneurysm is suspected.

Mycotic abdominal aortic aneurysm in a patient with systemic lupus erythematosus: A case of critical antinomy

Mycotic abdominal aortic aneurysms (MAAAs) are rare but life-threatening, and no standard therapy has yet been established. Effective surgery with intensive antimicrobial therapy is crucial; however, this can be fatal in immunocompromised patients. Only a few reports of MAAA with concomitant autoimmune disease exist; therefore, we were concerned about our lack of experience and knowledge about appropriate treatment. We report a 69-year-old male with an MAAA secondary to septic shock after spinal fusion surgery. He had also been on long-term oral immunosuppressants for systemic lupus erythematosus (SLE). After preoperative cephazolin, we performed debridement of infected tissue, graft replacement with a rifampicin-bonded prosthesis, and omentopexy. On the 52nd post-operative day, he was transferred back to the previous attending hospital under oral antibiotics and prednisolone. MAAA in patients with SLE should be treated with in situ replacement using an antimicrobial prosthetic or biological graft with thorough debridement and omentopexy, followed by antimicrobials and immunosuppressants, as needed.

Infected abdominal aorta aneurysm secondary to streptococcal toxic shock syndrome due to Streptococcus pyogenes: a case report from Japan

Background

Infected aortic aneurysm secondary to streptococcal toxic shock syndrome caused by Streptococcus pyogenes is uncommon and associated with high mortality.

Case presentation

A 75‐year‐old man with metastatic lung cancer and an abdominal aortic aneurysm presented with high fever for 3 days. He was diagnosed with septic shock and was admitted to our hospital. The blood culture was positive for S. pyogenes, and streptococcal toxic shock syndrome was diagnosed. During treatment, enhanced computed tomography revealed an increase in the size of the abdominal aortic aneurysm, leading to the diagnosis of an infected aortic aneurysm. Replacement of the aneurysm with a synthetic graft was carried out successfully. The patient gradually recovered after the surgery.

Conclusion

We successfully managed an infected aortic aneurysm secondary to streptococcal toxic shock syndrome. Infected aortic aneurysms should be considered in patients with a medical history of aortic aneurysms and presenting with streptococcal toxic shock syndrome.

Mycotic aneurysm secondary to melioidosis in China: A series of eight cases and a review of literature

Burkholderia pseudomallei is the causative agent of melioidosis, endemic in Southeast Asia and Northern Australia, and increasingly recognized in southern China, especially in Hainan Province. Mycotic aneurysm caused by B. pseudomallei is a rare but potentially severe illness with a high mortality rate. The clinical features of the mycotic aneurysm secondary to melioidosis have not been illustrated in China. Over a seven-year period (2013 to 2019), 159 patients with bacteremic melioidosis were retrospectively analyzed in Hainan province, China, of whom eight patients were confirmed to have mycotic aneurysm through the combination of imaging examination, pathologic examination and aneurysm tissue culture. We summarized these eight patients' clinical characteristics, demographical features, treatments and outcomes. The susceptibilities to five commonly-used antibiotics for these eight B. pseudomallei isolates were also determined by E-test strips. Furthermore, the mycotic aneurysm cases secondary to melioidosis retrieved from the literature were also reviewed. Of the eight cases, six had abdominal mycotic aneurysms, one had a left iliac aneurysm, and the other one had an infectious mesenteric aneurysm. They were aged from 48 to 69 years old, and had the underlying risk factors of diabetes mellitus (2 patients), long-term smoking (4 patients), hypertension (6 patients), and soil and water contact history (6 patients), respectively. The positive arterial aneurysm imaging was observed in all patients via computed tomography (CT) or angiography. Eight B. pseudomallei isolates collected from both blood and mycotic aneurysm tissues remained 100% susceptible to imipenem and ceftazidime. After surgery combined with antibiotic administration, six patients survived, with a mortality rate of 25%. In melioidosis endemic areas, the mycotic aneurysm secondary to melioidosis might be underdiagnosed, and increased awareness of predisposing risk factors and clinical features of the mycotic aneurysm is required. Following a positive B. pseudomallei blood culture, the diagnosis of mycotic aneurysm should be under consideration in those with abdominal pain and/or hypertension. Imaging by CT or angiography is indispensable for its timely diagnosis and management.

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.

Isolated mycotic hypogastric artery aneurysm

Isolated iliac artery aneurysms are rare and commonly associated with aortic aneurysms. Hypogastric artery aneurysms (HAAs) are exceptionally rare. The general approach to HAAs has been exclusion and bypass, although when this is complicated by mycotic disease, endovascular techniques can provide unique approaches to management. We present the case of a patient with a mycotic HAA treated with endovascular coil and exclusion followed by aortic to external iliac artery bypass with cadaveric conduit.

Sandwich EVAR occludes Celiac and Superior Mesenteric Artery for Infected Suprarenal Abdominal Aortic Aneurysm Treatment

Introduction. Infected aortoiliac aneurysms are rare, representing only 1% to 2% of all aortic aneurysms; we present a case of infected suprarenal aortic aneurysm with a nearly occluded celiac artery and superior mesenteric artery treated using an endovascular technique to preserve collateral in the retroperitoneal space from the inferior mesenteric artery for supplying visceral organs.

Infected aortic and iliac aneurysms: Clinical manifestations in the emergency departments of two hospitals in southern Taiwan, China

BACKGROUND

Accurate diagnosis of infected aortic and iliac aneurysms is often delayed, hampering timely treatment and potentially resulting in a fatal consequence. The aim of this study was to discover useful clinical features that can help physicians to identify these patients.

METHODS

We reviewed the discharge notes from two hospitals and identified all patients who had a diagnosis of infected aneurysms of the thoracoabdominal aorta and iliac arteries between July 2009 and December 2013. Eighteen patients, aged from 41 to 93, were reviewed. Only 6 patients were diagnosed accurately in their first visit to our ED.

RESULTS

Most patients had at least one underlying illness, and it took 1 to 30 (9.9±6.5) days for physicians to diagnose their infected aneurysm. Localized pain and fever were the two most commonly presented symptoms. The majority (92%) of isolated microorganisms were gram-negative bacilli, including Salmonella spp, Klebsiella pneumoniae, and Escherichia coli. Two of the 3 patients who underwent non-operative therapy died, and all of the patients who underwent a combination of medical and operative therapies survived.

CONCLUSION

We suggest that physicians liberally use computed tomography scans on patients with unknown causes of pain and inflammatory processes. A combination of surgical and medical treatments is indicated for all patients with infected aortic and iliac aneurysms.

Infrarenal Infected Aortic Aneurysm Caused by Streptococcus pyogenes

Infectious aneurysm is a rare entity associated with significant morbidity and mortality. Current knowledge on pathogenesis, outcome, diagnosis, management, and follow-up remains debatable. We report the case of a patient with Streptococcus pyogenes aneurysm who was successfully treated with a homograft implant and discuss microbiological characteristics, diagnostic methods, and treatment options currently available for this serious disease.

An iliac arterial pseudoaneurysm diagnosed 40 years after suffering blunt trauma

BACKGROUND

A chronic iliac arterial pseudoaneurysm caused by blunt trauma is very rare.

CASE PRESENTATION

The patient had gunshot wound in the right thigh and blunt trauma 40 years earlier. An abdominal computed tomography revealed the presence of a right iliac arterial pseudoaneurysm, and we successfully treated the pseudoaneurysm by resection and in situ reconstruction with a bifurcated vascular prosthesis.

CONCLUSIONS

We herein present a rare case of a pseudoaneurysm of the right iliac artery diagnosed decades after blunt trauma.

Successful Endovascular Repair of Mycotic Aortic Pseudoaneurysm Followed by Aortoesophageal Fistula

Mycotic aneurysm of the aorta is a rare, but life-threatening pathology. In recent years, endovascular stent graft placement has been introduced as an effective alternative for treating infected aortic aneurysms. A 64-year-old woman with a history of paraplegia due to spinal cord injury was referred to our institute with fever and blood-tinged sputum. Computed tomography (CT) scan showed an 11-cm pseudoaneurysm arising from the proximal descending aorta, which was normal 1 month ago at the previous CT scan. The patient underwent thoracic endovascular aortic repair for the pseudoaneurysm, deployed with a transiliac access approach, and received antibacterial medical therapy. On postoperative day 11, she developed signs of infection, caused by an aortoesophageal fistula. The infection was treated conservatively with parenteral nutrition and antibiotic administration. The patient had an uneventful recovery and was discharged on postoperative day 113. At 2-year follow-up, she had a normal physical examination and CT angiography showed a marked reduction of the pseudoaneurysm sac. We report a successful endovascular stent grafting and subsequent medical treatment in a patient with a mycotic thoracic aortic pseudoaneurysm followed by a postoperative aortoesophageal fistula.

Endovascular Management of Concomitant Thoracic and Abdominal Aortic Ruptures Resulting from Brucellosis Aortitis

BACKGROUND

Acute aortic symptomatology is an unusual manifestation of Brucella melitensis infection. We present a rare case of acute multifocal thoracic and abdominal aortic ruptures arising from Brucellosis aortitis managed exclusively with endovascular surgery.

METHODS

A 71-year-old Hispanic male with a history of atrial fibrillation and prior stroke on chronic anticoagulation presented with shortness of breath and malaise. In addition, he had been treated approximately 1 year previously in Mexico for B. melitensis bacteremia after eating fresh unpasteurized cheese. Computed tomography (CT) angiography demonstrated an acute rupture of the descending thoracic aorta just proximal to the celiac trunk and synchronous rupture at the abdominal aortic bifurctation.

RESULTS

The patient was taken emergently to the hybrid operating room, where synchronous supraceliac thoracic aorta and abdominal aortoiliac stent grafts were deployed under local anesthesia. Completion angiography demonstrated total exclusion of the thoracic and abdominal extravasation with no evidence of endoleak. Twenty hours postoperatively, the patient became acutely obtunded and hypotensive. Repeat CT angiography demonstrated contrast extravasation at the level of the excluded aortic bifurcation. Emergent angiography confirmed a type II endoleak with free extraluminal rupture. Multiple coils were placed at the level of the aortic bifurcation between the left limb of the stent graft and the aortic wall to tamponade the endoleak. No further extravasation was noted on final aortography. Postoperatively, blood cultures confirmed the diagnosis of B. melitensis. The patient was treated with systemic doxycycline, gentamicin, and rifampin. Resolution of the acute event occurred without additional sequelae and he was discharged from the hospital to a rehabilitation facility.

CONCLUSIONS

Concomitant multifocal aortic ruptures arising from Brucellosis aortic infection is a very rare event. In this case, the patient was successfully treated with thoracic and abdominal endovascular stent-graft exclusion, coiling, and long-term targeted antibiotics.

Aortitis causing rapid growth of a mycotic aortic aneurysm

Mycotic infrarenal aortic aneurysms are rare and often masquerade as other abdominal pathology. We present a case where serial imaging made the diagnosis and provided an insight into the pathophysiology of mycotic aneurysm. A 71-year-old man presents with abdominal pain, rigours and dysuria. Computed tomography reveals an irregular, thickened ectatic abdominal aorta, but cholescintigraphy suggests acalculous cholecystitis. Deterioration prompts repeat radiographical assessment, which demonstrates an increase in the size of the aorta over 10 days. The patient was treated emergently with an open aortic ligation, debridement and extra-anatomical bypass. Infections account for up to 2% of abdominal aortic aneurysms. The rate of growth of mycotic aneurysms is sparsely discussed in the literature and to our knowledge, there are no reports with serial single-modality imaging. The most significant finding was rapid expansion in aneurysm size. While mycotic aneurysm requires urgent treatment, diagnosis can be delayed and difficult.

Juxtarenal Mycotic Aneurysm as a Complication of Acute Exacerbation of Chronic Cholecystitis Treated by Resection and Replacement by a Fresh Allograft

We present a case of a female patient with infectious (mycotic) juxtarenal abdominal aneurysm with atypical symptoms beginning as acute exacerbation of chronic cholecystitis. Apart from common antibiotic treatment, the patient successfully underwent resection of the diseased segment and replacement by a fresh allograft in order to reduce the risk of infection of the graft, but with the need of subsequent life-long immunosuppressive therapy. Perioperative monitoring of the spinal cord by near infrared spectroscopy was used to identify possible spinal ischemia. The choice of the fresh allograft was based on our experience supported by review of the literature.