Patient-Tailored Approach for Diagnostics and Treatment of Mycotic Abdominal Aortic Aneurysm

David J Liesker,Douwe J Mulder,Marjan Wouthuyzen-Bakker,Niek H.J Prakken,Riemer H.J.A Slart,Clark J Zeebregts,Ben R Saleem

doi:10.1016/j.avsg.2022.01.006

Abstract

The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center. A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection. Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 ± 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular, or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In 8 patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n=4) and rupture of the mycotic abdominal aortic aneurysm (n=3). No patient characteristics could be identified as predictive for mortality. This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic and/or other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist.

Highlights

Mycotic aortic aneurysm (MAA) has a poor prognosis
3.1 Basic characteristics and comorbidities Twenty-four patients with an MAA were included in the analysis following the listed criteria
Patients had a mean age of 68 ± 9 years and 20 (83%) were male; 15 patients (63%) were known with tobacco use and 14 patients (58%) with hypertension

Summary

Introduction

Mycotic aortic aneurysm (MAA) has a poor prognosis. Because of its rapid expansion the risk of rupture is very high. The underlying mechanism is an infection of the aortic wall. The incidence of MAAs in Western countries is 0.65 to 2% of all aortic aneurysms, and at the moment of presentation most patients are younger than those with non-mycotic aneurysms.[1,2] MAAs can develop from septic emboli, by hematogenous spread, or directly spreading from infected tissue adjacent to the vascular wall. The most common causative micro-organisms are Staphylococcus and Salmonella species.[3] Clinical presentation can be diverse and range from systemic symptoms of infection to more localized symptoms.[4] It is important that MAAs be recognized early and prompt treatment be initiated

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Conclusion