Hybrid operation for infectious thoracic and abdominal aortic aneurysms complicated with Bacillus Calmette-Guérin therapy for bladder cancer: A case report

RATIONAL

Bacillus Calmette-Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication.

PATIENT CONCERNS

A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months.

DIAGNOSIS

Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms.

INTERVENTIONS

Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed.

OUTCOMES

BCG "Tokyo-172" strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation.

LESSONS

A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.

Lyme aortitis

A 72-year-old man was admitted with complaints of sudden-onset oppressive precordial pain radiating to the back for 1 hour. He had hypotension, peripheral cyanosis and cold extremities. An initial assessment was done and acute coronary syndrome was excluded. After the patient was admitted, he developed fever and increased levels of inflammatory markers. Data obtained from CT angiography and transoesophageal echocardiogram revealed diffuse parietal thickening of the arch and the descending thoracic aorta, as well as dilatation of the aortic root and the proximal ascending aorta. In addition, the test for Borrelia burgdorferi was positive, and the patient was diagnosed with Lyme vasculitis of the thoracic aorta. He was treated with doxycycline for 3 weeks. Two months later, the patient exhibited a Stanford type A aortic dissection (clinically stable), which was treated by prosthesis replacement. The patient has remained asymptomatic for 1 year after the episode, performing his routine daily activities.

A travel-loving woman in her eighties with lower back pain and weight loss

BACKGROUND

This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding.

CASE PRESENTATION

A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis.

INTERPRETATION

An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

Mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection causing a diagnostic dilemma

Mycotic pseudoaneurysms usually arise from an infectious arteritis or mycotic aneurysms secondary to weakening and destruction of the arterial wall resulting in a contained rupture. We report a case of a mycotic pseudoaneurysm affecting the aortic isthmus of the thoracic aorta which is an extremely rare infection. To our knowledge no case report of mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection has thus far been described. The specific case we present is also unique in that it posed a diagnostic imaging dilemma where the initial imaging revealed a periaortic mass which could not be accurately characterized and only on subsequent imaging reveal itself to be a thrombosed mycotic pseudoaneurysm. We hope that our case report highlights to the medical community the high degree of suspicion one should have regarding pseudoaneurysms when dealing with a complex mass intimately related to a vascular structure.

[Infected Thoracic Aortic Aneurysm Secondary to the Purulent Pericarditis;Report of a Case]

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

Management of a Mycotic Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery

A mycotic aneurysm that also involves the visceral arteries is a life-threatening condition. Surgical management typically consists of débridement and in situ repair with a Dacron graft and reimplantation of the involved visceral branches. We report a rare case of a mycotic saccular thoracoabdominal aortic aneurysm involving the celiac artery, with Streptococcus pneumoniae as the responsible organism. Successful repair of the aneurysm and concomitant revascularization of the celiac artery were achieved.

Pericardial fat flap: surgical technique for infection control after graft replacement

Surgical treatment of mycotic aneurysm of the thoracic aorta is challenging because contamination from surrounding tissues may occur even after complete debridement with a prosthetic graft replacement of the aneurysm. This study describes the simple but very useful technique of using a pericardial fat flap to protect the prosthetic graft from reinfection.

Graft Replacement and Muscle Wrap for Infected Aneurysm of Thoracic Aorta

A 68-year-old man was admitted with high fever and enlargement of the distal aortic arch on chest radiography. Computed tomography showed a huge proximal descending thoracic aortic aneurysm. Graft replacement of the proximal descending thoracic aorta was performed on an emergency basis, and a pectoralis major muscle flap was wrapped around the graft. Salmonella enteritidis was detected in the resected tissue. The patient recovered well, with no signs of infection.

Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts: A Retrospective Cohort Study

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039-0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17-098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

[Mycotic Aneurysm of Distal Aortic Arch, after Total Arch Replacement with Open-stent Graft;Report of a Case]

The patient was a 72-year-old man, who had undergone total arch replacement with an open-stent graft due to saccular aneurysm of distal arch, 2 years before. He was admitted to a local hospital with the complaint of high fever, and was diagnosed as having pyothorax, after computed tomography (CT) scanning. After transferred to our hospital, he was treated by drainage, and antibiotic therapy. But CT scans showed the enlargement of distal arch aneurysm, and migration of the stent graft. Urgent operation was performed. We approached to the site by a full sternotomy, and left anterolateral thoracotomy. Segment 1+2 of the left lung was resected to avoid bleeding and lung injury. Graft replacement of distal arch and descending aorta was performed on cardiopulmonary bypass, with hypothermia, selective brain perfusion and systemic circulatory arrest. To protect from recurrence of infection, the omental flap was transposed to the graft site. Until now, there is no recurrence of infection.

Group B streptococcal (GBS) bacteremia with mycotic thoracic aortic aneurysm and suppurative pericardial effusion

Mycotic aortic aneurysm associated with suppurative pericardial effusion is a rare and serious clinical phenomenon that is linked with significant morbidity and mortality. We report a case of a 78-year-old man who presented with purulent pericardial effusion with tamponade physiology in association with a progressively enlarging, transverse aortic arch, mycotic aneurysm due to group B streptococci. To our knowledge, this is only the second reported case of this nature. Despite advances in the current era of antibiotics and surgical techniques, early diagnosis and aggressive treatment remain sentinel to successful management of the cardiovascular complications of group B streptococcus bacteremia.

Salmonella mycotic thoracoabdominal aortic aneurysm associated with chronic lymphocytic leukemia

Non-typhoidal Salmonella infections typically cause self-limiting gastroenteritis. However, extraintestinal focal infections, including mycotic aneurysms of the aorta, can also occur. We present the case of a 71-year-old man with chronic lymphocytic leukemia (CLL) and a large type V thoracoabdominal mycotic aneurysm infected with Salmonella enteritidis, complicated by thoracolumbar spondylodiscitis, paravertebral collections, and epidural abscess. This is the first report of Salmonella aortitis in the setting of CLL, and the unusual extent of local infective invasion seen here with Salmonella enteritidis infection raises a suspicion of CLL-related immunosuppression as a direct predisposing factor. This case illustrates the need to consider the possibility of an immune defect, even in CLL patients with normal leukocyte counts. The underlying mechanisms are unclear, but are likely to involve defects in cell-mediated immunity, thought to be of particular importance in invasive infections with intracellular pathogens such as Salmonella spp.

Stanford type A aortic dissection secondary to infectious aortitis: a case report

Nowadays, infectious aortitis has become a rare disease thanks to antibiotics, but remains life-threatening. We present a case of a patient with acupuncture-induced infectious aortitis leading to aortic dissection. Chest computed-tomogram scan revealed Stanford type A dissection with pericardial effusion. Under the impression of an impending rupture, emergent surgery was performed. During surgery, infectious aortitis was identified incidentally, so she underwent resection of the infected aorta including surrounding tissues. Then the ascending aorta and hemi-arch were replaced with a prosthetic graft as an in situ fashion. The resected tissue and blood cultures revealed Staphylococcus aureus, so prolonged antibiotherapy was prescribed.

Salmonella mycotic aneurysm: a rare cause of fever and back pain in elderly

An 85-year-old man with history of hypertension presented with fever, cough and abdominal pain. Unfortunately fever and leukocytosis persisted despite treatment. Blood cultures obtained on admission grew Salmonella enteritidis. Subsequently he developed increasing back pain and transoesophageal echocardiography (TOE) was performed, demonstrating a complex ulcer at the aortic arch with multiple small mobile strandlike densities suggestive of vegetation. Contrast thoracic CT scan confirmed an ulcerated atherosclerotic plaque which progressively increasing in size over 3 months despite antibiotics. Therefore, a stent was deployed in view of high risk of perforation and he was placed on prolonged antibiotics. Post-stenting CT scan a few months later showed a patent stent with the aneurysm remained stable in size. Cardiovascular infections develop in approximately 25 % of patients with Salmonella bacteremia. Most patients with Salmonella aortitis have preexisting atherosclerosis at the site of the subsequently infected aneurysm. The diagnosis of S. aortitis can be challenging, because the clinical course may be indolent and the symptoms are nonspecific. A high index of suspicion is required to make the diagnosis of S. aortitis, especially in patients with Salmonella bacteraemia, fever, back pain and/or abdominal pain. This case highlights the usefulness of TOE in the evaluation of diseases involving the thoracic aorta, leading to a successful intervention.

Endovascular aneurysm repair of saccular descending thoracic pseudoaneurysm possibly associated with tuberculosis

In 2010, an 84-year-old man underwent thoracic endovascular aneurysm repair (TEVAR) for the saccular descending thoracic pseudoaneurysm (DTAA), which was adherent to the pulmonary lobe and thoracic vertebrae. Past medical history comprised twice anti-tuberculous medications for pulmonary tuberculosis and tuberculous vertebral osteomyelitis. The dilated aorta was detected at the time of medication for tuberculous vertebral osteomyelitis 24 years ago. However, he was not indicated for the operation, and he was lost to follow-up until now. The association of tuberculosis bacilli was suspected through clinical course as an origin of DTAA, although the histopathological examination was not performed because of invasion. TEVAR was performed considering: (1) no preoperative ongoing inflammation, (2) no evidence of tuberculosis recurrence, and (3) risk factors, such as pulmonary impairments and high age. Several months have been passed since the operation, and the patient remains well without perioperative anti-tuberculous medications.

[Large infectious thoracoabdominal aortic aneurysm in a chronic contained rupture, treated successfully using the "simplified technique"]

The clinical case of a 72-years old male is reported, admitted into a Medical Department through the Emergency Service, with a clinical picture of heavy lumbar pain, with walking compromise and acute urinary retention, lasting for several hours. Laboratory analysis revealed a marked elevation of acute inflammatory parameters and a renal failure, expressed by 108 mg/dl of urea and 4.4 mg/dl of creatinine. The patient was admitted with the provisional diagnosis of acute prostatitis, pos-renal acute renal insufficiency and dorso-lumbar pathology of unknown etiology. Three consecutive and subsequent hemocultures allowed the isolation of a Streptococcus pneumonae strain and a CT dorso lumbar spine evaluation disclosed a D11 to D12 spondylodiscitis, with a partial destruction of the vertebral bodies and an extensive throracoabdominal aortic aneurysm adjacent to those vertebrae, with some characteristic features of an infectious aneurysm. Simultaneously, an hemothorax on the left chest was noticed, consequence of a chronic contained rupture of the aneurysm. Following an intensive and specific antibiotic therapy and with an almost completed recovery of the renal function, he underwent surgical management, consisting in the evacuation and drainage of the hemothorax, followed by resection of the aneurysm and extensive tissular debridmente, culminating in the vascular reconstruction utilizing the "simplified technique", introduced in 1984 by A. Dinis da Gama for the surgical management of thoracoabdominal aortic aneurysms. The patiente tolerated the procedure well, with no intercorrences or complications and the post operative course was unventfull. One month later, a CT-angio control disclosed the revascularization procedure working in excellent condition. Finally, an orthopedic artrodhesis of the injuried vertebrae was performed, allowing an easy and pain-free walking and he was discharged on day 60, under antibiotic treatment. The main features of this clinical case are emphasized and discussed, namely those aspects related to its pathogenesis, clinical presentation, diagnosis and surgical management.

[Treatment of a patient with a ruptured infectious aneurysm of the aortic arch]

Described in the article is a clinical case report concerning surgical treatment of a 65-year-old male patient presenting with a ruptured infectious aortic arch aneurysm. He was subjected to an operation consisting in prosthetic repair of the ascending portion of the aorta and aortic arch with a homograft under conditions of artificial circulation, deep hypothermia, and antegrade cerebral perfusion.

Endovascular repair of a tuberculous aneurysm of descending thoracic aorta

Tuberculous aortic aneurysm (TBAA) is an extremely rare clinical event with life-threatening implication. Management for this condition is challenging and its therapeutic option has not been yet established. A few recent reports described endovascular repair rather than open surgery as the method for treatment. Although this remains controversial, endovascular exclusion has been gaining acceptance for some surgeons. We present a case of TBAA who was treated by endovascular stent grafting for a descending thoracic aortic aneurysm with simultaneous anti-tuberculous medication. The outcome was favorable.

Endovascular stent-graft repair of a tuberculous mycotic aortic aneurysm

Mycobacterium tuberculosis is a rare cause of mycotic aortic aneurysms, which have been classically treated with a combination of antimycobacterial medical therapy and open surgery. Endovascular therapy has been gaining popularity as an alternative to open surgery for mycotic aneurysms. We report a case of a tuberculous mycotic aneurysm of the descending thoracic aorta that was successfully treated with endovascular stent-graft placement with complete resolution of the pseudoaneurysm at 1 year. We also review other cases in the previously published data to identify factors that may affect the outcome of endovascular treatment of tuberculous mycotic aneurysms.

[Extra-anatomical bypass grafting from the ascending to the descending aorta combined with removal of the thoracic-aorta stent graft and a para-aortic abscess following endoscopic repair of the descending portion of the thoracic aorta]

The outcomes of reconstructive repair operations for aneurysms of the descending portion of the thoracic aorta typically appear to be relatively satisfactory. However, a certain cohort of patients presenting with the pathology concerned require repeated secondary interventions due to the development of false aneurysms in the area of the anastomosis and infection of the synthetic vascular stent graft, with the number of such patients steadily increasing with each year. The authors describe herein a clinical case report regarding successful treatment of a patient diagnosed with an infected pseudoaneurysm of the descending portion of the thoracic aorta after an endovascular repair operation. This case report demonstrated a present-day approach to appropriate treatment of patients presenting with the pathology involved.

Successful surgical repair of an infectious thoracic aortic pseudoaneurysm accompanied by aortobronchopulmonary fistula and advanced hepatic dysfunction without assisted circulation

The patient was a 59-year-old female. Because of massive hemoptysis, she was brought to our emergency center by ambulance. Thoracic computed tomography led to a diagnosis of an infectious thoracic aortic pseudoaneurysm accompanied by an aortobronchopulmonary fistula. Emergency surgery followed. Also noted was an advanced hepatic dysfunction, assessed as Child-Pugh score B, caused by an alcoholic liver disease. A localized affected area made it possible for us to perform an aneurysmectomy using a temporary bypass rather than assisted circulation. A patch plasty using expanded polytetrafluoroethylene completed the procedure. Streptococcus agalactiae (GBS) was detected in a sample obtained during the surgery from an abscess located in the aneurysm. The patient made satisfactory postoperative progress and left the hospital walking unaided on the 36th postoperative day.

A case of Lactobacillus casei bacteraemia associated with aortic dissection: is there a link?

We describe an unusual case of Lactobacillus casei bacteraemia in a heavy dairy consumer woman, with a one month history of low grade fever and admitted to our hospital for sudden onset of severe thoracic pain due to dissection of the aortic arch and ascending aorta. The patient underwent four weeks of intravenous ampicillin (2 g every 4 hours) followed by 2 weeks of oral amoxicillin (1 g every 8 hours) with resolution of fever, thoracic pain and progression of aortic disease. On the basis of the patient's symptoms, a possible penetration of L. casei in an aortic wall defect with development of aortic dissection is hypothesized.

[Concomitant syphilitic aneurysms of the thoracic and abdominal aorta. Case report]

The aneurismatic aortic disease is one of the most frequent conditions challenging the vascular surgeon. It can be caused by atherosclerosis, vasculitis, trauma, infection or others. The treatment, even when elective, can be associated to high rates of morbid-mortality, related to the etiology, anatomic location and type of treatment. The authors describe the case of a patient with concomitant syphilitic aneurysms of the descending thoracic aorta, pararenal and aortic bifurcation. The diagnostic presumption was supported by clinical and epidemiology data (the patient was treated for a syphilitic saccular infrarenal aortic aneurysm 5 years before). The etiology was confirmed by the pathological studies of the surgical specimen.

Palliative stent-graft insertion followed by an allograft replacement for an infected and ruptured aortic aneurysm

We report a surgical case of infected thoracic aortic aneurysm. Before arrival of the cryopreserved aortic allograft, the patient had hemoptysis resulting from aneurysm rupture. Therefore endovascular stent grafting was urgently performed three days prior to in situ allograft implantation. Palliative stent grafting prevented circulatory collapse and stabilized the patient until successful allograft implantation.

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

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

Thoracic aortic aneurysm patients with Chlamydophila pneumoniae infection showed a shift in trace element levels in serum and diseased aortic tissue

Few studies have been performed on trace elements in tissues and serum in cardiovascular disease and none in aortic aneurysm. In this study the concentrations of 10 trace elements were determined in serum and aneurysmatic aortic tissue from 23 patients undergoing thoracic surgery. Macroscopically, normal thoracic aortic tissue specimens from 10 forensic autopsies and serum from 23 healthy blood donors served as controls. DNA from the intracellular respiratory pathogen Chlamydophila pneumoniae (C. pneumoniae), which may be involved in the pathogenesis of atherosclerosis, was found in 26% (6/23) of the patients but in none of the controls. The serum copper/zinc ratio, a well-known marker of ongoing infection and/or inflammation, was higher (26%, p<0.001) in aneurysm patients. C. pneumoniae requires iron for its growth. In our aneurysm patients iron was higher in serum (by 54%, p<0.001) and aneurysmal tissue (by 60%, p<0.001). Although calcium was lower in patient sera (by 8%, p<0.001), it tended to be higher (by 20%, ns) in aneurysmatic tissue. In addition, mercury concentrations in serum and aneurysmatic tissue were positively correlated (r=0.51, p<0.05). Moreover, C. pneumoniae-positive aneurysmatic tissues had lower concentrations of manganese (46%, p<0.05) and zinc (26%, ns) but a higher concentration of mercury (50%, p<0.05) than C. pneumoniae-negative aneurysmatic tissues. In conclusion, aneurysm patients showed a shift in trace element levels in serum and in the diseased part of the aorta, the pattern being partly different in C. pneumoniae-positive compared with C. pneumoniae-negative patients. The results are compatible with active infection and/or inflammation, possibly initiated by C. pneumoniae.

[Successful management of ruptured aortic arch aneurysm infected with methicillin-resistant Staphylococcus aureus]

A 64-year-old woman was admitted due to back pain and dyspnea. She was suffering from fever of unknown origin for a few weeks without aortic aneurysm by enhanced chest computed tomography (CT). Chest CT taken 1 month later revealed rupture of aortic arch aneurysm. Total arch replacement was performed with in situ grafting under selective cerebral perfusion combined with deep hypothermic circulatory arrest. Rifampicin (RFP) was sprinkled on the graft at operation and omentopexy was done 5 days after the 1st operation. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated on the culture of the aneurysmal wall, therefore, polymyxin B immobilized fiber with direct hemoperfusion (PMX-DHP) was also conducted with antibiotic therapy. Her clinical course after the 2nd operation was uneventful with no infective complication. We report a successful case of ruptured aneurysm of aortic arch infected with MRSA and review our strategy as one of feasible options without using homograft or preparative RFP-bonded vascular prosthesis.

Infected thoracoabdominal aortic aneurysms including the major abdominal branches in 4 cases

We present four cases of infected thoracoabdominal aortic aneurysm (TAAA), including abdominal branches that underwent surgical repair. The mean age of patients at the time of operation was 61+/-18 (range: 39-83) years. The extent of the aneurysm was Crawford type III in 1 case and type IV in the other 3. They all underwent an emergency or urgent operation, which consisted of a debridement of the infected tissue, in situ four-branched Dacron graft replacement, and iodine gauze packing for 48 h followed by omental wrapping of the graft. To prevent postoperative spinal ischemia, intercostal and lumbar arteries were reimplanted under motor-evoked potential (1.25 pairs per patient). There was one (25%) hospital death, but postoperative graft infection did not occur in these present cases during a mean follow-up period of 15+/-43 (1-96) months. Antibiotics were administered intravenously for 8 weeks after the operation, then continued orally for a lifelong period. Postoperatively, paraplegia occurred in one (25%) patient. Our strategy for infected TAAA including major abdominal branches may prevent postoperative graft infection.

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.

Non-typhoid Salmonella mycotic aneurysm of the aortic arch

Salmonella mycotic aneurysm is a rare but potentially fatal condition. Mortality is high without timely intervention. The clinical presentation is protean and early diagnosis requires a high degree of clinical alertness. Prompt surgical intervention and prolonged antimicrobial therapy are keys to successful treatment. We report an 81-year-old man with an atypical presentation of Salmonella mycotic aneurysm in the aortic arch. The case highlights the need to evaluate all patients over 50 years with non-typhoid Salmonella bacteraemia for possible endovascular infections. Contrast-enhanced computed tomography is useful for making an early diagnosis of this disease.

Type B aortic dissection associated with Salmonella infection

A 59-year-old man with a long history of hypertension and diabetes was admitted to our hospital with acute type B aortic dissection 14 days after the sudden onset of back pain. The dissecting descending thoracic aorta was enlarged to 5.2 cm in diameter, and laboratory tests showed an elevated white blood cell count (15530/mm3) and an increased C-reactive protein level (19.2 mg/dl). Computed tomography performed 2 days after admission revealed rapid growth of the aortic dissection. Blood cultures obtained upon admission were positive for Salmonella. Impending rupture of the aortic dissection complicated by Salmonella infection was strongly suspected, and the patient underwent emergency surgery consisting of debridement and prosthetic graft placement covered by an omental flap. In this case, it is believed that insidious Salmonella aortitis caused acute type B aortic dissection.

Detection and serotype distribution of Actinobacillus actinomycetemcomitans in cardiovascular specimens from Japanese patients

Actinobacillus actinomycetemcomitans, an important pathogen in periodontitis, has also been detected in cardiovascular tissues. Sixty heart valves were collected during valve replacement surgery from 60 patients (one from each), 10 were from patients with infective endocarditis (IE group) and 50 were from patients with other valvular diseases (non-IE group). In addition, 46 samples of aneurysmal tissue were taken from 46 patients with a thoracic or abdominal aneurysm (Aneurysm group, one from each). Dental plaque samples were taken from 54 of the patients, 31 in the IE and non-IE groups and 23 in the aneurysm group. First, the distribution of A. actinomycetemcomitans in all specimens was analysed using a polymerase chain reaction method, which resulted in a positive reaction in 33 (31.1%) of the cardiovascular specimens and 25 (46.3%) of the dental plaque samples. Next, using serotype-specific sets of primers, the serotype distribution of A. actinomycetemcomitans in the cardiovascular specimens and dental plaque samples was found to be significantly different compared to dental plaque samples from Japanese subjects reported previously.

Traitement par voie endovasculaire d'un faux anévrisme tuberculeux de l'isthme aortique

INTRODUCTION

Aortic aneurysms are a well known but rare complication of tuberculosis. Their major complication is aneurysmal rupture, unforeseeable and lethal.

EXEGESIS

Chest pain and hemoptoic expectoration revealed a false aneurysm of the aortic isthmus in a 48-year-old man. Endovascular repair with a stent graft was urgently undertaken. Tuberculosis was diagnosed 6 weeks thereafter by the growth of gastric juice cultures and medically treated. Most tuberculous aortic aneurysms are false aneurysms, caused by an adjacent tuberculous focus eroding the aortic wall. They present with pain, bleeding or as para-aortic masses.

CONCLUSION

Tuberculous false aneurysms of the aorta necessitate an early intervention before they rupture. Surgical treatment remains the preferred option but endovascular repair with a stent graft is a therapeutic alternative, to be considered in high-risk surgical patients.

[Impending rupture of aneurysm of Salmonella-infected aortic arch]

We report a case of a 67-year-old man with Salmonella infected aortic arch aneurysm. The patient presented with persistent high fever, chest pain, back pain and hoarseness. Laboratory studies showed the presence of severe inflammation. Both impending rupture and saccular aneurysm were suspected by preoperative computed tomography (CT), magnetic resonance imaging (MRI) and angiography and diagnosis was, therefore difficult to make. We conducted semi-emergency total aortic arch replacement, under deep hypothermic circulatory arrest and retrograde cerebral perfusion. Salmonella was identified in the aneurysmal wall and antibiotics were administered for 6 weeks until CRP was normalized, when they were replaced by oral antibiotics. Postoperative course was uneventful. The patient was discharged on the 60th postoperative day. He continues to take oral antibiotics.

Mycotic Pseudo-aneurysm of the Ascending Thoracic Aorta After Cardiac Transplantation

A large mycotic pseudo-aneurysm of the ascending thoracic aorta was found in a patient with empyema and infectious mediastinitis after an orthotopic heart transplant procedure. The patient underwent surgical resection of the pseudo-aneurysm with patch aortoplasty and was treated with appropriate long-term antibiotic therapy. The patient continues to do well 3 months after surgery. Early surgical intervention combined with pre-operative and prolonged post-operative antibiotic therapy and close follow-up is essential in these patients.

Mycotic aneurysm of the distal aortic arch caused byAspergillus

We describe an unusual case of a thoracic aortic aneurysm caused by Aspergillus. A 70-year-old man underwent prednisolone and Ara-C treatments for a myelodysplastic syndrome. Blood examination revealed pancytopenia. Under these treatments, an aneurysm presented at the distal aortic arch. He underwent resection of the aneurysm with a graft repair covered by a pedicled omentum flap, followed by prolonged administration of micafungin and itraconazole for a mycotic aneurysm. The postoperative course was favorable without complications. Serum C-reactive protein became negative and he was discharged 2 months after the surgery. However, 4 months after the surgery, he died from worsening of the myelodysplastic syndrome. The prognosis for patients with mycotic aneurysms is poor due to their immunocompetent condition arising from underlying diseases. Therefore, in addition to prompt treatment with antifungal agents combined with surgical debridement, control of the underlying disease is essential for improving the outcome.

Recurrent tuberculous pseudoaneurysm of the descending thoracic aorta--a case report

Tuberculous pseudoaneurysm of the aorta is a rare disease that is uniformly fatal if not treated properly. The authors present a case of a recurrent tuberculous false aneurysm of the descending thoracic aorta that was treated surgically with excision and primary repair of the lesion. To their knowledge, this is the first reported case of recurrent disease after a successful surgical treatment.

Early sternal erosion and luetic aneurysms of thoracic aorta: report of 6 cases and analysis of cause-effect relationship

Six patients with luetic aneurysm of the ascending aorta eroding the sternum are presented. The erosion was an early and principal presentation and the site of erosion and location and morphology of aneurysm were identical in all six patients. The erosion mainly affected the right half of the manubrium and medial end of right clavicle. The aneurysms arose from the junction of the ascending and transverse arches of the thoracic aorta and had narrow opening close to the origin of the innominate artery. The identical presentation, aetiology, angiographic location and morphology, corroborated further at surgery, suggests that syphilitic aneurysms in this location have a strong tendency to cause early sternal erosion.