Mycotic Abdominal Aortic Aneurysm Research Articles

Outcomes Following Different Management of Mycotic Infrarenal Abdominal Aortic Aneurysms.

The objective was to present our experience on managing mycotic infrarenal abdominal aortic aneurysm (MIAAA) through a retrospective cohort study. Data of patients with MIAAA managed in our center from July 2016 to October 2022 were retrospectively analyzed. The diagnosis of MIAAA was made based on: (1) preoperative clinical signs of infection; (2) elevated serologic infection parameters; (3) para-aneurysmal infection features on enhanced computed tomography; and (4) positive blood or tissue cultures. All the patients received standard antibiotic therapy. Surgical management including endovascular aneurysm repair (EVAR), initial EVAR followed by open re-operation, and initial open surgical repair (OSR) were conducted according to disease seriosity, physical condition, and patient's will. Infection index and clinical outcome were evaluated during the follow-up time. A total of 23 patients (21 men; averaged=66.3 years, range=49-79 years) were included, with a mean follow-up time of 19.9 months (range=1-75 months). Bacteria culture from blood or tissue specimen was positive in 15 patients (Salmonella, n=8; Escherichia coli, n=3; methicillin-sensitive Staphylococcus aureus [MSSA], n=1; Klebsiella pneumoniae, n=1; Staphylococcus epidermidis, n=1; Mycobacterium tuberculosis, n=1). Seven patients received OSR as the initial surgical intervention, whereas 14 patients chose EVAR instead. The 2 conservatively managed patients (refused surgery) died within 30 days. The 7 patients who received initial OSR survived till now. Among the 14 patients who underwent initial EVAR, infection deteriorated without exception (14/14, 100%). Three of these patients refused re-operation and died within 6 months. Eleven patients received secondary surgical intervention (10 cases of aneurysm and endograft resection, thorough debridement, subclavian to bi-femoral artery bypass, or in situ aorta reconstruction; 1 case of laparoscopic debridement) and 7 survived the follow-up time. The overall mortality rate was 39.1% (9/23). The mortality rates differed greatly following different intervention methods (merely antibiotic management, 100%; initial open operation, 0%; initial EVAR without secondary operation, 100%; initial EVAR plus secondary operation, 36.4%). Open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely EVAR is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary OSR. The management of mycotic or primary-infected aortic aneurysm is challenging; treatment remains controversial. Our center has reviewed our experience over the past 6 years and found that open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely endovascular aneurysm repair (EVAR) is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary open surgical repair.

Outcomes of Mycotic Abdominal Aortic Aneurysms in the Native Aorta: A Single Referral Center Study

Outcomes of Mycotic Abdominal Aortic Aneurysms in the Native Aorta: A Single Referral Center Study

Abstract 10768: Double Whammy: An Unusual Case of Mycotic Abdominal Aortic Aneurysm in a Bacteremic Patient - Case Report

Introduction: Ruptured mycotic aortic aneurysm is a relatively rare, life-threatening disease, which is associated with remarkable mortality. In East Asia, mortality caused by this disease is high and it is commonly caused by Salmonella species. Majority of cases of mycotic aneurysms caused by Salmonella were in the abdominal aorta wherein most of them presented with chills and fever while some presented with diarrhea from 2 days to 1 month before the aneurysm was diagnosed. Patients who present with diarrhea and abdominal pain are likely to be missed. It is therefore important that mycotic abdominal aneurysm be recognized early, and prompt treatment be initiated. Case: A 78-year-old American male, Philippine immigrant with history of ischemic stroke and chronic smoking presented with diarrhea and severe abdominal pain. Complete blood count showed leukocytosis with neutrophilic predominance. A computed tomography scan of whole abdomen exhibited a fusiform aneurysm of the infrarenal abdominal aorta with large periaortic hematoma indicating prior rupture. Open abdominal aortic aneurysm repair was successfully done and intravenous Meropenem and Ciprofloxacin were given. Blood, urine, thrombus, and aortic plaque cultures were obtained and all revealed Salmonella specie with same antibiogram. Intravenous Meropenem and Ciprofloxacin was transitioned to intravenous Ceftriaxone and was continued for 6 weeks post-operatively. Conclusion: Mycotic abdominal aortic aneurysm can be diagnosed with the combination of clinical symptoms, laboratory, radiological findings, and intraoperative findings. However, vague and non-specific symptoms do not rule out the diagnosis. High index of suspicion and low threshold for CT imaging is necessary in any patient age >60 years who present with abdominal pain and with previous history of gastroenteritis. Prompt initiation of antibiotic therapy and surgical intervention are the treatment of choice.

Mycotic tubercular abdominal aortic aneurysm: A case report

The mycotic tuberculous aneurysm of the Abdominal Aorta is an extremely rare disease. An aortic mycotic aneurysm is a life-threatening condition caused by tuberculous infection. Tuberculous aneurysms of the aorta usually present as rapidly growing or ruptured pseudoaneurysms. Most of these aneurysms are of the pseudoaneurysm type. We presented a case of a 61-year-old man who was diagnosed with a tubercular abdominal aortic mycotic aneurysm associated with the posterior invasion of the vertebral body leading to discitis. The patient underwent a mycotic aneurysm repair with grafting. Even with a combination of surgical and medical treatment, a favorable outcome could not be achieved.

Surgical strategy for treating mycotic aneurysms of thoracic and abdominal aorta and iliac artery: Analysis of long-term follow-up data.

Mycotic aneurysms of the aorta and iliac arteries are rare, but life-threatening conditions. We reviewed our experience to determine the best surgical strategy. Between 2007 and 2015, we operated 14 patients with mycotic aneurysms of the aortic arch (n = 6), descending aorta (n = 1), thoracoabdominal aorta (n = 2), abdominal aorta (n = 4), and iliac artery (n = 1). The mean age was 70.4 ± 8.8 years, and 10 males were included. Blood culture, tissue culture, or both were positive in 11 patients. Four of five patients with mycotic aneurysms of the abdominal aorta and iliac artery underwent extra-anatomical bypass. Ten underwent in-situ graft replacement for managing mycotic aneurysms of the thoracic aorta. One patient with a mycotic thoracoabdominal aortic aneurysm underwent visceral bypass of the descending aorta and extra-anatomical bypass. Omental pedicle grafting was performed in 10 patients. The mean follow-up period was 8.6 ± 3.1 years. Three patients (21.4%) died. Recurrent infection was observed in one patient with a mycotic aneurysm of iliac artery three months after the initial surgery. The patient underwent extra-anatomical bypass with omental pedicle grafting as a redo. Nine patients were discharged, and no recurrence of infection was observed. Two patients died of cancer and heart failure. The five- and seven-year survival rates were 100% ± 0.0% and 85.7% ± 13.2%, respectively. A combination of radical debridement of the infectious source and omental pedicle grafting with either in-situ graft replacement or extra-anatomical bypass is an effective strategy.

Imaging characteristics and diagnostic accuracy of FDG-PET/CT, contrast enhanced CT and combined imaging in patients with suspected mycotic or inflammatory abdominal aortic aneurysms.

PurposeTo evaluate the diagnostic accuracy and specific imaging characteristics of positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT), contrast enhanced CT (CE-CT), and a combined imaging approach (CE-PET/CT) in patients with infectious/mycotic (MAA), inflammatory (IAA), and non-infected, non-inflammatory abdominal aortic aneurysm (AAA).Materials and methodsIn this single-center retrospective cohort study, all imaging data sets of 29 consecutive patients with clinically suspected MAA or IAA were anonymised with different, reshuffled identification numbers and retrospectively and independently analysed by two experienced readers, blinded to all clinical patient data. Readers determined the presence or absence and MAA, IAA and AAA and of predefined imaging characteristics (e.g. fluid collection), and measured metabolic activity and wall thickness of all aneurysms. A multidisciplinary team of specialists served as standard of reference and re-evaluated every clinical case, considering all clinical, laboratory, microbiological, histopathological and imaging results, including all follow-up examinations.ResultsDiagnostic accuracy was higher in PET/CT as compared to CE-CT in differentiating AAA from MAA and IAA: area under the receiver operating characteristic curve (AUC-ROC) 0.81 (95% confidence intervals 0.69–0.92) and 0.63 (0.52–0.74) (P = 0.027). Specific imaging characteristics were significantly associated with different types of aneurysms (P<0.05), i.e. very high metabolic activity and dorsal sparing of metabolic activity in PET/CT and wall thickening in CE-CT were indicative for IAA; fat stranding and fluid collections in CE-CT were associated with MAA; while low metabolic acitivity and absence of wall thickening in PET/CT, and less fat stranding and absence of wall thickening in CE-CT were indicative for non-infected, non-inflammatory AAA.ConclusionSpecific imaging characteristics of PET/CT and CE-CT may be helpful in differentiating between MAA, IAA, and non-infected, non-inflammatory AAA.

Use of a Silver-Impregnated Vascular Graft: Single-Center Experience.

Introduction: Vascular graft infection is a life threatening situation with significant morbidity and mortality. Bacterial graft infection can lead to false aneurysms, bleeding and sepsis. There are a lot of risky situations where grafts can become infected. It is therefore highly desirable to have a vascular graft that is resistant to infection. In this retrospective clinical study, a silver-impregnated vascular graft was evaluated in various indications. Methods: Our study included a total of 71 patients who received a silver-impregnated vascular graft during the period from 2013 to 2018. Patients had an aortoiliac localization of vascular graft in 61 cases (86%), and a peripheral localization on the lower limbs in 10 cases (14%). Indications for the use of these special vascular grafts were trophic lesions or gangrene in the lower limbs in 24 cases (34%), suspicious mycotic abdominal aortic aneurysm (mAAA) in 4 cases (5.5%), salmonela aortitis or aneurysms in 4 cases (5.5%), infection of the previous vascular graft in 11 cases (15.5%), other infections in 12 cases (17%), AAA rupture in 10 cases (14%) and other reasons (pre-transplant condition, multiple trauma, graft-enteric fistula) in 6 cases (8.5%). Thirty-day mortality, morbidity, the need for reintervention and amputation, primary and secondary graft patency, and finally the presence of a proven vascular graft infection were evaluated. Results: The 30-day mortality was 19.7%, and morbidity was 42.2%. The primary patency of the vascular graft was 91.5%. Reoperation was necessary in 10 cases (14%) and amputation was necessary in 10 cases (14%). The median length of hospital stay was 13 days and the mean follow-up period was 48 ± 9 months. During the follow-up period, six patients (8.5%) died from reasons unrelated to surgery or without any relation to the vascular graft. Secondary patency after one year was 88%. Infection of the silver graft was observed in three patients (4.2%). Conclusions: Based on our results, the silver graft is a very suitable alternative for solving infectious, or potentially infectious, situations in vascular surgery. In particular, in urgent or acute cases, a silver graft is often the only option.

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

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.

Mycotic abdominal aortic aneurysm caused by Borrelia afzelii: a case report

BackgroundInflammatory aneurysms and mycotic aneurysms make up a minority of abdominal aortic aneurysms. Mainly autoimmune mechanisms are proposed in the pathogenesis of inflammatory aneurysms, and it is not routine to check for infectious agents as disease culprits.Case presentationA 58-year-old European male with complaints of abdominal and back pain for 8 weeks was admitted after a semi-urgent computed tomography scan revealed an 85 mm inflammatory abdominal aortic aneurysm. The patient had normal vital signs, slightly elevated inflammatory markers, and mild anemia on admission. Clinical examination revealed a tender pulsating mass in his abdomen. His clinical condition was interpreted as impending rupture and urgent repair of the aneurysm was deemed necessary. Due to the patient’s relatively young age and aneurysm neck morphology, open aortic repair was preferred. Preoperatively, the aneurysm appeared inflamed, with fibrous wall thickening and perianeurysmal adhesions. Aneurysm wall biopsies were sent to histopathological and microbiological diagnostics. Routine cultures were negative, but 16S rRNA gene real-time polymerase chain reaction was positive and Borrelia afzelii was identified by DNA sequencing of the polymerase chain reaction product. B. afzelii was also identified by sequencing the polymerase chain reaction product of a Borrelia-specific groEL target. Immunoglobulin G and M anti-Borrelia antibodies were present on serological analysis. Histopathological analysis displayed loss of normal aortic wall structure and diffuse infiltration of lymphocytes and plasma cells. The patient had an uneventful recovery and was discharged after 1 week to a regional rehabilitation facility. Though the patient fares clinically well and inflammatory markers had normalized, antimicrobial treatment with doxycycline continues at 3 months follow-up due to remaining radiologic signs of inflammation.ConclusionsBorrelia infection in the setting of acute aortic pathology is a rare entity. To our knowledge, this is the first case report to demonstrate a mycotic abdominal aortic aneurysm as a rare manifestation of Lyme disease. Aortic wall biopsies and real-time polymerase chain reaction analysis of the specimen were essential for accurate diagnosis. This finding may contribute to the understanding of the etiology of inflammatory aneurysmal disease and abdominal aneurysms in general.

Endovascular aortic repair of mycotic abdominal aortic aneurysm with multiple systemic abscesses

Mycotic abdominal aortic aneurysms (MAAAs) are rare, but severe aortic infection and subsequently infected aortic aneurysms can cause a lethal condition. The gold standard for treatment is resection, infected tissue debridement, and graft replacement. Despite meticulous surgical planning, the mortality rate after open surgical repair can reach 40%. Endovascular aortic repair (EVAR) is another treatment option because of its simplicity and low invasiveness. We report a case of symptomatic MAAA successfully treated with EVAR and antibiotic therapy. EVAR is valuable for postoperative physical recovery. Here, the endovascular approach was feasible, and an acceptable outcome could be obtained.

Evolution and Treatment of Infected Aortic Arch Pseudoaneurysm Associated with Ruptured Mycotic Abdominal Aortic Aneurysm

Evolution and Treatment of Infected Aortic Arch Pseudoaneurysm Associated with Ruptured Mycotic Abdominal Aortic Aneurysm

Ruptured mycotic abdominal aortic aneurysm with perforated colonic malignancy – “Quadruple Jeopardy”

We describe an unusual presentation where a patient referred for ruptured abdominal aortic aneurysm was detected to have a concurrent colonic growth with perforation and localized spillage. Aneurysm repair was done with neoaortoiliac system reconstruction and Hartmann's procedure was done. This case report describes the management of a rare intraoperative challenge.

Cryopreserved venous allograft in the treatment of a mycotic abdominal aortic aneurysm caused by group B Streptococcus

We report a case of a mycotic abdominal aortic aneurysm caused by invasive group B streptococcus. Given the anatomical suitability with healthy segments of aortoiliac vessels, in situ repair was performed. A cryopreserved femoral vein graft was chosen because of risks of graft reinfection and negated the need for bilateral femoral vein harvest. The patient remained clinically well and the graft patent with no concerns at 6 months of follow-up. A review of literature on group B Streptococcus aortitis was performed.

Rare Triple Presentation of Tuberculous Mycotic Aortic Aneurysm

Mycotic Abdominal Aortic Aneurysm (MAAA) is a rare entity that accounts for around 2% of aortic aneurysms. Tuberculous involvement of the aorta is either through hematogenous route or by the way of direct extension of disease from the adjacent structures. It may affect the intima or several layers of the vessel wall resulting in inflammation of the aorta, termed as aortitis, which weakens the aortic wall. The variable immune response to this aortitis can thicken the aorta or can perforate it leading to aneurysm formation. Tuberculosis affects both abdominal and thoracic aorta equally. Neither medical treatment nor surgical repair is curative, when used alone. The various surgical techniques which have been used by the investigators, had refined over period of time and importance of complete clearance of the infective foci is emphasized. Despite advanced imaging techniques, anti-tubercular drugs and adequate surgical options in the present times, the prompt diagnosis and successful repair of tuberculous MAAA are very few in number and there is also possible risk of reactivation of tuberculous process and recurrence. A presentation of a combination of Pott’s spine, psoas abscess and tubercular MAAA is a rare entity with very high mortality. We report the successful surgical and medical treatment of this precarious presentation.

Mycotic Abdominal Aortic Aneurysms—A Tertiary Centre Experience and Formulation of a Management Protocol

A retrospective, single-center review was performed from 2001 to 2018. Seventeen patients with infected aortic aneurysms (10 ruptures, 11 saccular) were treated by endovascular repair in 13 (endovascular aortic aneurysm repair [EVAR], n = 9; surgeon-modified fenestrated EVAR, n = 4) and open repair in 4 patients. The 1- and 5-year overall survival was 94% and 75%, respectively. The 1- and 5-year infection-free survival was 88% and 63%, respectively. The management of infected aortic aneurysms with the selective use of open or endovascular repair, combined with appropriate long-term antibiotic therapy, can achieve acceptable outcomes.

742 Conventional Surgery vs Endovascular Abdominal Aortic Aneurysm Repair in the Management of Mycotic Abdominal Aortic Aneurysms

Abstract Introduction This study aimed to look into the short and long-term outcomes in Mycotic Abdominal Aortic Aneurysms (MAAA) managed by Conventional Surgery (CS) and Endovascular Abdominal Aortic Aneurysm Repair (EVAR) Method Data of 17 patients who underwent CS or EVAR for MAAA from 2001 to 2017 in a single centre were collected. Complications and mortality at 3 years post-procedure were also analysed. Results Mean age was 66 (54 - 82 years), 15 (88.2%) were males. Mean aortic anterior-posterior diameter was 5.8cm (2.1 – 9.0 cm). 10 patients (58.8%) presented with rupture. 6 (35%) patients demonstrated positive cultures. 4 patients (23.5%) underwent CS and 13 (76.5) had EVAR of which 4 were surgeon modified EVARs. 5 (29%) patients developed complication within 30 days. 4 patients (23.5%) developed graft infection in long term. Total mortality was 5 (29.4%) of which one patient died within 30 days and two within 3 years of procedure. Long-term mortality was found to be significantly higher in patients treated with CS compared to EVAR (p-value 0.022). Conclusions CS for MAAA has a high mortality rate compared to EVAR. EVAR might be a simple and good alternative for this critical condition in centres with adequate expertise.

Ruptured Mycotic Abdominal Aortic Aneurysm Caused by &lt;i&gt;Capnocytophaga ochracea &lt;/i&gt;after EVAR

Ruptured Mycotic Abdominal Aortic Aneurysm Caused by &lt;i&gt;Capnocytophaga ochracea &lt;/i&gt;after EVAR

Mycotic Abdominal Aortic Aneurysms – A Tertiary Centre Experience and Formulation of a Management Protocol

Mycotic abdominal aorta aneurysm (MAAA) is a rare and life-threatening condition. Because of its rarity, there is a lack of adequately powered studies and consensus on its treatment and follow up. This study aimed to review the outcomes following surgical intervention for MAAA in a single tertiary centre and to formulate a management protocol based on available evidence and expert opinion. Data were collected by retrospective review of case records of all patients who underwent repair of MAAA in a single tertiary referral centre from 2001 to 2018. Demographic, clinical and outcome data were analysed and compared with previously published series in the literature. A management protocol was formulated based on available literature which was then reviewed and modified as per expert opinion from multidisciplinary discussions. Seventeen patients underwent repair of MAAA during the study period including 4 Open repairs, 4 surgeon modified fenestrated endovascular aortic aneurysm repairs (SM FEVAR) and 9 endovascular aortic aneurysm repairs (EVAR). One-year overall survival was 94.1%, 3-year survival was 81.8% and 5-year survival was 75.0%. The infection-free survival at 1, 3, and 5 years was 87.5%, 81.8% and 62.5%, respectively. The overall survival and infection-free survival curves for Open repair, EVAR and SM FEVAR when compared using Log Rank (Mantel-Cox) test and did not show any statistically significant difference. Management of MAAA with selective use of open or endovascular repair, in combination with appropriate long-term antibiotic therapy, can achieve acceptable outcomes. The proposed protocol can aid as a guiding document for the management of MAAA but needs taking into consideration individual patient variability and local expertise.

Artifacts in Contrast-Enhanced Ultrasound during Follow-up after Endovascular Aortic Repair: Impact on Endoleak Detection in Comparison with Computed Tomography Angiography

The study described here systematically analyzed how specific artifacts in contrast-enhanced ultrasound (CEUS) can affect the detection of endoleaks during follow-up after endovascular aortic repair (EVAR). Patients undergoing EVAR of atherosclerotic or mycotic abdominal aortic aneurysms using various standard and branched stent-graft material for visceral and iliac preservation were enrolled over 5 y and followed up with computed tomography angiography (CTA) and CEUS simultaneously. CEUS artifacts were frequently identified after EVAR procedures (59% of examinations) and were caused mainly by contrast agent, different prosthesis or embolization material and postinterventional changes in the aneurysm sac. This article describes how to identify important artifacts and how to avoid false-negative or false-positive interpretations of endoleaks. Despite artifacts, CEUS had higher sensitivity for endoleak detection after EVAR than CTA. CEUS was superior to CTA in the identification of late endoleaks type II and in follow-up examinations after embolization procedures, where beam-hardening artifacts limited CTA.

Leaking Mycotic Aneurysm of Abdominal Aorta in a 14-Year-Old Boy with Infective Endocarditis and Severe Mitral Regurgitation—A Rare Case Report

We present a case of leaking mycotic aneurysm of abdominal aorta complicated by infective endocarditis in a young boy of 14 years age. This boy with history of rheumatic heart disease with vegetations on mitral valve and severe mitral regurgitation landed up in complications of infective endocarditis like femoral artery thrombo embolism followed by an abdominal aortic aneurysm with contained rupture. This case was successfully managed addressing two problems i.e. valve and aneurysm repair in single sitting.