Infected Aneurysm Research Articles

Myocardial ischaemia as a result of external coronary compression from infective aortic root aneurysm: atypical presentation of prosthetic valve endocarditis

SummaryThis case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA.

FT13. Aneurysm Sac Thrombus Volume Predicts Endoleak With Aneurysm Expansion After Endovascular Aneurysm Repair

Several studies have analyzed risk factors that may influence the incidence of endoleak with sac expansion after endovascular aneurysm repair (EVAR). Previous studies demonstrated a quantitative protective effect of intraluminal thrombus for endoleak. However, they assessed the amount of intraluminal thrombus indirectly by thrombus thickness, percentage of circumferential luminal thrombus, thrombus area, and so on. Therefore, the correlation still has not been well demonstrated. The aim of this study was to examine the correlation of preoperative intraluminal thrombus, measured by thrombus volume, with the incidence of endoleak and late sac expansion. Between June 2007 and March 2014, there were 423 patients who underwent EVAR at our institution. Ruptured, inflammatory, and infected aneurysms were excluded; 214 patients who had preoperative and postoperative computed tomography angiography (CTA) and at least 3 years of follow-up were included in this study. Prospectively collected data were supplemented with a retrospective review of medical records and radiologic images. The demographic and clinical characteristic profiles were collected. CTA was evaluated with Aquarius iNtuition software (TeraRecon, Foster City, Calif) to obtain aneurysm sac, intraluminal thrombus volume, and other anatomic factors. Late endoleak was defined as a leak observed at 30 days. Significant abdominal aortic aneurysm sac expansion was defined as an increase of 5 mm. Logistic regression and Cox regression analysis were used to assess the association of each variable with the incidence of late endoleak and sac expansion. Of 214 patients, 49.1% (105 patients) had late endoleak and 19.6% (48 patients) had late endoleak with sac expansion on CTA. The mean follow-up duration was 53.4 months (range, 18.5-109.4 months). Univariate analysis demonstrated that number of total patent lumbar arteries (P = .011), a patent inferior mesenteric artery (IMA; P < .01), diameter of IMA (P < .01), Excluder (W. L. Gore & Associates, Flagstaff, Ariz) stent graft (P < .01), smoking history (P = .022), and preoperative intraluminal thrombus volume/sac volume (P = .018) are significant factors regarding the incidence of late endoleak . Logistic regression analysis showed that variables such as diameter of IMA (P = .006), Excluder stent graft use (P < .01), and preoperative intraluminal thrombus volume/sac volume (P = .026) are predictors of incidence of late type II endoleak. Cox regression analysis showed that the preoperative intraluminal thrombus volume/sac volume is the only significant predictor of incidence of late endoleak with sac expansion (P = .015). Preoperative aneurysm sac thrombus volume predicts incidence of endoleak with aneurysm expansion after EVAR.

FT07. Follow-up Results of Arterial Reconstructions With Cryopreserved Arterial Allografts: Infected Abdominal Aortic Aneurysm and Aortic Prosthesis Infection

FT07. Follow-up Results of Arterial Reconstructions With Cryopreserved Arterial Allografts: Infected Abdominal Aortic Aneurysm and Aortic Prosthesis Infection

FT08. Retrospective Review of Underlying Causes of Endovascular Aneurysm Repair Failure Requiring Open Conversion

Most endovascular aneurysm repair (EVAR) complications can be treated by endovascular means. However, some patients require open conversion (OC) after EVAR because of complications that are resistant to endovascular treatment. The frequency of OC after EVAR has been variously reported because of different follow-up duration and diagnostic program of the EVAR complications. Surgical morbidity and mortality associated with OC were reported to be significantly higher compared with the standard open surgical repair of abdominal aortic aneurysm. We attempted to search for underlying causes of EVAR failure requiring OC. OC was defined as surgical opening of the aneurysmal sac after EVAR regardless of aortic cross-clamping or stent graft removal. To find underlying causes of EVAR failure requiring OC, we retrospectively reviewed history of infection after EVAR, endovascular reintervention after EVAR, pre- and post-EVAR computed tomography images, and angiographic images during the EVAR procedure. Diagnosis and type of endoleak depended on computed tomography, ultrasound, and operative findings. For the diagnosis of endograft infection (EGI), we followed the Management of Aortic Graft Infection Collaboration (MAGIC) criteria (EJVES 2016;52:758-63). Twenty-three OCs (institutional, n = 8) were performed for 22 patients (median age, 75 years; male, 83%) at a mean 26 months (2-130 months) after EVAR during the past 14 years. Our institutional frequency of OC was 1.8% after standard EVAR. Indications for OC were end leak (n = 11 [48%]), EGI (n = 9 [39%]), aortic rupture (n = 4 [17%]; 1 intraoperative and 3 late ruptures), and continuous sac enlargement without evidence of endoleak (n = 2 [9%]). Endoleaks requiring OC were type IA (n = 5), type IB (n = 1), type IIIA (n = 1), and type IIIB (n = 2). Among nine EGIs, three (33%) patients presented with aortoenteric fistula or erosion. Among the patients with EGI, the infection source was identifiable in four (44%) patients, which included EVAR for patients with infected abdominal aortic aneurysm (n = 2) and coexisting psoas abscess at the time of EVAR (n = 2). Among five late EGIs, three patients showed a remote site infection source, including leg cellulitis, gingival abscess, and bacteremia. Among four aortic ruptures, one patient required OC because of intraoperative aortic rupture during EVAR. As a result of OC, we have experienced one (4%) surgical death and three early postoperative complications, including late midcolic artery rupture in type I neurofibromatosis, left colon ischemia, and acute renal insufficiency. We think that at least 73% of OCs due to endoleak, 44% of OCs due to EGI, and 25% of aortic ruptures are preventable by proper selection of EVAR candidates and careful endovascular technique.

Cerebral microbleeds predict infectious intracranial aneurysm in infective endocarditis

Magnetic resonance imaging (MRI) features such as cerebral microbleeds and sulcal susceptibility-weighted imaging (SWI) or gradient-echo T2* lesions in infective endocarditis (IE) have been associated with the presence of infectious intracranial aneurysm (IIA). Our aim was to validate these MRI predictors for IIA in order to better assist in assessing the appropriate indications for digital subtraction angiography (DSA). The derivation cohort comprised IE patients with neurological evaluation, MRI and DSA at a single tertiary referral center from January 2015 to July 2016. Validation was performed in a cohort of IE patients who underwent MRI and DSA at the same center from 2010 to 2014. Of 62 patients in the derivation cohort, 10 (16%) had IIAs. Of 129 in the validation cohort, 19 (15%) IIAs were identified. The MRI predictors for IIA consist of (i) contrast enhancement with microbleeds, (ii) cerebral microbleeds >5 mm or sulcal SWI lesions and (iii) any MRI hemorrhages. The sensitivity for the presence of IIA in each group of the derivation cohort was 90%, 80% and 100%, respectively. The sensitivity in the validation cohort was 47%, 68% and 94% respectively. The specificity in the derivation cohort was 87%, 85% and 18%. In the validation cohort, the specificity was similar at 87%, 75% and 27%. The absence of MRI hemorrhages may not necessitate the need for DSA.

Natural History of Infectious Intracranial Aneurysms Undergoing Antibiotic Treatment (P1.229)

Natural History of Infectious Intracranial Aneurysms Undergoing Antibiotic Treatment (P1.229)

Bloodstream infection is associated with infectious intracranial aneurysm in left ventricular assist device (P6.206)

Bloodstream infection is associated with infectious intracranial aneurysm in left ventricular assist device (P6.206)

Infectious Intracranial Aneurysm During Cardiac Valve Repair (P6.207)

Infectious Intracranial Aneurysm During Cardiac Valve Repair (P6.207)

Optimization of rifampin coating on covered Dacron endovascular stent grafts for infected aortic aneurysms

ObjectiveIn the treatment of an infected aorta, open repair and replacement with a rifampin-impregnated Dacron vascular graft decrease the risk of prosthetic graft infections, with several protocols available in the literature. We hypothesize that the same holds true for endovascular aneurysm repair, and after studying and optimizing rifampin solution concentration and incubation period to maximize the coating process of rifampin on Dacron endovascular stent grafts (ESGs), we propose a rapid real-time perioperative protocol. MethodsSeveral prepared rifampin solutions, including a negative control solution, were used to coat multiple triplicate sets of Dacron endovascular aortic stent grafts at different but set incubation periods. Rifampin elution from the grafts was studied by spectroscopic analysis. Once an optimized solution concentration and incubation time were determined, the elution of rifampin over time from the graft and the graft's surface characteristics were studied by ultraviolet-visible spectroscopy and atomic force microscopy. ResultsAll coated ESGs with any concentration of prepared rifampin solution, regardless of incubation time, immediately demonstrated a visible bright orange discoloration and subsequently after elution procedures returned to the original noncolored state. At the 25-minute incubation time (standard flush), there was no statistical difference in the amount of rifampin coated to the ESGs with 10-mg/mL, 30-mg/mL, and 60-mg/mL solutions (0.06 ± 0.01, 0.07 ± 0.05, and 0.044 ± 0.01, respectively; P > .05). This was also true for a 10-minute incubation time (express flush) of 10-mg/mL and 60-mg/mL rifampin solution concentrations (0.04 ± 0.007 and 0.066 ± 0.014, respectively; P = .22). The elution-over-time of coated rifampin ESG, although not statistically significant, did seem to plateau and to reach a steady state by 50 hours and was confirmed by surface characteristics using atomic force microscopy. ConclusionsHaving studied two variables of rifampin coating techniques to Dacron ESGs, the authors propose a rapid real-time perioperative coating protocol by using a 10-mg/mL rifampin solution for a 10-minute incubation period. As rifampin loosely binds to Dacron ESGs by weak intermolecular forces, a rifampin-coated ESG would need to be inserted in a timely fashion to treat the diseased aorta and to deliver its antibiotic affect. A rapid perioperative coating protocol followed by immediate deployment makes our proposed technique especially useful in an urgent and unstable clinical scenario.

Delayed cerebral thrombosis complicating pneumococcal meningitis: an autopsy study

BackgroundDelayed cerebral thrombosis (DCT) is a devastating cerebrovascular complication in patients with excellent initial recovery of pneumococcal meningitis. The aetiology is unknown, but direct bacterial invasion, activation of coagulation or post-infectious immunoglobulin deposition has been suggested.Methods We studied histopathology of 4 patients with pneumococcal meningitis complicated by DCT. Results were compared with 8 patients who died of pneumococcal meningitis without DCT and 3 non-meningitis control cases. Furthermore, we evaluated vascular immunoglobulin depositions (IgA, IgG and IgM) and the presence of pneumococcal capsules by immunofluorescence.Results Patients who died after pneumococcal meningitis showed inflammation in the meninges and blood vessels with extensive infarction and thrombosis. We did not observe gross differences between DCT and non-DCT patients, except that 2 of 4 DCT patients had a basilar artery aneurysm compared to none of the non-DCT patients. We observed high density of IgM and IgG deposition in meningitis cases as compared to controls, but no difference between DCT and non-DCT patients. Immunofluorescence staining of pneumococci demonstrated the presence of bacterial capsules in the meninges of all meningitis patients, even 35 days after the initiation of antibiotic treatment.ConclusionThe aetiology of DCT complicating pneumococcal meningitis seems to be of multifactorial aetiology and includes vascular inflammation, thromboembolism of large arteries and infectious intracranial aneurysms. Pneumococcal cell wall components can be observed for weeks after pneumococcal meningitis and may be a source of resurging inflammation after the initial immunosuppression by dexamethasone.

The Results of In Situ Prosthetic Graft Replacement for Infected Aortic Disease.

Infected aortic disease is a serious clinical condition associated with significant morbidity and mortality. This study reviewed the outcomes of in situ aortic replacement with a prosthetic graft for infected aortic disease, including primary infected abdominal aortic aneurysms (PIAAA), infected aortic prosthetic grafts (IAPG), and infected aortic stent grafts (IASG). Twenty-eight consecutive patients who underwent in situ aortic replacement with a prosthetic graft for PIAAA, IAPG, and IASG at a single center from January 2001 to December 2015 were retrospectively analyzed. Demographics, clinical characteristics, medical management, surgical procedure, and clinical outcomes were included. Nineteen patients with a PIAAA, three with an IAPG following open repair of abdominal aortic aneurysm (AAA), and six with an IASG following endovascular aortic repair underwent in situ prosthetic graft replacement with infected tissue and graft removal. In-hospital mortality was 7.1% (2/28). One died of bleeding on postoperative day 12, and the other died of hepatic failure on postoperative day 32. Of six patients with an IASG, two had major complications that were related to barb injury at the proximal aorta. The reinfection rate was 14.3% (4 of 28) during a mean follow-up of 35.7months (1-142months). All new grafts of three patients with IAPG were reinfected. The other patient became reinfected after surgery for PIAAA with iatrogenic small bowel perforation that was not detected during surgery. In situ graft replacement of PIAAA and IASG is feasible with acceptable outcomes, but the outcome for IAPG is questionable.

Abstract 163: Natural History of Infectious Intracranial Aneurysms Undergoing Antibiotic Treatment

Introduction: Infectious intracranial aneurysm (IIA, or mycotic aneurysm) is a cerebrovascular complication of infective endocarditis. We aimed to describe the clinical course of IIAs during antibiotic treatment. Methods: We reviewed medical records of persons with infective endocarditis who underwent cerebral angiography at a single tertiary referral center from 2011-2016. Aneurysms were followed with subsequent angiography for bad outcome (growth, rupture or new IIA formation) or good outcome (regression or resolution) until endovascular therapy, aneurysm resolution, or end of observation. Results: Of 618 patients included, 40 (6.5%) had 43 IIAs. Eighteen (42%) aneurysms underwent initial endovascular treatment. Twenty-five unruptured aneurysms were treated with antibiotics alone for a median 36 days (interquartile range (IQR) 9-57). Nine (36%) aneurysms had bad outcome (2 new IIA formation, 7 enlargement) at median 8 days, IQR 1-25. Angiography revealed good outcome in 7 (28%) patients (6 resolution, 1 regression) at median 36 days, IQR 16-49. Two patients had no IIA change after median 27 days, and both underwent endovascular treatment. Seven aneurysms had no angiographic reevaluations but no rupture during clinical follow-up for median 4 days, IQR 3-12. There were no aneurysmal ruptures during observation. Conclusion: IIAs represent a dynamic disease. Only a quarter of IIAs resolve with antibiotics alone.

Abstract WP325: Peri-operative Neurological Complications of Valve Surgery for Infective Endocarditis Patients With Stroke

Introduction: Surgical valve repair is often delayed for infective endocarditis (IE) patients with stroke. We compared neurological outcome of early and delayed valve surgery and identified pre-surgical imaging characteristics that were associated with perioperative neurological complications. Methods: We reviewed 228 patients with acute IE diagnosed by modified Duke’s Criteria who underwent cerebral angiogram (CA) between January 2010 - December 2016 at a single center. Patients without pre-surgical CT and MRI were excluded. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis, delayed as &gt;14 days. Peri-operative neurological complication is any new clinical or radiologic diagnosis of ischemic or hemorrhagic stroke, and seizure. Results: 148 of 228 patients underwent valve surgery. 69 patients (46.6%) had early surgery at median 9 days after IE diagnosis, and 79 patients (53.4%) had delayed surgery at median 28 days. On pre-surgical imaging, acute to subacute ischemic stroke was seen in 81% of the early group (n=56) and 78% of the delayed group (n=62, p=0.69). However, 22.8% of patients (n=18) in the delayed group had evidence of subarachnoid hemorrhage (SAH) compared to 10.1 % of patients in the early group (n=7, p=0.04). Despite this finding, delayed group did not have higher rate of perioperative neurological complication than that of the early group (24.1% vs 13%, p=0.95). Overall, 15 surgical patients (10.1%) had perioperative neurological complications: 4 with acute ischemic stroke, 9 with ICH, 1 with both an infarct and ICH, and 3 with seizures. 33.3% of patients who had a perioperative neurological complication had evidence of SAH on pre-surgical imaging (n=6) compared to 14.6% of patients who did not have any neurological complications (n=19, p=0.012). In the group of patients with complications, SAH found prior to surgery were all cortical in the sulci, and 3 cases of SAH were associated with presence of infectious intracranial aneurysm found on pre-surgical CA. Conclusion: In IE patients with stroke, presence of sulcal SAH on pre-surgical imaging is associated with developing perioperative neurological complications irrespective of surgical timing.

Abstract WP85: Infectious Intracranial Aneurysm During Cardiac Valve Repair

Introduction: A complication of infectious endocarditis (IE) is infectious intracranial aneurysm (IIA, or mycotic aneurysm). Diagnosis and resolution of IIA prior to cardiac valve repair in IE patients is thought to reduce the risk of IIA rupture during perioperative anticoagulation. We report a series of patients undergoing cardiac valve replacement with unresolved IIAs. Methods: The study was designed as a review of medical records at a single tertiary referral center from 2011-2016. A total of 618 patients with infective endocarditis undergoing cerebral angiogram were reviewed. Patients with secured unruptured IIA prior to surgery were compared to patients with unsecured unruptured IIA prior to surgery. Perioperative intracranial hemorrhage and death were compared between the two groups. Results: Of 27 patients with IIA undergoing valve surgery, 7 (26%) had preoperative unsecured aneurysms, while 20 (74%) had angiographically resolved or occluded aneurysms (14 resolved by endovascular occlusion, 6 by antibiotics). The 7 unsecured IIAs were not resolved for various reasons (3 had high risk of vessel sacrifice, 1 had small size, 3 had patient clinical instability). Median time from last angiogram to valve surgery was 7 days (IQR 2-8) in the unsecured group, and 5.5 days (IQR 3-9) for secured group. There was no postoperative subarachnoid hemorrhage (SAH) or aneurysmal rupture seen in either group. Perioperative hemorrhagic transformation of a subacute ischemic stroke was observed in one patient in each group (14% versus 5%, p=0.46). There were no deaths or further bleeding in the unsecured aneurysm group. Conclusion: There was no post-operative death or SAH seen in seven patients undergoing cardiac valve surgery with unsecured IIA.

Abstract WMP66: Infection and Coagulopathy in Left Ventricular Assist Device (LVAD)-Associated Intracranial Hemorrhage: A Case-Crossover Study

Introduction: Left ventricular assist device (LVAD)-associated intracranial hemorrhage carries a high morbidity and mortality rate. Despite the common occurrence, the etiology of intracranial hemorrhage is uncertain. We aim to explore the impact of infection and coagulopathy on intracranial hemorrhage in a case-crossover study. Methods: We reviewed consecutive patients with intracranial hemorrhage in a prospectively collected data of LVAD patients from a single, tertiary center from October 2004 to December 2016. Information on infection and international normalized ratio (INR) values were collected at the time of hemorrhage and 1 month prior to the ictus as controls. Cerebral angiogram studies were reviewed to investigate the presence of infectious intracranial aneurysm (IIA). Results: Of 477 persons with LVAD, 47 (10%) developed intracranial hemorrhage (27 intracerebral, 14 subarachnoid, and 6 subdural hemorrhages). Of 47 (median age 58 [interquartile range 47-67]; 39 male), 27 (54%) persons had active infection at the time of intracranial hemorrhage, and 7 (15%) at 1 month prior to the ictus. The relative risk of intracranial hemorrhage due to active infection compared to the infections at 1-month was 2.4 (95% CI 1.6-3.5; p&lt;0.0001). Using a paired t-test, the mean INRs at the time of intracranial hemorrhage were also significantly higher at the time of hemorrhage compared to those at 1-month (2.6±1.9 vs. 1.8±0.8; p=0.01). Thirteen persons underwent cerebral angiogram (7 subarachnoid hemorrhage, 6 intracerebral hemorrhage). Four (57%) IIAs were identified only in SAH patients who also had acute bloodstream infections. In contrast, none of intracerebral hemorrhages had IIAs. Conclusions: Active infection and elevated INR increase the risk of LVAD-associated intracranial hemorrhage. Bloodstream infection and subarachnoid hemorrhage are associated with the presence of IIA in LVAD.

Abstract 162: Microhemorrhages in MRI Predict Infectious Intracranial Aneurysm in Infective Endocarditis

Background: MRI features such as cerebral microbleeds and sulcal susceptibility weighted imaging (SWI) or gradient-echo T2* (GRE-T2*) lesions have been reported to be associated with the presence of infectious intracranial aneurysm (IIA) in infective endocarditis (IE). We aimed to describe the MRI imaging features that predict the presence of IIA. Methods: The derivation cohort comprised 116 IE patients with neurological evaluation at a single tertiary referral center from January 2015 to July 2016. The MRI predictors associated with IIA was evaluated, and we developed the MRI imaging predictors and assessed sensitivity and specificity. External validation was performed in a cohort of 129 IE patients who underwent digital subtraction angiogram (DSA) at the same center from 2010-2014. We assessed the validity using a receiver operating characteristic curve (ROC). Results: Of 116 IE patients in the derivation cohort, 10 (9%) had IIAs. Of 129 in the validation cohort, 19 (15%) IIAs were identified. The MRI imaging predictors for IIA consist of 1) contrast enhancement with SWI lesions, 2) cerebral microbleeds &gt; 5mm plus sulcal SWI lesions, and 3) any MRI hemorrhages. The sensitivity for the presence of IIA in each group of the derivation cohort was: 90%, 80%, and 100%, respectively. The sensitivity in the validation cohort was: 47%, 68%, and 94% respectively. The specificity in the derivation cohort was: 87%, 85%, and 18%. In the validation cohort, the specificity was similar (87%, 75%, and 27%). Conclusions: The suggested MRI imaging predictors can be used as a sensitive and specific tool to support clinical decision-making, especially when invasive DSA is considered for assessment for presence of IIA. The absence of MRI hemorrhages may not necessitate the need for DSA.

Neo aortoiliac system repair of burkholderia cepacia infected mycotic aneurysm with impending rupture

Mycotic or infected aneurysms are focal vascular dilatations from inflammation or infection that results in weakening of the blood vessel wall. It poses a high risk of complications such as aneurysm rupture, uncontrolled sepsis, and extensive para-aortic infection. We report a case of a middle-aged man with a 2-week history of fever, abdominal pain, and backache. Computed tomography angiogram was done which showed infrasaccular aneurysm with impending rupture. The patient underwent neoaortoiliac system repair which was done by harvesting bilateral superficial femoral vein. We report a case of an infected mycotic aneurysm caused by Burkholderia cepacia, a Gram-negative lactose nonfermenting bacterium which is commonly seen in livestock and has not been reported earlier.

Occult aortic fistulation affects late outcome of ruptured descending thoracic aortic aneurysms after emergency thoracic endovascular aortic repair in patients with initial hematemesis/hemoptysis

Background: Although thoracic endovascular aneurysm repair (TEVAR) has been widely used as the first choice of emergency surgical procedure for ruptured descending thoracic aortic aneurysms (rDTAAs), the risk factors of adverse outcome have less been investigated. Purpose: To investigate the outcomes of patients undergoing TEVAR for rDTAA and to identified risk factors of worse prognoses. Materials and Methods: The surgical outcome of TEVAR for rDTAA in National Cheng Kung University Hospital was retrospectively analyzed. From February 2008 to December 2016, 27 patients were included, after excluding patients with traumatic aortic injury, infected aneurysm, esophageal malignancy-related aortoesophageal fistula or those in association with aortic dissection. Results: There were 5 (18.5%) 30-day mortalities, including 3 (11.1%) intraoperative deaths. Seven additional patients died during follow-up and the estimated survival rate at 1 year and 3 years was 61.3 ± 9.7% and 50.5 ± 10.6%, respectively. Among these patients with late mortality, five patients presented with hematemesis or hemoptysis preoperatively. Aortoesophageal fistula was confirmed in three patients by esophagogastroduodenoscopy presenting with hematemesis. These patients underwent subsequent open debridement along with esophagectomy after TEVAR and remained alive during follow-up. On the other hand, those with possible occult aortic fistulations that were not detected by endoscopic examinations and not surgically managed had worse late outcomes (P = 0.058). Conclusions: For patients with rDTAA having hematemesis or hemoptysis as part of the initial presentations, careful survey for possible aorta-related fistulation is important. Although definite diagnosis of fistulation might be difficult, surgical exploration for hematoma evacuation, adequate debridement, and repair of intraoperative identified fistulation should be advocated.

Repair of Infective Thoracic Aortic Aneurysm Ruptured in the Lung Using Total Arch Replacement with a Frozen Elephant Trunk Graft

Repair of Infective Thoracic Aortic Aneurysm Ruptured in the Lung Using Total Arch Replacement with a Frozen Elephant Trunk Graft

Large Vessel Giant Cell Arteritis as an Initial Manifestation of Infected Abdominal Aortic Aneurysm

Large Vessel Giant Cell Arteritis as an Initial Manifestation of Infected Abdominal Aortic Aneurysm