Infected Abdominal Aortic Aneurysm Research Articles

Comparing Treatment Outcomes of Infected Abdominal Aortic Aneurysm: Open Repair vs. Endovascular Aneurysm Repair

Comparing Treatment Outcomes of Infected Abdominal Aortic Aneurysm: Open Repair vs. Endovascular Aneurysm Repair

Long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral bypass grafting for abdominal aortic infection

ObjectivesThe stapled suture is used to close the aortic stump during surgery for abdominal aortic infection. The current study aimed to investigate the short- and long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral (AxBF) bypass grafting. MethodsThe short- and long-term outcomes of 11 patients who underwent surgery for abdominal aortic infection were retrospectively analyzed. ResultsOf 11 patients, 7 underwent stapled closure of the aortic stump with AxBF bypass grafting, and four underwent other reconstructive procedures with no aortic stump. Four patients (three who underwent stapled closure of the aortic stump and one who underwent other reconstructive procedures without the aortic stump) had operative death. However, none of the patients had aortic stump blow-out during the same hospitalization for surgery. The 1- and 5-year survival rates of the patients who underwent stapled closure of the aortic stump with AxBF bypass grafting were 57% and 29%, respectively. One patient developed aorto-duodenal fistula at 32 months after surgery. The patient survived for 12 months until bleeding in the recurrent aorto-enteric fistula occurred. ConclusionStapled closure of the aortic stump is durable. The use of a linear stapler is a useful technique for reinforcing the aortic stump in patients who underwent excision of an infected abdominal aortic aneurysm or an infected abdominal graft.

A Comparison of Surgical Techniques and Outcomes for Primary Infected Abdominal Aortic Aneurysms

Primary infected abdominal aortic aneurysms (PIAAAs) are associated with high morbidity and mortality. Three repair approaches include open in-situ repair (OIR), extra-anatomic repair (EAR), and endovascular abdominal aortic aneurysm repair (EVAR). This study is one of the largest single-center case series comparing the outcomes of the different surgical approaches for PIAAA. This is a retrospective cohort study of all patients treated surgically for PIAAA between 2000 and 2021. PIAAA diagnosis was defined as the presence of an abdominal aortic aneurysm with evidence of infection on clinical presentation, laboratory markers, radiology, or surgically. Patients with prior aortic surgery were excluded from this study. Basic demographics were compared across the 3 surgical groups using standard statistical methods. Our primary outcomes included mortality at 1 and 5 years. Kaplan-Meier curves were generated and compared using log-rank testing. Multivariate Cox proportional hazards models were created to assess determinants of mortality. A total of 43 patients were included in the full cohort. Patients undergoing EVAR more often had diabetes, end-stage renal disease, and coronary artery disease. EVAR was also more often done in patients with a saccular aneurysm rather than fusiform. (93% vs. 70% in EAR and 42% in OIR; P=0.015). All-cause mortality rates at 1 year were not significantly different between the 3 groups. Survival at 5years did show a significant benefit of OIR over EVAR and EAR: OIR had an 8% mortality rate with EAR having a 53% rate and EVAR having the highest (72%) mortality rate at 5 years (P=0.03). Multivariable Cox regression analysis showed that EVAR (aHR 12.1, (95% CI 1.42 to 103.9), P=0.02) and EAR (aHR 15.1, (95% CI 1.59 to 143.3), P=0.0.02) had an increased 5-year mortality risk when compared to OIR. Repair of primary infected aortic aneurysm is associated with high complication and mortality rates regardless of the approach. In our studied sample, OIR offered an improved long-term survival without added benefits in terms of complication rates. In infected AAA, EVAR should be considered bridging stage between the urgent situation and eventual open repair.

Open repair of an infected abdominal aortic aneurysm in a patient with vascular Ehlers-Danlos syndrome.

Open repair of an infected abdominal aortic aneurysm in a patient with vascular Ehlers-Danlos syndrome.

Repeat aortic valve replacement (AVR) for pseudoaneurysm of mitral-aortic intervalvular fibrosa (P-MAIVF) repair due to hemolytic anemia 6 years after AVR: a case report

BackgroundPseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) after infective endocarditis and/or valve replacement is rarely reported, and transesophageal echocardiography and cardiac multidetector computed tomography are useful for diagnosis. Surgery is mostly recommended to prevent fatal complications.Case presentationA 61-year-old man underwent repeat aortic valve replacement (AVR) with repair of a P-MAIVF due to hemolytic anemia 6 years after AVR, and 4 months after treatment of sepsis and an infected abdominal aortic aneurysm. Two years after the surgery, the patient is alive and well with no recurrence.ConclusionsThe present case was considered to be a very rare case in which surgery was performed because the blood flow entering and leaving the P-MAIVF contacted the prosthetic valve ring, resulting in hemolysis, severe anemia, and heart failure.

Clinical outcomes of in situ graft reconstruction in treating infected abdominal aortic stent grafts following endovascular aortic aneurysm repair: a single-center experience.

This study aimed to review our experience with the explantation of infected endovascular aneurysm repair (EVAR) grafts. This single-center, retrospective, observational study analyzed the data of 12 consecutive patients who underwent infected aortic stent graft explantation following EVAR between January 1, 2010 and December 31, 2019, of which 11 underwent in situ graft reconstruction following graft removal. The presentation symptoms, infection route, original pathology of abdominal aortic aneurysms (AAA), graft materials, and clinical outcomes were analyzed. Six patients underwent total explantation, whereas 5 underwent removal of only the fabric portions. For in situ reconstructions, prosthetic grafts and banked allografts were used in 8 and 3 patients, respectively. Four mechanisms of graft infection were noted in 11 patients: 4 had bacteremia from systemic infections, 3 had persistent infections following EVAR of primary infected AAA, 3 had ascending infections from adjacent abscesses, and 1 had an aneurysm sac erosion resulting in an aortoenteric fistula. No infection-related postoperative complications or reinfections occurred during the mean 65.27-month (standard deviation, ±52.51) follow-up period. One patient died postoperatively because of the rupture of the proximal aortic wall pseudoaneurysm that had occurred during forceful bare stent removal. Regardless of graft material, in situ graft reconstruction is safe for interposition in treating an infected aortic stent graft following EVAR. In our experience, the residual bare stent is no longer a risk factor for reinfection. Therefore, it is important not to injure the proximal aortic wall when removing the bare stent by force.

Open versus endovascular repair of primary infected thoracic and abdominal aortic aneurysms.

Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms. A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors. Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24months in the endovascular repair group and 38months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1year, 2years, 5years and 10years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1year, 2years, 5years and 10years, respectively. Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

Epicardial adipose tissue volume is associated with abdominal aortic aneurysm expansion.

The epicardial adipose tissue volume (EATV) is associated with cardiovascular diseases such as coronary artery disease. However, no information is available regarding the relationship between the EATV and abdominal aortic aneurysm (AAA) expansion. In the present study, we evaluated the association between the EATV and AAA growth and sought to identify the predictors of AAA expansion. Between June 2009 and December 2019, 906 patients had undergone endovascular or open repair of AAAs at our institution. Patients with previous cardiac surgery, previous ascending thoracic aortic surgery, a ruptured AAA, an infected AAA, an inflammatory AAA, a saccular aneurysm, a solitary iliac aneurysm, or reintervention after treatment of the AAA were excluded. A total of 237 patients with at least two preoperative computed tomography (CT) scans performed >180days apart were included in the present study. The EATV within the pericardium was retrospectively quantified from the preoperative non-contrast-enhanced CT images using a three-dimensional workstation. The EATV index was defined as the EATV divided by the body surface area. The AAA expansion rate was defined as an increase in the AAA diameter annually, and the patients were divided into the slow-expansion group (expansion rate,<5mm/y) and the fast-expansion group (expansion rate, ≥5mm/y). The correlation between the expansion rate and the EATV index was analyzed, and the cutoff value for the EATV index was determined using a receiver operating characteristics curve. Multivariate analysis was used to assess the predictors of the AAA expansion rate. The expansion rate of AAA correlated positively with the EATV index (R= 0.237; P< .001). The initial aneurysm diameter (P< .001) and EATV index (P= .009) differed significantly between the two groups. The cutoff for the EATV index was 60.3cm3/m2 (area under the curve, 0.658; 95% confidence interval [CI], 0.568-0.749; sensitivity, 1.000; specificity, 0.309). Multivariate analysis revealed that the initial aneurysm diameter and an EATV index of >60.3cm3/m2 were significantly associated with the AAA expansion rate. The results of the present study have demonstrated that the EATV index is associated with AAA expansion.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms

Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72years; range, 18-94years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P=0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P=0.034) and preoperative serum albumin level <3g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P=0.033) were preoperative parameter that predicted persistent infection. AC-reactive protein level more than 5mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P<0.001) was observed in patients with persistent infection. EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Meta-analysis finds recurrent infection is more common after endovascular than after open repair of infected abdominal aortic aneurysm.

Controversy has continued regarding the use of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) for infected abdominal aortic aneurysms (AAAs). In the present study, we investigated the comparative outcomes of EVAR and OAR for the treatment of infected AAAs. We conducted a systematic review and meta-analysis using the MEDLINE and EMBASE databases through May 2021. We included studies that had described both EVAR and OAR for the treatment of infected AAAs. The primary endpoints were the rates of recurrent infection and related rupture and/or death. Perioperative and 1-year mortality and readmissions and reinterventions were also analyzed. Fourteen observational studies describing a total of 1203 patients (EVAR, 359 [29.8%]; OAR, 844 [70.2%]) were eligible for qualitative analysis. The baseline characteristics included diabetes mellitus (33.2%), fever at presentation (71.6%), rupture at diagnosis (26.1%), and positive blood cultures (52.5%). The mean follow-up period ranged from 12 to 40months. The use of EVAR became more prevalent in recent years (2016-2020, 32.4%) compared with the former period (2010-2015, 13.8%; P< .0001). Fenestrated, branched, or concomitant visceral debranching EVAR was performed in 6.1% of cases. In OAR, surgical debridement was consistently performed, and in situ reconstruction was applied in 82.2% and an omental flap in 51.5%. In nine studies considered for quantitative analysis, the patients' background (EVAR, n= 264; OAR, n= 274) were statistically balanced. The crude rates of recurrent infection and related rupture or death were 13.6% (95% confidence interval [CI], 8.8%-18.5%) and 4.9% (95% CI 1.8%-8.0%), respectively. The pooled analyses depicted significantly higher rates of recurrent infection after EVAR than after OAR (relative risk [RR], 2.42; 95% CI, 1.80-3.27; P< .0001; I2= 0%). Recurrent infection-related rupture or death (RR, 1.51; 95% CI, 0.70-3.23; P= .29; I2= 0%), perioperative death (RR, 0.80; 95% CI, 0.39-1.65; P= .55; I2= 35%), 1-year mortality (hazard ratio, 1.12; 95% CI, 0.97-1.28; P=.13; I2= 0%), and readmission or reintervention (RR, 1.16; 95% CI, 0.74-1.82; P=.52; I2= 0%) were not significantly different statistically between the two groups. Funnel plots showed no evidence of publication bias. Sensitivity analyses of leave-one-out meta-analysis confirmed higher rates of recurrent infection after EVAR. EVAR has become more prevalent as the initial treatment of infected AAAs. Although operative and 1-year survival were similar between OAR and EVAR groups, recurrent infection was more frequent after EVAR. This limitation should be weighed in selecting patients for EVAR in infected AAAs. Postoperative graft and infection surveillance are critical, especially after EVAR.

Comment on: Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

Comment on: Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

Author response to: Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

Author response to: Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

Infected Abdominal Aortic Aneurysm Which Dilated 30 mm over 3 Days and Ruptured without Pain

3日間で30 mmの拡大と無痛性の破裂所見を来した感染性腹部大動脈瘤を経験したので報告する。症例は78歳の女性。下痢と食思不振を主訴に前医に搬送され，感染性腹部大動脈瘤の診断で当院に紹介となった。入院3日目に理学療法士が腹囲の急激な拡大に気づいたため緊急CTを撮影し，瘤径の拡大と破裂所見を認めた。緊急で非解剖学的再建を行い救命し得た。培養からはサルモネラ菌が検出されこれが起因菌と考えられた。

Treatment of Ruptured Infected Abdominal Aortic Aneurysm Caused by Salmonella spp.: A Case Report.

Despite significant advances in diagnostic methods, sepsis is still a current medical problem, and its complications contribute to increased mortality among different age groups. The article presents the case of a 71-year-old man who developed an inflammatory aneurysm of the abdominal aorta in the course of sepsis of Salmonella spp. etiology, followed by its rupture. The case confirms that we must not forget about rare, especially unusual complications, which may depend on the type of microorganism. Properly quick diagnosis allowed for the implementation of appropriate treatment and survival of the patient.

Gallium-67 Scan with Single Photon Emission Computed Tomography for the Evaluation and Monitoring of Infected Abdominal Aortic Aneurysms: A 10-Year Case Series.

PurposeThis study aimed to evaluate the role of gallium-67 single photon emission computed tomography (SPECT) with contrast computed tomography (CT) in the evaluation and monitoring of infected abdominal aortic aneurysms (IAAA).MethodsMaterials and A retrospective cohort analysis was performed using prospectively collected data of consecutive patients with IAAA in Princess Margaret Hospital in Hong Kong between January 2010 and December 2020. The patients were identified using the Radiology Information System.ResultsAll five patients had proven IAAA on CT and/or metabolic imaging. Among them, three were further supported by positive blood culture results. Gallium-67 SPECT with contrast CT was useful in the detection of residual disease, monitoring, and detection of recurrence.ConclusionGallium-67 SPECT with contrast CT is helpful for evaluating IAAA. It serves an important role in guiding management, especially during long-term follow-up.

FDG PET/CT in infected abdominal aortic aneurysm due to Brucellosis

A 66-year-old man with a history of aortic aneurysm, treated 5 years before by endovascular aneurysm repair (EVAR), underwent a follow-up CT angiography showing an increased aneurysm size to 64 mm, a proximal endoleak, and an inflammatory thickening of the aneurysm wall. The patient did not have fever or abdominal pain. Laboratory tests showed a normal blood count, a slightly elevated C-reactive protein and a normal procalcitonin.

Time-to-Event Analysis of the Impact of Endovascular Aortic Aneurysm Repair on Chronic Renal Decline

Although randomized studies have revealed the long-term outcomes of the endovascular repair (ER) of abdominal aortic aneurysm (AAA) compared to open repair (OR), there is controversy surrounding chronic renal decline (CRD) after ER. This study reviewed our propensity-matched cohorts of ER and OR to compare CRD rates using a time-to-event analysis. The ER groups undergoing suprarenal (SR) or infrarenal (IR) proximal fixation were also compared with the OR group. This retrospective review of infrarenal AAA repair was conducted from June 2007-December 2017. Patients with ≥1 year of follow-up were included. Cases of supra/pararenal AAAs, infectious AAAs, rupture, or severe chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 or dependence on renal replacement therapy) were excluded. CRD was defined as eGFR decline of >20% or de novo hemodialysis during follow-up. Patients treated with ER (ER group) and OR (OR group) were propensity-score matched for age, sex, comorbidities, ejection fraction, respiratory function, and baseline eGFR. Kaplan-Meier analysis compared the freedom from CRD rates of the matched cohorts (mER and mOR groups). Patients treated with SR and IR fixation devices (SR and IR groups) were also separately matched to the OR group, followed by analysis. In total, 1087 patients underwent elective AAA repair. Among them, 944 (512 ER and 432 OR) were enrolled. The ER group was older than the OR group (median age 79 vs 71; P<0.001). The ER group had significantly lower baseline eGFR and more comorbidities than the OR group. Among 187 propensity-score matched pairs (187 mER and 187 mOS patients), background characteristics, including age and baseline eGFR, were comparable, but median renal function follow-up was significantly longer in the mER group than in the mOR group (48 vs 26 months; P<0.001). CRD was observed in 57 patients in the mER group and 30 patients in the mOR group. Kaplan-Meier analysis of the freedom from CRD showed no significant difference between the matched groups (P=0.268); however, in the later follow-up of >4 years, CRD was more common in the mER group. The matched analyses between the OR group and specific fixation groups, comprising 102 OR-SR and 73 OR-IR pairs, demonstrated no significant differences in CRD. Compared to OR, there was no significant impact of ER on CRD at up to 4 years, supporting the safety of ER in terms of the mid-term renal outcome of our present clinical practice.

16S rRNA遺伝子解析によりHelicobacter cinaediを同定しえた感染性腹部大動脈瘤の一例

16S rRNA遺伝子解析によりHelicobacter cinaediを同定しえた感染性腹部大動脈瘤の一例

Salmonella Aortitis Causing Primary Aortoenteric Fistula

A 70-year-old male presented with overt upper gastrointestinal bleeding in the forms of hematemesis and melena. He was evaluated and detected to have an infrarenal abdominal aortic aneurysm (AAA) with the involvement of duodenum and presence of air within the aneurysmal sac hematoma suggestive of primary aortoenteric fistula (PAEF). He underwent emergency endo-aneurysmorraphy and debridement of the aortic wall. The infected aneurysmal wall grew Salmonella Typhi. Post-surgery, he was treated with culture-specific antibiotics for 3 months and had an uneventful recovery. Infected AAA secondary to Salmonella Typhi infection presenting as primary aortoenteric fistula (AEF) is a rare entity. Treatment of this entity is early surgical intervention followed by long-term culture-specific antibiotics.

Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined. A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR). Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639days. Cumulative overall survival rates at 30days, 90days, 1year, 3years and 5years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P < 0.001). Propensity score-matched analyses demonstrated no significant differences between EVAR and in situ graft replacement in terms of 3-year all-cause and aorta-related mortality rates (P = 0.093 and P=0.472 respectively). In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.