Mycotic Aortic Pseudoaneurysm Research Articles

The cervical branch-first technique in complex resternotomy

BackgroundBranch-first total aortic arch repair is a paradigm shift in the technical approach for uninterrupted neuroprotection during open aortic surgery. This technique is further modified to instigate hazardous sternal reentry in patients with hostile mediastinal anatomy at risk of aortic injury. MethodsIntraoperative preparation and the illustrated operative technique of the cervical branch-first technique are described. The accompanying case series narrates the experiences and outcomes of 4 patients who underwent successful complex reoperative aortic surgery utilizing this technique. ResultsThe indications for resternotomy included a sixth reoperation for recurrent mycotic aortic pseudoaneurysm, a third reoperation for extensive infective endocarditis, a reoperation for complete Bentall graft dehiscence with contained aortic rupture, and a third reoperation for residual type A dissection. All patients survived their proposed surgery. Two patients were operated on in an emergency setting. Two patients separated from cardiopulmonary bypass with extracorporeal support. None experienced permanent neurological sequelae, gut ischemia, peripheral arterial complications, or in-hospital mortality. One mortality due to decompensated heart failure was reported at 6 months postoperatively. ConclusionsThe cervical branch-first technique offers unparalleled advantage in neuroprotection from an early stage of complex reoperative aortic surgery. It provides an independent circuit for complete antegrade cerebral perfusion, irrespective of suspension to circulatory flows to the rest of the body during complex reentry into hostile chests. Our experience to date has demonstrated promising outcomes and further refinements will guide patient selection best suited for this technique.

Mycotic Aortic Pseudoaneurysm Following ECMO Cannulation

<h3>Introduction</h3> Mycotic aortic pseudoaneurysms (MAP) are a rare but often fatal complication of thoracic surgery. Recently, our institution has transitioned to performing all lung transplants on venous-arterial extracorporeal membrane oxygenation (VA-ECMO) support when possible. Reinforcement of aortic cannulation sites with pledgeted sutures is often necessary to control bleeding; however, pledgets could also represent an iatrogenic risk for infection. Here we present a fatal case of MAP at the cannulation site in a lung transplant recipient (LTR). <h3>Case Report</h3> We present a 56-year-old female who underwent bilateral lung transplant for scleroderma-related interstitial lung disease. Two months following transplant, she was admitted with methicillin-resistant staphylococcus aureus bacteremia. Initial echocardiogram was inconclusive for endocarditis and thus she was treated with IV vancomycin for six weeks with clinical improvement. Unfortunately, two months later she presented with recurrent bacteremia. Initial imaging revealed evidence of ascending MAP formation, confirmed by positron emission tomography (Figure 1). She underwent surgical repair with identification of a palpable MAP and pathology consistent with acute and organizing inflammation with microabscess formation. Despite aggressive medical and surgical management, our patient suffered a catastrophic embolic stroke. <h3>Summary</h3> While performing lung transplant on ECMO support has many potential benefits, it is not without risk. Closure of ECMO cannulation sites with pledgets in immunosuppressed patients may lead to the development of an infected MAP and can have devastating consequences. To our knowledge this is the first case of an infected MAP at pledget site in a LTR.

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

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.

A Tale of Three Surgeries: Management of a Massive Recurrent Mycotic Aortic Pseudoaneurysm

A Tale of Three Surgeries: Management of a Massive Recurrent Mycotic Aortic Pseudoaneurysm

Successful Endovascular Repair of Mycotic Aortic Pseudoaneurysm Followed by Aortoesophageal Fistula

Mycotic aneurysm of the aorta is a rare, but life-threatening pathology. In recent years, endovascular stent graft placement has been introduced as an effective alternative for treating infected aortic aneurysms. A 64-year-old woman with a history of paraplegia due to spinal cord injury was referred to our institute with fever and blood-tinged sputum. Computed tomography (CT) scan showed an 11-cm pseudoaneurysm arising from the proximal descending aorta, which was normal 1 month ago at the previous CT scan. The patient underwent thoracic endovascular aortic repair for the pseudoaneurysm, deployed with a transiliac access approach, and received antibacterial medical therapy. On postoperative day 11, she developed signs of infection, caused by an aortoesophageal fistula. The infection was treated conservatively with parenteral nutrition and antibiotic administration. The patient had an uneventful recovery and was discharged on postoperative day 113. At 2-year follow-up, she had a normal physical examination and CT angiography showed a marked reduction of the pseudoaneurysm sac. We report a successful endovascular stent grafting and subsequent medical treatment in a patient with a mycotic thoracic aortic pseudoaneurysm followed by a postoperative aortoesophageal fistula.

Mycotic Pseudoaneurysm of the Ascending Aorta After Heart Transplantation: Case Report

Mycotic pseudoaneurysm of the ascending aorta is a rare but potentially life-threatening complication after orthotopic heart transplantation. We present a case of a 53-year-old man who developed a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation. The pseudoaneurysm was surgically resected and the ascending aorta was replaced with allograft. The Gram stain and multiple cultures of the pseudoaneurysm wall revealed that the causative microorganism was coagulase-negative Staphylococcus. To the best of our knowledge, this is the first case report that describes mycotic pseudoaneurysm owing to coagulase-negative Staphylococcus infection after heart transplantation. Although S aureus and Pseudomonas aeruginosa are common pathogens in previously published literatures describing mycotic pseudoaneurysms in heart transplant recipients, coagulase-negative Staphylococcus is aslo an important and virulent pathogen that can cause mycotic aortic pseudoaneurysm in immunosuppressed patients. Once diagnosed, aggressive surgical treatment with prudent operative strategy, appropriate postoperative antibiotic therapy and close follow-up by radiographic study are mandatory in managing patients with this potentially fatal condition.

Acute Cholecystitis Preceding Mycotic Aortic Pseudoaneurysm in a Heart Transplant Recipient

Mycotic pseudoaneurysm is a rare complication after orthotopic heart transplantation (OHT). This case describes a middle-aged OHT recipient who developed a mycotic pseudoaneurysm after an episode of acute cholecystitis. The region of involved aorta was effectively repaired using a patch of bovine pericardium and a brief period of hypothermic circulatory arrest.

Successful treatment of a mycotic aortic pseudoaneurysm in a patient with type 2 diabetes mellitus while treating primary aldosteronism with spironolactone

We describe a diabetic patient successfully treated for an acute mycotic aortic arch pseudoaneurysm with primary aldosteronism. The patient first complained of severe pain in the left upper extremity and left back with high C reactive protein (CRP) and high-grade fever. It was suspected that acute aortic dissection had developed in association with mycotic pseudoaneurysm of the aortic arch because of chest X-ray findings of enlargement of the aortic arch. Computed tomography (CT) of the aortic arch revealed an aortic aneurysm protruding in the superior direction. Staphylococcus aureus was detected in blood culture, suggesting a mycotic aortic aneurysm, and artificial blood vessel replacement of the aortic arch was performed. Intraoperative findings suggested aortic pseudoaneurysm, which consisted of mediastinal rupture of the aorta at the distal arch. Our patient had a 2-year history of type 2 diabetes mellitus and poor blood sugar control, even with twice-daily injection of insulin. Blood pressure was not always well controlled because of primary aldosteronism. Thus, it was speculated that hyperaldosteronism, as well as diabetes-associated atherosclerosis, had persisted for a long time. No reports have described mycotic pseudoaneurysm in the aortic arch in a diabetic patient associated with primary aldosteronism. It is necessary to note that serious vascular complications are possible if aldosteronism is left untreated or is treated insufficiently as essential hypertension.

Ruptured mycotic aortic pseudoaneurysm with concomitant aorto-tracheal and aorto-oesophageal fistulas

Ruptured mycotic aortic pseudoaneurysm with concomitant aorto-tracheal and aorto-oesophageal fistulas

Repair of mycotic aortic pseudoaneurysm with a stent graft using transesophageal echocardiography

A 54-year-old man who underwent uneventful orthotopic heart transplantion 1 year previously had low-grade fever and dyspnea. Imaging studies revealed an ascending aortic pseudoaneurysm (AAP), which was repaired with a 5-mm polyester patch, with circulatory arrest and cardiopulmonary bypass. Intraoperative cultures of the AAP grew methicillin-resistant Staphylococcus aureus, and the pseudoaneurysm recurred after 6 weeks despite intravenously administered antibiotic therapy. A 28.5-mm × 3.3-cm Gore Excluder aortic cuff was deployed in the ascending aorta through a left axillary artery cutdown with use of combined transesophageal echocardiography and fluoroscopy. In addition, controlled hypotension and asystole were established with administration of adenosine to facilitate precise device deployment. Postoperative imaging with transesophageal echocardiography and magnetic resonance angiography revealed complete resolution of the AAP, and the patient had done well at 7-month follow-up. Treatment of a mycotic aortic pseudoaneurysm with an endoprosthesis in a patient without other treatment alternatives can be performed safely, with acceptable short-term results.