Tuberculous aneurysm of the aorta is exceedingly rare. To date, the standard therapy for mycotic aneurysm of the abdominal aorta has been surgery involving in-situ graft placement or extra-anatomic bypass surgery followed by effective anti-tuberculous medication. Only recently has the use of a stent graft in the treatment of tuberculous aortic aneurysm been described in the literature. We report two cases in which a tuberculous aneurysm of the abdominal aorta was successfully repaired using endovascular stent grafts. One case involved is a 42-year-old woman with a large suprarenal abdominal aortic aneurysm and a right psoas abscess, and the other, a 41-year-old man in whom an abdominal aortic aneurysm ruptured during surgical drainage of a psoas abscess.
Aorta, disease; Aorta, aneurysm; Aorta, grafts and prostheses
We report a rare case of mycotic abdominal aortic aneurysm associated with
Campylobacter fetus. A 72-year-old male admitted to the hospital
because of pain in the right lower quadrant with pyrexia. The enhanced abdominal computed
tomography (CT) examination showed abdominal aortic aneurysm (AAA) measuring 50 mm in
maximum diameter and a high-density area of soft tissue density from the right lateral
wall to the anterior wall of the aorta. However, since the patient showed no significant
signs of defervescence after antibiotics administration, so we performed emergency surgery
on the patient based on the diagnosis of impending rupture of mycotic AAA. The aneurysm
was resected in situ reconstruction using a bifurcated albumin-coated knitted Dacron graft
was performed. The cultures of blood and aneurysmal wall grew Campylobacter
fetus, allowing early diagnosis and appropriate surgical management in this
case, and the patient is making satisfactory progress. This is the fifth report of mycotic
AAA characterizing culture positive for Campylobacter fetus in blood and
tissue culture of the aortic aneurysm wall.
mycotic abdominal aneurysm; Campylobacter fetus; vascular surgery
We designed this study to evaluate a multi-institutional experience regarding the efficacy of cryopreserved aortic allografts in the treatment of infected aortic prosthetic grafts or mycotic aneurysms. We reviewed clinical data of all patients from 4 institutions who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft or mycotic aneurysms from during a 6-year period. Relevant clinical variables and treatment outcomes were analyzed.
A total of 42 patients (37 men; overall mean age 63 ± 13 years, range 41–74 years) were identified during this study period. Treatment indications included 34 primary aortic graft infections (81%), 6 mycotic aneurysms (22%), and 2 aortoenteric erosions (5%). Transabdominal and thoracoabdominal approaches were used in 38 (90%) and 4 patients (10%), respectively. Staphylococcus aureus was the most commonly identified organism (n=27, 64%). Although there was no intraoperative death, the 30-day operative mortality was 17% (n=7). There were 21 (50%) nonfatal complications, including local wound infection (n=8), lower-extremity deep venous thrombosis (n=5), amputation (n=6), and renal failure requiring hemodialysis (n=2). The average length of hospital stay was 16.4 ± 7 days. During a mean follow-up period of 12.5 months, reoperation for allograft revision was necessary in 1 patient due to graft thrombosis (6%). The overall treatment mortality rate was 21% (n=9).
In situ aortic reconstruction with cryopreserved allografts is an acceptable treatment method in patients with infected aortic prosthetic graft or mycotic aneurysms. Our study showed that mid-term graft-related complications such as reinfection or aneurysmal degeneration were uncommon.
Aneurysm, infected/surgery; bacterial infections/complications/surgery; arteries/transplantation; blood vessel prosthesis/adverse effects; cryopreservation; prosthesis-related infections/ surgery; staphylococcal infections/surgery; surgical wound infection/surgery; reoperation; transplantation, homologous
Mycotic aneurysms constitute a small proportion of aortic aneurysms. Endovascular repair of mycotic aneurysms has been applied with good short-term and midterm results. However, the uncommon aortoenteric fistula formation remains a potentially fatal complication when repairing such infective aneurysms. We present the case of an 80-year-old woman with thoracic and abdominal aortic mycotic aneurysms, which were successfully treated with endografting. However, the patient presented 3 months later with upper gastrointestinal bleeding secondary to erosion of the thoracic graft into the oesophagus. The patient was treated conservatively due to the high risk of surgical repair. There is currently little exposure to the management of mycotic aortic aneurysms. If suspected, imaging of the entire vasculature will aid initial diagnosis and highlight the extent of the disease process, allowing for efficient management. Aortic endografting for mycotic thoracic aneurysms is a high-risk procedure yet is still an appropriate intervention. Aortoenteric fistulae pose a rare but severe complication of aortic endografting in this setting.
Infected abdominal aortic aneurysms (AAAs) can present insidiously with non-specific symptoms or they may present as ruptured AAA in the classical manner.
PRESENTATION OF CASE
We report two cases of mycotic AAA with Listeria monocytogenes. One patient presented with a ruptured aneurysm, while the other patient had a symptomatic non-ruptured presentation with computer tomography (CT) angiogram demonstrating peri-aortic inflammatory change of a rapidly expanding aneurysm. Both patients were treated with excision of the infected tissue and inlay prosthetic surgical repair as well as long term antibiotics.
Arterial aneurysms caused by L. monocytogenes are rare. Risk factors include immunosuppression, infective endocarditis, intravenous drug use and septicaemia. Listeria infections should be discussed with the Health Protection Agency and local microbiologists due to their ubiquity.
Abdominal aortic aneurysm due to L. monocytogenes is best managed via surgical resection in combination with long term antimicrobial therapy. The role of endovascular exclusion is unclear.
Mycotic; Aneurysm; Listeria; Monocytogenes; Aortic
Primary infections of the aorta and infected aortic aneurysms are rare and are life threatening. Most of them are due to bacterial infection occurring in an atheromatous plaque or a pre existing aneurysm during bacteremia. Rarely spread from a contiguous septic process may be the cause. The reported hospital mortality ranges from 16–44%. Gram positive bacteria are still the most common causative organisms. More recently, Gram negative bacilli are seen increasingly responsible. The mortality rate is higher for the Gram negative infection since they most often cause supra renal aneurysms and are more prone for rupture. Best results are achieved by appropriate antibiotics and aggressive surgical treatment. Excision of the infected aneurysm sac as well as surrounding tissue and in situ reconstruction of aorta is the preferred treatment. Pedicled omental cover also helps to reduce infection. Long term antibiotic is needed to prevent reinfection. Mortality is high for those who undergo emergency operation, with advanced age and for nonsalmonella infection.
aorta; aortitis; pseudo aneurysm; mycotic aneurysm
Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient.
A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14x7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.
The patient was discharged on the 9th postoperative day.
This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.
We describe a 54-year-old man who had an ascending aortic prosthetic graft and a porcine aortic valve prosthesis that were infected by Candida albicans. This infection led to the formation of a dissecting false aneurysm of the remaining transverse and entire descending thoracic aorta, and the man was admitted to our hospital for surgical treatment in February of 1991. Staged in situ graft replacement was performed using Borst's "elephant trunk" repair for the proximal aortic reconstruction and an open distal anastomosis technique for the distal repair. Candida albicans in the residual prosthetic graft was identified, and therapy with high-dose liposomal amphotericin B was initiated. The use of liposomal amphotericin B reduces the incidence of adverse effects and allows administration of higher doses than those possible with conventional amphotericin B therapy. Lifelong antifungal therapy is recommended for patients with C. albicans infection of prosthetic aortic grafts.
A 61-year-old man complaining of lumbago and high-grade fever was admitted to our
institution. Computed tomography (CT) revealed a saccular aneurysm in the
infrarenal abdominal aorta and blood culture results were positive for
Streptococcus pneumoniae. He was diagnosed with infected
abdominal aortic aneurysm, and antibiotic therapy was initiated. Follow-up CT
demonstrated a rapidly-enlarging abdominal aortic aneurysm and a newly-developed
descending thoracic aortic aneurysm. For this case, two-stage surgery consisting
of extra-anatomical bypass and in-situ reconstruction using rifampicin-soaked
Dacron graft was performed after an interval of 37 days. The patient was
discharged 14 days after the second surgery without any complications.
infected aortic aneurysm; multiple aneurysms; rifampicin-soaked graft
Cases of true mycotic popliteal artery aneurysm are rare. Presentation is variable but invasive and non-invasive investigations collectively facilitate diagnosis and guide operative procedures. Definitive treatment generally utilizes surgical intervention with excision and reconstruction using autologous vein graft. Prolonged targeted antibiotic therapy is an important adjuvant.
We describe the clinical presentation, radiological investigations and strategies on the management of a 47-year-old Caucasian Irish man who presented with a mycotic aneurysm of the popliteal artery due to thromboembolisation from Streptococus pneumoniae endocarditis.
Cases of true mycotic popliteal artery aneurysms are rare. To the best of our knowledge this is the first documented case of a popliteal artery mycotic aneurysm developing secondary to Streptococus pneumoniae highlighting the changing profile of causative microorganisms.
A 46-year-old man was admitted for surgery on a ruptured mycotic abdominal aortic aneurysm. Emergency repair was performed, during which certain anomalies were noted. First, the bifurcation of the aorta was posterior to the left common iliac vein. Second there were no internal iliac arteries. Also, there were prominent lumbar arteries compensating for the absent internal iliac arteries bilaterally. This, we consider, is the first reported case of congenitally absent bilateral internal iliac arteries.
Bilateral congenital absence of internal iliac arteries
Infective abdominal aortic aneurysm (IAAA) is relatively rare, but a case which is caused by Haemophilus influenzae type B is very rare. We experienced one IAAA case due to H. influenzae type B. The patient was 69-year-old man presenting with severe abdominal and back pain and elevated C-reactive protein (CRP), as inflammatory marker. The patient was found to have saccular aneurysm infrarenal aorta on computed tomography scanning. First, we started to treat him with antibiotic agent and second, we operated him at day 8 after admission with expanded polytetrafluoroethylene graft. Revascularization was made in situ reconstruction. As the result of culture with aneurysm wall, we found that the cause of this aneurysm was the infection of H. influenzae type B. As far as we know, this bacterium is scarcely reported as the cause of infective aortic aneurysms. We reported this IAAA case with the review of the English literature.
abdominal aortic aneurysm; infection; mycotic aneurysm; polytetrafluoroethylene; C-reactive protein; in situ reconstruction; false aneurysm
Purpose: To assess the feasibility of endovascular thoracoabdominal aortic aneurysm (TAAA) repair using a standard off-the-shelf multi-branched stent-graft.
Methods: The aortic anatomy of 66 patients (45 men; mean age 74 years, range 57–87) referred for endovascular repair of TAAA was measured using 3-dimensional reconstructed images from computed tomographic angiograms. In particular, the orientation and longitudinal position of the orifice of each celiac artery, right renal artery, and left renal artery were measured relative to the location of the superior mesenteric artery (SMA) orifice. Based on prior experience, branch insertion with a standard endograft was considered feasible under the following conditions: (1) no more than 4 indispensable (target) arteries to the abdominal viscera, (2) the celiac artery and SMA were 6 to 10 mm in diameter, (3) the renal arteries were 4 to 8 mm in diameter, (4) all target arteries were accessible from a transbrachial approach, (5) the distance between each cuff and the corresponding arterial orifice was ≤50 mm, and (6) the line between the cuff and the orifice deviated by ≤45° from the long axis of the aorta.
Results: Seven (11%) of 66 patients violated conditions 1 through 4: 2 had target arteries that were either too wide or too narrow, 2 had >4 indispensable visceral or renal branches, and 3 patients had inaccessible upward directed renal artery branches. Three of the remaining 59 patients had renal arteries outside the boundaries defined by conditions 5 and 6 when the hypothetical stent-graft was positioned with its SMA cuff 25 mm proximal to the corresponding SMA orifice. However, if the stent-graft were deployed in a more caudal location, only 1 of these 3 renal arteries would have been out of range. Therefore, 58 (88%) of 66 patients met all the eligibility criteria for repair using the off-the-shelf stent-graft.
Conclusion: A standardized, off-the-shelf, multi-branched stent-graft is applicable in 88% of cases of TAAA that would otherwise have been treated using customized stent-grafts. The use of a pre-made stent-graft has the potential to eliminate long manufacturing delays and expand the scope of endovascular repair of TAAA.
thoracoabdominal aortic aneurysm; pararenal aortic aneurysm; endovascular aneurysm repair; branched stent-graft
Aortic stent graft infection is a rare but serious complication associated with high mortality. This report emphasizes the need for continued awareness of potential graft-related septic complications in patients undergoing Endovascular Aortic Repair (EVAR). We report a case in which a post-EVAR patient became unwell about 30 days post operatively and was shown on CT scanning to have a psoas abscess. The abscess was managed with percutaneous drainage and antibiotics. The patient remains well with no evidence of psoas collection or perigraft infection one year on. We review the available literature and discuss the merits of different management strategies.
This case report describes a useful and unusual route for insertion of an intraaortic balloon in 63-year-old man who was operated upon for calcific aortic stenosis, coronary atherosclerosis involving the left anterior descending and right coronary arteries, and a large abdominal aortic aneurysm. Aortic valve replacement was accomplished with a porcine heterograft prosthesis. Bypasses to the left anterior descending and right coronary arteries were constructed with reversed saphenous vein grafts, and the abdominal aneurysm was resected and repaired with a bifurcated woven Dacron vascular graft. An electively placed intraaortic balloon was inserted through the right limb of the aortic graft prosthesis and used to assist the patient during the immediate postoperative period. Uneventful recovery ensued.
We report the case of a 69-year-old man who presented with a symptomatic mycotic aneurysm of the aortic arch. Diagnosis was confirmed by positron emission tomography and by blood cultures positive for Salmonella species. A complete resection of the aortic arch process was performed via left thoracotomy using a cryopreserved aortic homograft and normothermic left heart bypass. The left-sided cerebral vessels were clamped, and adequacy of collateral left brain flow and oxygenation was confirmed by neurophysiologic monitoring. Using this less-invasive operative strategy, we avoided the risks inherent to deep hypothermic circulatory arrest and the use of prosthetic materials.
Aneurysm, infected/pathology/surgery; aorta, thoracic/surgery; aortic aneurysm, thoracic/complications/surgery; cardiac surgical procedures; monitoring, intraoperative/methods; spectroscopy, nearinfrared; ultrasonography, Doppler, transcranial
The patient was an 82-year-old man who was found to have a juxtarenal abdominal aortic aneurysm accompanied by a circumaortic left renal vein (CLRV). During dissection of the proximal anastomosis site the CLRV was injured, but was successfully repaired. A graft implantation was performed below the renal arteries. The incidence of CLRV is thought to be rare, however it is found in 7% of cadavers donated for anatomy. CLRV may cause unexpected bleeding by inadvertent dissection of the abdominal aorta. To prevent unexpected bleeding, surgeons should always keep in mind this potential risk when performing surgery.
venous anomaly; circumaortic left renal vein; abdominal aortic aneurysm
Coxiella burnetii, the causative agent of Q fever, may cause endocarditis and vascular infections that result in severe morbidity and mortality. We report a case of a C. burnetii-infected abdominal aorta and its management in a patient with a previous endovascular aortic aneurysm repair.
A 62-year-old Caucasian man was admitted to our hospital three months after endovascular aortic aneurysm repair with a bifurcated stent graft. He had increasing abdominal complaints and general malaise. A computed tomography scan of his abdomen revealed several para-aneurysmal abscesses. Surgery was performed via midline laparotomy. The entire abdominal wall of his aneurysmal sac, including the abscesses, was removed. The vascular endoprosthesis showed no macroscopic signs of infection. The decision was made to leave the endograft in place because of the severe cardiopulmonary comorbidities, thereby avoiding suprarenal clamping and explantation of this device with venous reconstruction. The proximal and distal parts of the endograft were secured to the aortic wall and common iliac artery walls, respectively, to avoid future migration. Polymerase chain reaction for C. burnetii was positive in all specimens of aortic tissue. Specific antibiotic therapy was initiated. Our patient was discharged in good clinical condition after six days.
In our patient, the infection was limited to the abdominal aneurysm wall, which was removed, leaving the endograft in place. Vascular surgeons should be familiar with this bailout procedure in high-risk patients.
Endovascular stent graft repair of abdominal aortic aneurysm (AAA) has undergone rapid developments since it was introduced in the early 1990s. Two main types of aortic stent grafts have been developed and are currently being used in clinical practice to deal with patients with complicated or unsuitable aneurysm necks, namely, suprarenal and fenestrated stent grafts. Helical computed tomography angiography has been widely recognized as the method of choice for both pre-operative planning and post-operative follow-up of endovascular repair (EVAR). In addition to 2D axial images, a number of 2D and 3D reconstructions are generated to provide additional information about imaging of the stent grafts in relation to the aortic aneurysm diameter and extent, encroachment of stent wires to the renal artery ostium and position of the fenestrated vessel stents. The purpose of this article is to provide an overview of applications of EVAR of AAA and diagnostic applications of 2D and 3D image visualizations in the assessment of treatment outcomes of EVAR. Interference of stent wires with renal blood flow from the hemodynamic point of view will also be discussed, and future directions explored.
Abdominal aortic aneurysm; Stent graft; Computed tomography; Image visualization; Three-dimensional reconstruction; Follow-up
We report the successful removal of a mycotic false aneurysm of the descending thoracic aorta. The aneurysm developed after a sepsis secondary to Canadida albicans. General signs of infection were absent at the time of surgery, although the aortic wall was still infected. A Dacron graft was inserted after resection of the entire aortic wall, and irrigation of the left pleura with amphotericin B was started postoperatively. The patient recovered fully and is in good condition one year after the operation. (Texas Heart Institute Journal 1986; 13: 459-462)
Mycotic false aneurysm; Candida albicans
Perigraft seroma usually occurs both polyester and polytetrafluoroethylene (PTFE) graft which are placed superficially for axillofemoral and femorofemoral bypasses, while it is a rare complication of conventional abdominal aortic and iliac arterial aneurysm repair. The cause of the seroma has not been elucidated, and several hypotheses have been proposed such as immunologic response to graft materials, discharge of serous fluid through the graft wall, and so on. The seroma sac occasionally increases their size finally leading to rupture. The treatment of perigraft seroma has not been established so far; there have been various recommended procedures including aspiration, graft removal followed by other material graft replacement, cessation of antithrombotic drugs, and careful observation. We report two cases of perigraft seroma after conventional aortoiliac aneurysm repair with a knitted polyester graft via left pararectal retroperitoneal approach, which were gradually shrinking by theirselves.
perigraft seroma; aortoiliac aneurysm; polyester graft
Aneurysms are common in our increasingly elderly population, and are a major threat to life and limb. Until the advent of vascular reconstructive techniques, aneurysm patients were subject to an overwhelming risk of death from exsanguination. The first successful repair of an abdominal aortic aneurysm using an interposed arterial homograft was reported by Dubost in 1952. A milestone in the evolution of vascular surgery, this event and subsequent diagnostic, operative and prosthetic graft refinements have permitted patients with an unruptured abdominal aortic aneurysm to enjoy a better prognosis than patients with almost any other form of major systemic illness.
Intravesical BCG-instillation for bladder cancer is considered safe but is not without risk. While most side-effects are localised and self-limiting, the development of secondary vascular pathology is a rare but significant complication.
PRESENTATION OF CASE
A 77-year-old male presented with a mycotic abdominal aortic aneurysm and associated aorto-enteric fistula 18 months after receiving intravesical BCG-instillations for early stage transitional cell carcinoma.
Response rates to intravesical BCG for early stage transitional cell carcinoma are high. The procedure produces a localised inflammatory response in the bladder but the exact mechanism of action is unclear. The treatment is generally well tolerated but BCG-sepsis and secondary vascular complications have been documented.
Mycotic abdominal aortic aneurysm with associated aorto-enteric fistula secondary to BCG is very rare. Few examples have been documented internationally and the extent of corresponding research and associated management proposals is limited.
Surgical options include in situ repair with prosthetic graft, debridement with extra-anatomical bypass and, occasionally, endovascular stent grafting. Recommended medical therapy for systemic BCG infection is Isoniazid, Rifampicin and Ethambutol.
Current screening methods must be updated with clarification regarding duration of anti-tuberculous therapy and impact of concomitant anti-tuberculous medication on the therapeutic action of intravesical BCG. Long-term outcomes for patients post graft repair for mycotic aneurysm are unknown and more research is required regarding the susceptibility of vascular grafts to mycobacterial infection.
Recognition of the risks associated with BCG-instillations, even in immunocompetent subjects, is paramount and must be considered even several months or years after receiving the therapy.
BCG; Aortic aneurysm; Aorto-enteric fistula; Bladder carcinoma
Spinal “stroke” is an uncommon cause of paraplegia. Spinal cord infarction from unruptured aortic aneurysm is rare. When encountered it poses diagnostic challenge to the clinician due to its rarity, which may lead to incorrect or delayed diagnosis. We report a case of 62-year-old man presenting to casualty as caudaequina syndrome due to spinal cord infarction secondary to emboli from an infra renal abdominal aortic aneurysm. To the authors knowledge this is first case of its kind and has not been reported in literature. Patient had improvement in proximal motor function following repair of the aneurysm, although he remained doubly incontinent in six months follow up.
The potential complications of an abdominal aortic aneurysm include rupture, compression of surrounding structures, thrombo-embolic events and fistula. The most common site of arterio-venous fistula is the inferior vena cava. Fistula involving a renal vein is particularly uncommon.
This report describes a 54-year-old Caucasian woman who was admitted to the emergency department with fatigue, severe dyspnea and bilateral lower limb edema. In the first instance this anamnesis suggested possible heart failure. In fact, our patient presented with multi-organ system failure due to a fistula between an infra-renal aortic aneurysm and an aberrant retro-aortic renal vein.
To our knowledge, this is the first report of a woman with a fistula between an infra-renal aortic aneurysm and an aberrant retro-aortic left renal vein. Aorto-venous fistulas may be asymptomatic or may present with symptoms characteristic of arterio-venous shunting and/or aneurysm rupture. This type of fistula is a rare cause of heart failure. Clinical examination and imaging are essential for detection.