Treatment Of Mycotic Aortic Aneurysms Research Articles

Treatment of a descending thoracic mycotic aneurysm secondary to disseminated aspergillosis infection with thoracic endovascular aortic repair

Mycotic aortic aneurysms are a rare and potentially fatal aortic pathology. Advancements in vascular technology have allowed endovascular repair to be a durable and less invasive option for the treatment of mycotic aortic aneurysms. We have presented the case of a 51-year-old man with a mycotic aneurysm of the descending thoracic aorta secondary to chronic, disseminated aspergillosis infection after liver transplantation. The aneurysm was successfully treated with thoracic aortic stent graft deployment. No perioperative complications occurred, and follow-up computed tomography angiography showed no signs of an endoleak. The patient will continue with lifelong antifungal therapy and close follow-up with vascular surgery.

RUPTURED GASTRIC DUODENAL ARTERY FROM MYCOTIC ANEURYSM DUE TO CANDIDA ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycotic aneurysms refers to the irreversible vascular dilations caused by weakening and destruction of the vessel intimal wall by an invasive organism. Due to the advent of early treatment with antibiotics, mycotic aneurysms are quite rare, constituting only about 1-3% of all arterial aneurysms. We present a case of a 64 year old intravenous (IV) drug user who was admitted for candida endocarditis and developed hemorrhagic shock due to a ruptured gastric duodenal artery from a mycotic aneurysm. CASE PRESENTATION: A 64 year old male with a history of IV drug use and chronic steroid use for erythrodermic psoriasis presented with fevers for several days. In the emergency department, he was febrile to 101.9 degrees Fahrenheit, tachycardic to 120 beats per minute, and hypotensive to 88/46 mmHg. Blood cultures were drawn and he was started on IV fluids, broad-spectrum antibiotics, and vasopressor support for septic shock. His cultures were positive for candida fungemia. He had a transthoracic echocardiogram (TTE) which revealed a focal thickening on the anterior mitral valve leaflet which prompted a transesophageal echocardiogram (TEE). TEE confirmed a small, mobile vegetation on the anterior mitral valve leaflet consistent with endocarditis. Furthermore, his hospitalization was complicated by hemorrhagic shock with computed tomography of the abdomen revealing a large hematoma from a ruptured gastric duodenal artery requiring massive transfusion and emergent embolization for resolution of the bleed. The cause of the arterial bleed was found to be due to a mycotic aneurysm. DISCUSSION: Mycotic aneurysm is a rare phenomenon only constituting about 1-3% of all visceral aneurysms. They were first described by Dr. William Osler as aneurysms associated with bacterial or fungal endocarditis which had the appearance of a “fresh fungus vegetation” 2. Although mycotic aneurysms were initially thought to be due only to infective endocarditis, emerging literature revealed that these aneurysms can develop as a result of any hematogenous spread, lymphatic spread, contiguous extension, or direct inoculation. The initial presenting signs and symptoms of mycotic aneurysms constitute a febrile illness that eventually leads to fulminant sepsis. If left untreated, 20% of mycotic aneurysms will rupture leading to massive hemorrhage. Treatment of mycotic aneurysms includes antibiotic therapy, removal of the source of infection, and surgical or endovascular repair of the aneurysm itself. Endovascular intervention has been a successful intervention for mycotic aneurysms with a 2-year survival rate of 75%. CONCLUSIONS: Clinicians should recognize the risk of developing mycotic aneurysms and possible rupture as a complication of infective endocarditis with the mainstay of treatment being early antibiotic administration, removal of the source of infection, and surgical or endovascular repair of the mycotic aneurysm. Reference #1: Parkhurst GF, Dekcer JP. Bacterial aortitis and mycotic aneurysm of the aorta; a report of twelve cases. Am J Pathol. 1955;31(5):821-835. Reference #2: Gomes MN, Choyke PL. Infected aortic aneurysms: CT diagnosis. J Cardiovasc Surg (Torino). 1992;33(6):684-689. Reference #3: Sörelius Karl, Mani Kevin, Björck Martin, et al. Endovascular Treatment of Mycotic Aortic Aneurysms. Circulation. 2014;130(24):2136-2142. doi:10.1161/CIRCULATIONAHA.114.009481 DISCLOSURES: No relevant relationships by Everardo Arias Torres, source=Web Response No relevant relationships by Tim Cheng, source=Web Response No relevant relationships by Richard Lee, source=Web Response No relevant relationships by George Nasr, source=Web Response

Sustained local delivery of high-concentration vancomycin from a hybrid biodegradable, antibiotic-eluting, nanofiber-loaded endovascular prosthesis for treatment of mycotic aortic aneurysms

BackgroundEndovascular repair for mycotic aortic aneurysm (MAA) is a less invasive alternative to open surgery, although the placement of a stent graft in an infected environment remains controversial. In this study, we developed hybrid biodegradable, vancomycin-eluting, nanofiber-loaded endovascular prostheses and evaluated antibiotic release from the endovascular prostheses both in vitro and in vivo. MethodsPoly(D,L)-lactide-co-glycolide and vancomycin were dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol. This solution was electrospun into nanofibrous tubes, which were mounted onto commercial vascular stents and endovascular aortic stent grafts. In vitro antibiotic release from the nanofibers was characterized using an elution method and high-performance liquid chromatography. Antibiotic release from the hybrid stent graft was analyzed in a three-dimensional-printed model of a circulating MAA. The in vivo drug release characteristics were examined by implanting the antibiotic-eluting stents in the abdominal aorta of New Zealand white rabbits (n = 15). ResultsThe in vitro study demonstrated that the biodegradable nanofibers and the nanofiber-loaded stent graft provided sustained release of high concentrations of vancomycin for up to 30 days. The in vivo study showed that the nanofiber-loaded stent exhibited excellent biocompatibility and released high concentrations of vancomycin into the local aortic wall for 8 weeks. ConclusionsThe proposed biodegradable vancomycin-eluting nanofibers significantly contribute to the achievement of local and sustainable delivery of antibiotics to the aneurysm sac and the aortic wall, and these nanofibers may have therapeutic applications for MAAs.

Long-term Outcome of Endovascular Treatment for Mycotic Aortic Aneurysm

Endovascular repair (EVAR) of mycotic aortic aneurysm (MAA) has become an alternative treatment for high risk patients. The aim of this study was to evaluate long-term survival and outcomes. Retrospective analysis of 40 consecutive patients with MAAs undergoing EVAR and subsequent intravenous antibiotic treatment between September 2009 and April 2015. Follow-up was truncated on 30 April 2015. Uni- and multivariate logistic regression were used to assess risk factors of adverse outcomes. Cumulative survival was calculated using the Kaplan-Meier method. Median age at repair was 73 years (range 48-88 years) and 31 (77%) were men. Eleven (27%) patients were infected with Salmonella, 12 (30%) with non-Salmonella species, and 17 (42%) had negative cultures. Anatomical locations included the aortic arch/thoracic area in 10 (25%), the paravisceral area in seven (17%), and the infrarenal area in 23 (57%). Ten (25%) patients presented with aneurysm rupture and underwent emergency repair. Median follow-up was 25 months (range 1-69 months). Cumulative 1 and 5 year survival rates were 71% and 53%, respectively. Persistent or recurrent infection occurred in 20% (n=8). Patients with persistent infection were treated with long-term medical therapy, but all died (75%; n=6) within 6 months of repair. No survival difference was found between patients with or without Salmonella infections. However, there was a trend toward better survival in culture negative patients. EVAR of MAA is an acceptable alternative treatment of MAA. However, persistent infection after endovascular treatment does occur and is often fatal without surgical treatment.

Endovascular treatment of mycotic aortic aneurysms: a paradigm shift.

Treatment of mycotic aortic aneurysms (MAAs) composes a particularly difficult challenge. Open repair has been considered the gold standard, despite lack of evidence supporting its superiority compared with the emerging alternative endovascular aortic repair (EVAR). This review discusses the pros and cons of EVAR for MAAs by dissecting the three largest publications on MAAs, and concludes that there has been a paradigm shift in treatment of MAAs for the benefit of EVAR.

Ruptured Mycotic Aortic Aneurysm Secondary to Escherichia Coli Bacteremia in an HIV-Positive Patient

Mycotic aortic aneurysms are an aggressive form of degenerative remodeling reported more commonly in immunosuppressed patients. These aneurysms carry a high risk of progression to rupture, fulminant sepsis, and death, and therefore require prompt operative intervention. The human immunodeficiency virus (HIV) has also been associated with a broad spectrum of vascular disease, including development of aneurysms, however these have typically been identified in the peripheral vasculature. We report the case of a 71-year-old, HIV-positive male who presented with Escherichia coli bacteremia and aortitis which rapidly progressed to a ruptured infrarenal mycotic aortic aneurysm. He was managed successfully with open debridement and in situ implantation of a rifampin-soaked prosthetic graft as well as long-term antibiotic therapy. Here, we review the epidemiology, pathophysiology, and optimal surgical treatment of mycotic aortic aneurysms.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Endovascular treatment of mycotic aortic aneurysms: a European multicenter study.

Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection-related complications and long-term survival. All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39-86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella-positive culture as predictors for late infection-related death. Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella-positive blood cultures were more likely to die from late infection.

Clinical, microbiologic, and outcome analysis of mycotic aortic aneurysm: the role of endovascular repair.

Mycotic aortic aneurysm (MAA) is an infrequent but devastating form of vascular disease. We conducted a retrospective cohort study at a major medical center to identify independent risk factors for MAA and to provide opinions about treating it. The study population consisted of 43 patients who had had 44 MAAs over a period of 15 y. All of the patients had positive blood cultures, radiologic findings typical of MAA, and clinical signs of infection (leukocytosis, fever, and elevated C-reactive protein). The mean age of the patients was 63.8±10.6 y and the mean period of their follow up was 35.7±39.3 mo. Twenty-nine patients with MAAs underwent traditional open surgery, 11 others received endovascular stent grafts, and four MAAs were managed conservatively. The most frequent causative pathogens were Salmonella (36/44 patients [81.8%]), in whom organisms of Salmonella serogroup C (consisting mainly of S. choleraesuis) were identified in 14 patients, organisms of Salmonella serogroup D were identified in 13 patients, and species without serogroup information were identified in nine patients. The overall mortality in the study population was 43.2% (with an aneurysm-related mortality of 18.2%, surgically related mortality of 13.6%, and in-hospital mortality of 22.7%). Shock is a risk factor for operative mortality. Misdiagnosis and treatment of MAA as low back pain, co-existing connective-tissue disease such as systemic lupus erythematosus and rheumatoid arthritis, and Salmonella serogroup C-associated bacteremia are risk factors for aneurysm-related death. Endovascular repair should be considered as an alternative option to the open repair of MAA.

The Efficacy of Aortic Stent Grafts in the Management of Mycotic Abdominal Aortic Aneurysm—Institute Case Management with Systemic Literature Comparison

Conventional surgery (CS) for treatment of mycotic aortic aneurysm has rather high surgical morbidity and mortality rates. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. We analyzed all mycotic abdominal aortic aneurysm (AAA) cases treated by CS or EVAR in our institute and the reported cases treated by EVAR from the literature to determine the risk factors for aneurysm-related mortality and morbidity and to clarify the efficacy of the EVAR technique. All relevant literature reports of EVAR management of mycotic AAA and all cases treated in our institute, 41 cases, were included and analyzed. Of the 20 cases treated by EVAR, one had early mortality (1/20, 5%); of the remaining 21 cases that received CS, the early mortality rate was 4.8% (1/21). Patients in the CS group had a higher late mortality rate than those in the EVAR group (45% vs. 10.5%, p<0.05). However, the 24-month actual survival rate and actuarial aneurysm-related event-free rate were 83.9+/-8.6% and 78.3+/-9.7%, respectively, for the EVAR group and did not significantly differ from the CS group (70.4+/-10.2% and 80.1+/-8.9%). The significant predictors for aneurysm-related mortality and morbidity were age, Salmonella species infection, and leukocytosis, and possibly aortoenteric fistula and shock, but not the EVAR or CS procedures themselves. Compared with CS, EVAR might be an alternative strategy for managing mycotic AAAs.

Endovascular Treatment of Mycotic Aortic Pseudoaneurysms with Stent-Grafts

Mycotic aortic aneurysms remain a therapeutic challenge, especially in patients who are not suitable for open surgery. Endovascular treatment with stent-grafts in this indication is still disputed. Between January 2002 and January 2006, six patients with mycotic aneurysms of the thoracoabdominal or abdominal aorta were admitted to our department. All patients were male, aged 57-83 years (mean, 74.6 years). The mycotic aneurysms were diagnosed on the basis of clinical signs of infection, on CT, and, in four cases, on a positive blood culture. In all patients the mycotic aortic aneurysms were treated endovascularly by stent-graft implantation. Technical and clinical success was achieved in all patients. There was no in-hospital or 30-day mortality. In the follow-up period (range, 2-47 months) four patients died of cancer, cardiac failure, or unknown cause (one case). Two patients are still alive with nearly complete regression of the aneurysms. We conclude that treatment of mycotic aortic aneurysms with stent-grafts may be an alternative in selected patients.

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.

Bilateral splenorenal bypass and axillofemoral graft for management of juxtarenal mycotic aneurysm

The principles of treatment of mycotic aortic aneurysms are not well established and the optimal method of revascularization — extra-anatomic bypass or in situ grafting — is still debated. Infection of the juxtarenal or suprarenal aorta poses an additional challenge in management because of the requirement for visceral revascularization. The case of a 73-year-old man is reported who developed several mycotic aneurysms of the juxtarenal, infrarenal aorta and right main iliac artery following a Candida infection. He was successfully treated with suprarenal aortic ligation, aneurysmal excision, splenorenal bilateral bypass and systemic antifungal therapy. The patient subsequently underwent extra-anatomic revascularization of the lower extremities with a left axillobifermoral bypass involving a polytetrafluoroethylene graft.

Bilateral Splenorenal Bypass and Axillofemoral Graft for Management of Juxtarenal mycotic Aneurysm

The principles of treatment of mycotic aortic aneurysms are not well established and the optimal method of revascularization - extra-anatomic bypass or in situ grafting - is still debated. Infection of the juxtarenal or suprarenal aorta poses an additional challenge in management because of the requirement for visceral revascularization. The case of a 73-year-old man is reported who developed several mycotic aneurysms of the juxtarenal, infrarenal aorta and right main iliac artery following a Candida infection. He was successfully treated with suprarenal aortic ligation, aneurysmal excision, splenorenal bilateral bypass and systemic antifungal therapy. The patient subsequently underwent extra-anatomic revascularization of the lower extremities with a left axillobifermoral bypass involving a polytetrafluoroethylene graft. Copyright © 1996 The International Society for Cardiovascular Surgery.

Cryopreserved aortic homograft for mycotic aneurysm

Mycotic aneurysm is a life-threatening pathologic entity with high morbidity and mortality. The optimal surgical management is a subject of controversy. 1Pasic M Carrel T Vogt M von Segesser L Turina M Treatment of mycotic aneurysm of the aorta and its branches: the location determines the operative technique.Eur J Vasc Surg. 1992; 6: 419-423Abstract Full Text PDF PubMed Scopus (42) Google Scholar We report in situ replacement of mycotic aneurysm of the aorta with cryopreserved aortic homografts. A 67-year-old man underwent an elective operation for a mycotic aneurysm of the infrarenal abdominal aorta (Fig 1). The aneurysm was resected and the infrarenal aorta was replaced with a cryopreserved aortic homograft tube (Fig. 2). Fig. 2A cryopreserved homograft has been implanted in the infrarenal position after excision of the entire infrarenal part of the abdominal aorta. Note that the intercostal arteries arising from the grafts had been ligated by clips (arrows).View Large Image Figure ViewerDownload (PPT)Preoperative blood cultures and cultures from the aneurysm both grew Streptococcus pneumoniae. Penicillin G, given intravenously before the operation, was continued after the operation for 4 weeks, followed by cephalosporin given by mouth for another 2 weeks. The second patient was a 59-year-old man with a mycotic aneurysm of the descending thoracic aorta caused by Streptococcus pneumoniae (Fig 3). The diseased part of the descending thoracic aorta was replaced with a cryopreserved homograft (Fig. 4). Fig. 4Intraoperative view with the descending thoracic aorta replaced by a cryopreserved homograft. The homograft has been implanted in situ after extensive debridement of the diseased part of the descending thoracic aorta.View Large Image Figure ViewerDownload (PPT)Preoperative intravenous antibiotic therapy with clindamycin was continued after the operation for another 4 weeks. After resection of the mycotic aneurysm and the adjacent parts of the aorta, both patients received cryopreserved homografts harvested from the descending thoracic aorta of donors during harvesting of the heart for transplantation (Fig 5). The intercostal arteries arising from the grafts were ligated by clips (see Fig. 2), and then the grafts were implanted with end-to-end anastomoses in the usual manner with continuous polypropylene suture. The postoperative courses of both patients were uneventful. The patients received the appropriate antibiotic therapy for 4 to 6 weeks after the operation. The two patients have remained free of complications 12 and 6 months, respectively, after the operation. The standard operation for the treatment of patients with mycotic aneurysm consists of arterial ligation, aneurysm excision, and extraanatomic bypass grafting. 2Taylor Jr, LM Deitz DM McConnell DB Porter JM Treatment of infected abdominal aneurysm by extraanatomic bypass, aneurysm excision, and drainage.Am J Surg. 1988; 155: 655-658Abstract Full Text PDF PubMed Scopus (79) Google Scholar This procedure is associated with late complications and, in certain situations, is difficult or technically impossible to do, necessitating in situ reconstruction. 3Chan FY Crawford SE Coselli JS Safi HJ Williams Jr, TW In situ prosthetic graft replacement for mycotic aneurysm of the aorta.Ann Thorac Surg. 1989; 47: 193-203Abstract Full Text PDF PubMed Scopus (277) Google Scholar, 4Pasic M Carrel T von Segesser L Turina M In situ repair of mycotic aneurysm of the ascending aorta.J THORAC CARDIOVASC SURG. 1993; 105: 321-326PubMed Google Scholar However, in situ prosthetic graft replacement increases the risk of recurrent infection. 3Chan FY Crawford SE Coselli JS Safi HJ Williams Jr, TW In situ prosthetic graft replacement for mycotic aneurysm of the aorta.Ann Thorac Surg. 1989; 47: 193-203Abstract Full Text PDF PubMed Scopus (277) Google Scholar The usefulness of homograft cryopreserved tissue has already been proved in cardiac surgery. 5Kirklin JK Smith D Novick W et al.Long-term function of cryopreserved aortic homografts: a ten-year study.J THORAC CARDIOVASC SURG. 1993; 106: 154-166PubMed Google Scholar When used for infective processes of the aortic valve, homograft tissue reduces the postoperative infection rate and improves survival. 6Doty DB Michielon G Wang N-D Cain AS Millar RC Replacement of the aortic valve with cryopreserved aortic allograft.Ann Thorac Surg. 1993; 56: 228-236Abstract Full Text PDF PubMed Scopus (30) Google Scholar The use of a cryopreserved aortic homograft conduit for treatment of mycotic aortic aneurysm might reduce the rate of late postoperative infections and improve survival of this high-risk group of patients. Therefore, we strongly suggest harvesting of the entire aorta with its branches for further cryopreservation during the harvesting of other organs from a donor. If stored in a tissue bank, the homograft might be used for emergency operations because mycotic aneurysms are usually ruptured when diagnosed.