Repair Of Mycotic Aortic Aneurysm Research Articles

Endovascular repair of mycotic aortic aneurysms confers good medium-term outcomes and aneurysmal sac resolution.

Mycotic aortic aneurysm (MAA) is a life-threatening condition. Endovascular repair (EVAR) of aortic aneurysms has been found to be a safe and effective alternative to open repair. We aimed to present the short- to medium-term outcomes for EVAR of MAA in our cohort. We conducted a retrospective study of 23 consecutive patients with MAA who underwent EVAR in our hospital from January 2008 to July 2017. The mean age of our study population was 62 years. The mean aneurysmal size was 3.2 cm. Abdominal MAAs (n = 16, 70%) were the most common, followed by thoracic MAAs (n = 4, 17%). There was no 30-day mortality in our cohort. Endoleak (Types 1, 3, 4) was detected in 3 (13%) cases. At the one-month surveillance computed tomography aortogram, all patients had a reduction in aneurysmal size and 5 (22%) had complete aneurysmal sac resolution. 7 (30%) patients had sac resolution at six months and 8 (35%) patients, at 12 months. The overall survival was 91%, 80% and 61% at one, 12 and 60 months, respectively. EVAR is a feasible and durable method for the repair of MAA, with a five-year overall survival of 61%. All patients in our study had a reduction in aneurysmal size at one month, with 65% having complete aneurysmal sac resolution by 12 months.

Early and late outcomes of surgical repair of mycotic aortic aneurysms: A 30-year experience

ObjectiveMycotic aortic aneurysm and its associated complications are often catastrophic. In this study, we examined the early and late outcomes of surgical repair of mycotic aortic aneurysm at our center over the last 3 decades. MethodsWe retrospectively reviewed our prospectively maintained aortic surgery database with supplemental adjudication of medical records. Aortic infection was confirmed through clinical, radiological, intraoperative, pathological, and treatment evidence. ResultsSeventy-five patients (median age, 68 years; interquartile range, 62-74) who underwent surgical repair of a mycotic aortic aneurysm between 1992 and 2021 were included. Almost all patients (n = 72; 96%) presented with symptoms, including 26 patients (35%) with rupture, and many underwent urgent or emergency repair (n = 64; 85%). Sixty-one patients underwent open repair, and 14 patients underwent hybrid or endovascular repair. Infection-specific adjunct techniques included rifampin-soaked grafts (n = 16), omental pedicle flaps (n = 21), and antibiotic irrigation catheters (n = 8). There were 15 early deaths (20%), including 10 of the 26 patients (38%) who presented with rupture; however, persistent stroke, paraplegia or paraparesis, and renal failure necessitating dialysis were uncommon (each <5%). Almost all early survivors (52/60; 87%) were discharged with long-term antibiotic therapy. Estimated survival at 2, 6, and 10 years was 55.7% ± 5.8%, 39.0% ± 5.7%, and 26.9% ± 5.5%, respectively. ConclusionsA substantial proportion of patients with mycotic aortic aneurysm present with rupture and generally require urgent or emergency repair. Operative mortality and complications are common, especially for patients who present with rupture, and late survival is poor.

Response Findings after Treatment and Outcomes on CT after Endovascular Repair of Mycotic Aortic Aneurysm

PurposeTo demonstrate post-treatment computed tomography (CT) findings and outcomes of endovascular aortic repair (EVAR) for mycotic aortic aneurysm (MAA). Materials and MethodsClinical data of patients with MAA who underwent EVAR from June 2010 to December 2017 were retrospectively reviewed. A total of 22 patients were included (19 men and 3 women). The periaortic features of the MAA regression after EVAR were graded and evaluated by follow-up CT. ResultsThe median follow-up was 36.5 months (range, 0.5–97 months.). The cumulative survival rate at 1 month, 6 months, 1 year, and 5 years was 95.5%, 86.4%, 81.6%, and 73.4%, respectively. The early and late infection-related complication (IRC) rate was 18.2% and 13.6%, respectively. One patient died within 1 month from severe acidosis and shock. Of the other patients, the median time to stable response of the MAA was 6 months (range, 3–36 months). Fourteen patients (66.7%) showed early response of the MAA, while 7 patients (33.3%) showed delayed response. A significant association was observed between delayed response and late IRCs (P = .026). ConclusionsThe post-EVAR periaortic features on follow-up CT aid in monitoring the treatment response of the MAA. Early response of the MAA was associated with a low rate of late IRCs and might aid in adjusting the antibiotic duration after the patient has achieved complete or nearly complete regression of the MAA.

VSICON 2018 Prize Paper Abstracts

VSICON 2018 Prize Paper Abstracts

Outcomes of Open Repair of Mycotic Aortic Aneurysms with In Situ Replacement.

BackgroundMycotic aortic aneurysms are rare and life-threatening. Unfortunately, no established guidelines exist for the treatment of patients with mycotic aortic aneurysms. The purpose of this study was to evaluate the midterm outcomes of the open repair of mycotic thoracic and thoracoabdominal aneurysms and suggest a therapeutic strategy.MethodsFrom 2006 to 2016, 19 patients underwent open repair for an aortic aneurysm. All infected tissue was extensively debrided and covered with soft tissue. We recorded the clinical findings, anatomic location of the aneurysm, bacteriology results, antibiotic therapy, morbidity, and mortality for these cases.ResultsThe median age was 62±7.2 years (range, 16 to 78 years), 13 patients (68%) were men, and the mean aneurysm size was 44.5±4.9 mm. The mean time from onset of illness to surgery was 14.5±2.4 days. Aortic continuity was restored in situ with a Dacron prosthesis (79%), homograft (16%), or Gore-Tex graft (5%). Soft-tissue coverage of the prosthesis was performed in 8 patients. The mean follow-up time was 43.2±11.7 months. The early mortality rate was 10.5%, and the 5-year survival rate was 74.9%±11.5%.ConclusionThis study showed acceptable early and midterm outcomes of open repair of mycotic aneurysms. We emphasize that aggressive intraoperative debridement with soft-tissue coverage results in a high rate of success in these high-risk patients.

Commentary: Following the Short-term Benefit of Endovascular Repair of Mycotic Aortic Aneurysm: What Is the Next Step?

Commentary: Following the Short-term Benefit of Endovascular Repair of Mycotic Aortic Aneurysm: What Is the Next Step?

EComment. Mycotic aortic aneurysms: a real challenge for the cardiac surgeon

We read with great interest the manuscript by Yano et al. regarding the surgical treartment of a mycotic aneurysm of ascending aorta [1]. We agree with the authors that the surgical repair of mycotic aortic aneurysms (extensive debridement of infected tissues, irrigation of the operative field with saline solution or antiseptic fluid and in situ reconstruction of the aorta) combined with wrapping of the prosthetic graft with pedicled omentum and administration of long-term antibiotics for prevention of the recurrence of infection is an acceptable mode of treatment [1]. Rifampicin-bonded prosthetic grafts can offer very good mid-term results. Uchida et al., in their retrospective study of 23 patients with mycotic aneurysms (6in thoracic aorta, 8 in thoracoabdominal aorta and 9 in abdominal aorta), who treated with in situ replacement of aorta with these grafts (plus omental pedicle grafts) found out that the overall survival at 5 years and freedom from aortic events was 95% and 86%, respectively. One patient died in the hospital due to recurrence of infection and another one required reoperation in another site of the aorta [2]. In addition, cryopreserved arterial homografts can be considered the treatment of choice and is our preferred option. Vogt et al., in their retrospective study of 19 patients with mycotic aneurysms (9/19) or infected grafts (10/19), in the thoracic (7/19) or abdominal aorta (12/19), apart from 16.2% mortality (1 early and 2 late deaths) didn't report on any recurrence of infection, homograft problems or anastomotic aneurysms in a mean follow-up period of 18.6 ± 13 months [3]. Silver-coated Dacron grafts compared to cryopreserved arterial homografts are reportable safe and present no significant difference in the treatment of infected abdominal aorta (in early mortality and mid-term survival) [4]. During the last years there is an increased use of thoracic endovascular stents and this modality of treatment has to be considered in the management of the complex cases, but with a higher incidence of recurrent infection. Patel et al., in their retrospective study of 20 patients with endovascular stenting of infected aortic pathological cases including 4 with infected grafts (10 aortobronchial fistulae, 2 aorto-oesophageal fistulae, 1 aortocutaneous fistula and 7 mycotic aneurysms) had an in-hospital mortality of 15%. Arch repair was needed in 8 patients, total descending, in 6 patients. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients (history of immunosuppression and concurrent malignancy in 4 and 5 patients respectively) with 3 related to recurrent infection of thoracic aorta [tendency for recurrence when endovascular stent was performed in an infected graft (p = 0.08)]. At last imaging follow-up, 14 patients had a healed aorta [5]. In conclusion, conventional surgical treatment (with cryopreserved homografts or mycotic resistant prosthetic grafts or omental wrapping) is still the treatment of choice. However, knowing and understanding its limitations, the consideration of endovascular treatment in challenging, high-risk patients may offer acceptable results. Conflict of interest: none declared

Endovascular repair of mycotic aortic aneurysms

We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.

Is Endovascular Repair of Mycotic Aortic Aneurysms a Durable Treatment Option?

Is Endovascular Repair of Mycotic Aortic Aneurysms a Durable Treatment Option?

Is Endovascular Repair of Mycotic Aortic Aneurysms a Durable Treatment Option?

Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.

Ten-Year Experience with Surgical Repair of Mycotic Aortic Aneurysms

Mycotic aneurysm remains a lethal pathologic entity, especially when rupture occurs. It may result from primary aortitis, be induced by septic emboli, or be secondary to an adjacent infection, such as pancreatitis or a psoas muscle abscess. Surgical intervention is the only way to treat such disease. Even when successful repair is achieved by insertion of an interposition in situ graft or by performance of an extra-anatomic bypass, the prognosis is poor. The aim of this study was to present our experience of managing mycotic aortic aneurysms during the past 10 years. From January 1994 to June 2004, a total of 734 patients with aortic aneurysms underwent surgical repair at our institution. Among these cases, 17 (2.3%) were shown to be mycotic aneurysms of the ascending aorta (n = 1), aortic arch (2), thoracic and thoracoabdominal aorta (3), or abdominal aorta (11); 14 patients (mean age, 58.8 years) were male. Preoperative imaging studies were performed in all patients. Mycotic aortic aneurysms were suspected in 12 of the 17 patients (70.6%) preoperatively, and 4 of these 12 patients were found to have ruptures on imaging. At the time of surgery, 9 of the 17 aneurysms (52.9%) were ruptured. Fifteen patients had an interposition graft inserted after meticulous debridement, 1 underwent an aorto-aortic bypass, and 1 underwent an extra-anatomic (axillo-femoral) bypass. An omentum patch was applied to wrap the graft in 8 of 11 mycotic aortic aneurysms of the abdominal aorta. The most common pathogens were Salmonella spp. (n = 7) and Staphylococcus spp. (4). All patients received antibiotic therapy, according to the culture report, for about 4-6 weeks postoperatively. In-hospital mortality was 11.8% (n = 2). Another patient died from massive upper gastrointestinal bleeding 6 months after operation because of complications involving an aorto-duodenal fistula, and another died from stomach cancer 6 years after surgery. Long-term follow-up (mean, 37 months; range, 3-111 months) revealed that, at the time of writing, the remaining 13 patients were alive and well, without any recurrence of aneurysm. Mycotic aneurysm of the aorta is a life-threatening disease, especially when rupture occurs. The high mortality rate is due not only to the high rupture rate, but also to sepsis. When mycotic aortic aneurysm is diagnosed, early surgical intervention is mandatory.

Treatment of Mycotic Aortic Aneurysms with Endoluminal Grafts

Purpose To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry. Methods Nine patients (five female) were identified over 5 years (1998–2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months. Results Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival. Conclusions Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.

11-Year Experience with Anatomical and Extra-anatomical Repair of Mycotic Aortic Aneurysms

Background. We have reviewed our management, of both ruptured and non-ruptured, abdominal and thoraco-abdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs.Methods. Data regarding presenting symptoms, investigations, operative techniques and outcome, were collected on patients treated at a singe centre over 11 years.Results. There were 11 men and four women, with a median age of 70 years (range, 24–79). All but one patient were symptomatic and six had a contained leak on admission. In six patients no organisms were identified in either blood or tissue cultures. Pre-operative CT identified; four infra-renal, four juxta-renal, three (Crawford thoraco-abdominal) type IV, three type III and one type II, aortic aneurysms. Thirteen were repaired with in situ prostheses and two required axillo-femoral prosthetic grafts. There were four early deaths. All surviving patients have been followed-up for a median duration of 38 months (range 1/2–112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection.Conclusions. In the absence of uncontrolled sepsis, repair of mycotic aortic aneurysms using prosthetic grafts can achieve durable results.

O11-05 10-Year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms

O11-05 10-Year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms

Six of the Best, Vascular 25

Aims: Mycotic aortic aneurysms present a surgical challenge. We reviewed our management of both ruptured and nonruptured, abdominal and thoracoabdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs. Methods: Data regarding presenting symptoms, investigations, operative techniques and outcome were prospectively collected on 15 consecutive patients treated at a single centre from 1991 to 2001 inclusive. Results: There were 11 men and 4 women, with a median age of 70 years (range: 24–79). The median duration of symptoms was 26 days (range: 1–1810). All but one patient were symptomatic. Nine had back pain, five were pyrexial, six had a raised white cell count, six were anaemic, four were septic and six had a contained leak on admission. Blood or tissue cultures isolated Salmonella (n = 3), staphylococci (n = 3), streptococci (n = 1), coliforms (n = 1), Treponema pallidum (n = 1), while in six patients no organisms were identified. Preoperative CT identified four infra-renal, four juxta-renal, three (Crawford thoracoabdominal) type IV, three type III and one type II aortic aneurysms. Thirteen were repaired with in situ prostheses following extensive local debridement and two required axillo-femoral prosthetic grafts. There were four early deaths, two (type IV) relating to blood loss, one secondary to myocardial event (type IV) and one secondary to multiorgan failure (juxta-renal). All surviving patients have been followed up for a median duration of 38 months (range: 1/2–112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection. Conclusions: In the absence of uncontrolled sepsis, in situ repair of mycotic aortic aneurysms using prosthetic grafts achieves durable results with only one late infection.