Mycotic aortic aneurysms are quite infrequent, 1 to 1.8% of aortic aneurysms [1
]. Nearly 50% are seen at the infrarenal aorta, and 25% is involved the juxtarenal or pararenal aorta [2
]. Despite advances in antibiotic treatment, pure medical management for mycotic aneurysms is often inadequate, and gold standard therapy remains surgical resection, debridement of the infected aorta and the surrounding tissue, and either an in situ
interposition or extra-anatomical bypass [3
]. However, these patients have high surgical risk and mortality, especially in non-Salmonella
infection and advanced age [4
]. Fillmore and Valentine [5
] determined that sepsis is the leading cause of death for surgical infected aneurysm patients. Five independent variables are known to associate with operative mortality: extensive peri-aortic infection, female sex, Staphylococcus aureus
infection, aneurysm rupture and supra-renal location [6
]. The negative effect of rupture on mortality is huge that the mortality rate of 13% with intact aneurysm increased to 33.3% in case of rupture.
Endovascular repair of atherosclerotic thoracic and abdominal aneurysms is well established. However, placing an endovascular graft in an infected area remains counter-intuitive and against general surgical principles. Semba et al. [7
] first proposed endovascular aortic repair (EVAR) as an alternative approach. A literature review about endoluminal management of mycotic aneurysm revealed that EVAR seemed a possible alternative method for treating mycotic aneurysm and the only significant independent risk factors for persistent infection were rupture of aneurysm and fever [8
]. If the fever persists after EVAR, a definite surgical treatment should be considered. EVAR has significant advantages over surgical resection as it avoids a large incision, full heparinization, extracorporeal circulation, aortic cross-clamping, interference with respiratory function, and the need for massive transfusion.
Age is a predictor of poor outcome with major surgery, with one report finding that individuals of 80 years old compared with patients 65 to 69 had a twofold higher operative mortality [9
]. The perioperative mortality in EVAR ranges from 1.9 to 5%; however, perioperative mortality in open procedures ranges from 5 to 10%. For octogenarians, one of the most important factors in recovery is rapid return to baseline and prompt discharge from hospital. EVAR had a statistically significant more rapid return to ambulation than the open repair. Thirty-six percentage of individuals who underwent open repair of abdominal aortic aneurysm did not return to be ambulatory (preoperatively 100% ambulatory) [10
Antibiotic treatment of infected aneurysms ranges anywhere from a few weeks to lifelong after surgery. And the regimens should be based on cultures and sensitivities when a pathogen can be isolated. If no pathogen is identified, the regimens should be broad, covering G(+), G(-), anaerobic and fungus.