An 80-year-old lady presented to the emergency department with haematemesis, melaena, and back pain of 1-day duration. Previously, she had undergone aortic endografting procedures for an abdominal and a thoracic mycotic aortic aneurysm (4 months and 3 months, resp.). Her past medical history included stage A chronic lymphoblastic leukaemia (CLL) diagnosed 12 years ago which was under surveillance with no current active treatment.
She was referred originally (4 months previously) to the vascular team with persistent abdominal pain and a palpable pulsatile mass. She denied any other symptoms, had not recently lost weight, or had a temperature and urine culture negative on admission. A chest radiograph at that time did not report any abnormality. An abdominal computed tomography (CT) angiogram revealed a saccular AAA, well below the renal arteries, 4
cm in diameter and 3.7
cm in length with inflammatory changes suggestive of periaortitis (). The presence of such inflammatory changes as well as high inflammatory markers (white blood cell (WBC) count: 30.2 × 109/L, erythrocyte sedimentation rate (ESR): 120
mm/hr) raised a suspicion of a mycotic abdominal aneurysm. Blood cultures were obtained but did not grow any microorganisms. It was decided the patient was not fit enough to undergo an open resection and aneurysm repair. After discussion with the patient that curative surgery was likely to prove fatal, she decided to undergo a palliative aortic endografting using Zenith stent-graft (Cook Incorporated, Bloomington, Ind).
CT scan of the abdominal aorta demonstrating a mycotic aneurysm below the renal arteries.
Subsequently, she was readmitted 2 weeks later with chest pain, and a chest CT scan revealed another mycotic aneurysm, this time in the descending thoracic aorta. This aneurysm was 6
cm in diameter, 8.5
cm long, and compressing the oesophagus anteriorly (). The diagnosis was again discussed with the patient, and, for symptomatic control a further endovascular repair utilising Zenith TX2 stent-graft (Cook Incorporated, Bloomington, Ind) was successfully undertaken and the patient, had an uneventful immediate postoperative recovery.
CT scan of the thoracic aorta demonstrating a mycotic aneurysm in the descending thoracic aorta.
She was put on long-term antibiotics to prevent recurrent septicaemia. Investigations were carried out for other septic foci, including an echocardiogram; however, nothing was demonstrated and blood cultures always remained negative.
Her last surveillance CT angiogram was 3 months after her original admission and demonstrated both stents to be well positioned without any evidence of extraluminal leak.
At the time of current admission (4 months after she initially presented), the patient had haematemesis, meleana, and back pain. Initial investigations showed haemoglobin of 6.5
g/dL, WBC count of 13.8 × 109/L (neutrophils 4.6 × 109/L, lymphocytes 8.7 × 109/L), Urea 6.8
mmol/L, and creatinine 70
umol/L. Emergency esophagogastroscopy revealed erosion of the thoracic aortic stent into the oesophagus with active bleeding (). The bleeding points were injected with adrenaline with good effect.
Esophagogastroscopy showing bleeding in the mid oesophagus with the aortic stent eroding into the oesophagus.
An urgent multidisciplinary team meeting including a consultant vascular surgeon, consultant vascular radiologist, consultant gastroenterologist, and consultant haematologist agreed that any further operative treatment was likely to prove fatal. The patient and her family were informed of this advice, and, after further discussion, the decision was made to proceed with active supportive medical treatment, including intravenous omeprazole and blood transfusion, but no further surgical procedures were contemplated.
The lady was transferred to hospice care on analgesia, and regular antibiotics and she died 33 days later due to general deterioration and sepsis.