Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 38-40

Mycotic Aneurysm: Case Series


Department of Vascular Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India

Date of Web Publication5-Mar-2015

Correspondence Address:
Dr. Albert Abhinay Kota
Department of Vascular Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.152836

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  Abstract 

Mycotic aneurysms are rare and usually occur secondary to embolization of septic foci. Early diagnosis is the crucial. They have high risk of rupture/complications and can pose a difficult management challenge especially in an acute setting. We describe the management of four patients with mycotic aneurysms in our case series.

Keywords: Endovascular treatment, infected aneurysm, mycotic aneurysm, surgical treatment


How to cite this article:
Kota AA, Sen I, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Mycotic Aneurysm: Case Series. Indian J Vasc Endovasc Surg 2015;2:38-40

How to cite this URL:
Kota AA, Sen I, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Mycotic Aneurysm: Case Series. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2020 Jun 4];2:38-40. Available from: http://www.indjvascsurg.org/text.asp?2015/2/1/38/152836


  Background Top


Infected aneurysms are classified into four categories based on their etiology. They include mycotic aneurysm, microbial arteritis, infected preexisting aneurysms and posttraumatic infected false aneurysms. [1]


  Case Report Top


  • Case 1: A 43-year-old male with alcohol-related decompensated chronic liver disease (Child Turcotte Pugh (CTP) class-C) underwent injection sclerotherapy and banding of the bleeding varices in 2010 and transjugular intrahepatic portosystemic shunt in 2011. In January 2014, he presented with worsening back pain and pulsatile mass around he umbilicus. On imaging, there was a 7 cm lobulated fusiform aneurysm of the infrarenal aorta with scalloping of the anterior L4 vertebral body [Figure 1]. Inflammatory markers like erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were elevated; however, the blood cultures were sterile. Trans-thoracic and trans-esophageal echocardiograms were normal. The options of open repair and endovascular treatment were discussed with the patient and treating hepatologist. He underwent endovascular aneurysm repair. At review, he was stable and doing well
    Figure 1: Mycotic aortic aneurysm

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  • Case 2: A 45-year-old lady presented with fever, pain, pulsatile left thigh mass [Figure 2] with absent distal pulses. She had history of fever. She was diagnosed to have left superficial femoral artery (SFA) aneurysm with necrotizing soft tissue infection of the thigh and underwent emergency debridement, resection of the mycotic aneurysm and SFA to popliteal artery bypass using reversed saphenous graft [Figure 2]. Her postoperative period was uneventful. Culture grew beta-hemolytic Group A streptococcus
    Figure 2: Mycotic SFA aneurysm

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  • Case 3: A 26-year-old male with infective endocarditis (Enterococcus on blood culture) was referred from a physician with lower abdominal pain. Evaluation revealed saccular left internal iliac mycotic aneurysm. He underwent percutaneous transluminal covered stenting of the aneurysm [Figure 3]. At review, he was asymptomatic
    Figure 3: Mycotic Internal Iliac artery aneurysm

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  • Case 4: A 71-year-old male presented with severe low back pain with recurrent episodes of urinary tract infection. He was diagnosed to have infrarenal saccular mycotic aneurysm, underwent debridement of the infected aorta and open aneurysm repair using 14 mm tube Dacron graft. Culturew grew Enterococcus. Postoperatively, he developed ventilator-associated pneumonia, renal failure, pulmonary oedema and succumbed to multiorgan dysfunction on the 15 th postoperative day [Figure 4].
    Figure 4: Infrarenal mycotic aneurysm -open repair

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  Introduction Top


Sir William Osler observed "fresh fungal vegetations" in infective endocarditis and introduced the term "mycotic aneurysm." [2] It is however a misnomer as the infected arterial aneurysm is commonly bacterial in origin. Mycotic aneurysms may be classified into primary or secondary. Primary is aneurysmal degeneration due to primary infective aortitis, and secondary is presence of preexisting aneurysm with secondary infection of the aneurysm wall due to septic embolization. Mycotic aneurysms have an incidence of 1-2% of all aortic aneurysms. [1],[3],[4]


  Discussion Top


Etiology and risk factors

In the preantibiotic era, "syphilitic aortitis" was quite commonly seen. However, with the advent of increasing interventional arterial procedures and intravenous (IV) drug abuse, Gram-positive organisms like Staphylococcus and Streptococcus are often seen. In Asia, Salmonella is found to be the common etiological organism. Other rare organisms like Propionibacterium, Pseudomonas, Micrococcus, Candida, Aspergillus are also reported. [1],[3],[4],[5],[6],[7] In our series organisms isolated on cultures were Enterococci, Streptococci and one patient was culture negative.

The risk factors include interventional vascular procedures, infective endocarditis, immunosuppression, prior infections (lung, intra-abdominal sepsis, soft tissue and bone infections), IV drug abuse and preexisting aneurysms. [1],[3],[5],[8],[9],[10]

Clinical presentation and diagnosis

It is a rare but life-threatening condition. In the initial phase, the symptoms are usually nonspecific and include general malaise, fever. Symptoms like backache, abdominal pain, haemoptysis, neuropathy, sudden hypotensive shock, can be secondary to complications. [1],[3],[4],[5],[8],[9],[11]

Diagnosis is often clinical (past history of sepsis, interventions, fever, sudden increase in size of preexisting aneurysm) aided with increased inflammatory markers (ESR, CRP), positive microbiological cultures (negative blood cultures do not exclude mycotic aneurysm) and radiological evidence (saccular, eccentric and multilobulated with periaortic gas/fluid/inflammation). [1],[8],[12]

Management

The cornerstone of management is having a high index of clinical suspicion and diagnosis. The options of management include open and endovascular with long-term antibiotics.

Open repair is the best option. Goals of surgical treatment include debridement of infected tissues (confirms the diagnosis and for sepsis control), resection of involved segment and reconstruction. If there is no gross perivascular infection in situ reconstruction using autogenous venous grafts, prosthetic grafts, cryopreserved allografts have been described. If there are gross periaortic infected tissues, extra-anatomic bypass has been advocated. Ligation, debridement without revascularization has also been done in few instances. The distal aortic stump is always closed in two layers and reinforced with omental pedicle as there is high risk for stump blowout. The use of long-term antibiotics is advocated ranging from 6 weeks to life long. [8],[9],[13],[14],[15]

Endovascular treatment option is also viable especially in setting when surgical risk is very high and has the advantage of being minimally invasive. It is advocated as the primary option but can also be used as a bridge therapy followed by definite open repair, as there is potential for the endo-graft to get secondarily infected and recurrent sepsis. The long-term benefits of primary endovascular therapy are not known. [8],[10],[11],[12],[16],[17],[18]

 
  References Top

1.
Wilson SE, Van Wagenen P, Passaro E Jr. Arterial infection. Curr Probl Surg 1978;15:1-89.  Back to cited text no. 1
    
2.
Osler W. The Gulstonian Lectures, on Malignant Endocarditis. Br Med J 1885;1:467-70.  Back to cited text no. 2
    
3.
Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS, Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541-7.  Back to cited text no. 3
    
4.
Oderich GS, Panneton JM, Bower TC, Cherry KJ Jr, Rowland CM, Noel AA, et al. Infected aortic aneurysms: Aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900-8.  Back to cited text no. 4
    
5.
Samore MH, Wessolossky MA, Lewis SM, Shubrooks SJ Jr, Karchmer AW. Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol 1997;79:873-7.  Back to cited text no. 5
    
6.
Brossier J, Lesprit P, Marzelle J, Allaire E, Becquemin JP, Desgranges P. New bacteriological patterns in primary infected aorto-iliac aneurysms: A single-centre experience. Eur J Vasc Endovasc Surg 2010;40:582-8.  Back to cited text no. 6
    
7.
Macbeth GA, Rubin JR, McIntyre KE Jr, Goldstone J, Malone JM. The relevance of arterial wall microbiology to the treatment of prosthetic graft infections: Graft infection vs. arterial infection. J Vasc Surg 1984;1:750-6.  Back to cited text no. 7
    
8.
Reddy DJ, Shepard AD, Evans JR, Wright DJ, Smith RF, Ernst CB. Management of infected aortoiliac aneurysms. Arch Surg 1991;126:873-8.  Back to cited text no. 8
    
9.
Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. New concepts in therapy. Arch Surg 1983;118:577-82.  Back to cited text no. 9
    
10.
Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review. J Vasc Surg 2007;46:906-12.  Back to cited text no. 10
    
11.
Mofidi R, Bhat R, Nagy J, Griffiths GD, Chakraverty S, East of Scotland Vascular Network. Endovascular repair of a ruptured mycotic aneurysm of the common iliac artery. Cardiovasc Intervent Radiol 2007;30:1029-32.  Back to cited text no. 11
    
12.
Lee WK, Mossop PJ, Little AF, Fitt GJ, Vrazas JI, Hoang JK, et al. Infected (mycotic) aneurysms: Spectrum of imaging appearances and management. Radiographics 2008;28:1853-68.  Back to cited text no. 12
    
13.
Mani K, Björck M, Lundkvist J, Wanhainen A. Improved long-term survival after abdominal aortic aneurysm repair. Circulation 2009;120:201-11.  Back to cited text no. 13
    
14.
Maeda H, Umezawa H, Goshima M, Hattori T, Nakamura T, Umeda T, et al. Primary infected abdominal aortic aneurysm: Surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period. Surg Today 2011;41:346-51.  Back to cited text no. 14
    
15.
Moneta GL, Taylor LM Jr, Yeager RA, Edwards JM, Nicoloff AD, McConnell DB, et al. Surgical treatment of infected aortic aneurysm. Am J Surg 1998;175:396-9.  Back to cited text no. 15
    
16.
Clough RE, Black SA, Lyons OT, Zayed HA, Bell RE, Carrell T, et al. Is endovascular repair of mycotic aortic aneurysms a durable treatment option? Eur J Vasc Endovasc Surg 2009;37:407-12.  Back to cited text no. 16
    
17.
Patel HJ, Williams DM, Upchurch GR Jr, Dasika NL, Eliason JL, Deeb GM. Late outcomes of endovascular aortic repair for the infected thoracic aorta. Ann Thorac Surg 2009;87:1366-71.  Back to cited text no. 17
    
18.
Inoue H, Iguro Y, Yamamoto H, Ueno M, Higashi A, Tao K, et al. Palliative stent-graft insertion followed by an allograft replacement for an infected and ruptured aortic aneurysm. Ann Thorac Cardiovasc Surg 2009;15:261-4.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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