Endovascular Repair of a Mycotic Aortic Aneurysm Infected With Bacillus Calmette-Guérin After Treatment of Bladder Cancer

Abstract

Bacillus Calmette-Guérin (BCG) is an attenuated form of Mycobacterium bovis used for intravesical therapy for bladder carcinoma. Disseminated infection is uncommon. Aortic involvement with aneurysmal degeneration is even rarer, with <30 cases reported. Prior reports documented aggressive open surgical repair. We have detailed a case of mycotic aortic pseudoaneurysm and para-aortic abscess from disseminated BCG treated with endovascular repair and percutaneous drainage. A 73-year-old man was found to have an infrarenal mycotic aortic pseudoaneurysm with para-aortic and iliopsoas abscess on computed tomography after complaining of persistent abdominal pain. His history was noTable for recurrent in situ bladder carcinoma treated with two sessions of intravesical BCG. He eventually underwent cystoprostatectomy with an ileal conduit and cecectomy. His postoperative course was complicated by bowel perforation requiring a diverting ileostomy and reversal—all performed several months before the current episode. Fine needle aspiration was positive for acid fast bacilli, raising concerns for BCG infection. Antibiotics were started, and he was offered surgical repair. Given the hostile abdomen, we decided to proceed with EVAR. With the patient under general anesthesia, a rifampin-soaked 22 × 94-mm thoracic endograft (Medtronic, Dublin, Ireland) was deployed across the pseudoaneurysm. This case was performed before the company recall of their device. The procedure was performed with a single access site, using an 18F Gore sheath (W.L. Gore & Associates, Flagstaff, Ariz) with a buddied pigtail catheter. A completion aortogram revealed an excellent seal. The procedure was well-tolerated, and the patient discharged on the second postoperative day after retroperitoneal drain placement by the radiology staff. He was seen in follow-up at 1 month, at which time his drain was removed and a computed tomography scan demonstrated resolution of his pseudoaneurysm and abscess. Aortic infection from disseminated BCG is a rare clinical entity. The few reported cases have mostly included open surgical repair. We have described the case of a patient treated with an endograft who had had clinical and radiologic resolution at short-term follow-up. The long-term prognosis has not yet been determined. However, our patient's favorable early outcome shows promise for the technique.