Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 121-123

Infected Abdominal Aortic Aneurysm with Severe Sepsis: Successful Outcome


1 Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana, India
2 Consultant Surgical Gastroentrologist, Yashoda Hospital, Hyderabad, Telangana, India
3 Consultant Urologist, Yashoda Hospital, Hyderabad, Telangana, India
4 Consultant Anaesthiologist, Yashoda Hospital, Hyderabad, Telangana, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_54_16

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  Abstract 


Primary infection of aorta, in absence of atherosclerosis, leading to aneurysm formation occurs in <1% of cases. Early diagnosis and surgical treatment are important to offset associated poor prognosis. A preoperative diagnosis is often missed due to nonspecific presentation. Computed tomography can confirm the diagnosis in suspected cases. Confirmation of diagnosis often warrants deviation from usual surgical techniques of management of abdominal aortic aneurysm. A case is described, of a toxic male patient, detected to have an infected aortic aneurysm with multiorgan dysfunction presented in septic shock. He could be successfully managed by an aggressive surgical and medical approach.

Keywords: Extra-anatomic bypass, infected aneurysm, pyelonephritis


How to cite this article:
Singh D, Sarathy P, Krishna V, Amte S. Infected Abdominal Aortic Aneurysm with Severe Sepsis: Successful Outcome. Indian J Vasc Endovasc Surg 2017;4:121-3

How to cite this URL:
Singh D, Sarathy P, Krishna V, Amte S. Infected Abdominal Aortic Aneurysm with Severe Sepsis: Successful Outcome. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2020 Jun 1];4:121-3. Available from: http://www.indjvascsurg.org/text.asp?2017/4/3/121/211915




  Introduction Top


Infected abdominal aortic aneurysm (AAA) can result from degenerative changes caused by primary infection or a secondary infection of an already established aneurysm. Salmonella species and Staphylococcus aureus are the predominant implicated organisms. Diagnosis is often delayed or unsuspected until surgery. The complication and mortality rate are extremely high in the absence of surgical treatment. Conventionally, the treatment for infected AAA has been aortic excision with proximal and distal closure, debridement of surrounding infected tissue, and extra-anatomic bypass. We report a case of male patient presented in septic shock, suffering from contained rupture of infected AAA caused by Escherichia coli, successfully managed by extra-anatomic bypass grafting.


  Case Report Top


A 65-year-old diabetic male referred with large infected AAA in septic shock with multiorgan dysfunction. Grossly anemic (hemoglobin 6.7%), elevated serum creatinine (4.5), deranged liver functions (serum bilirubin 12), presented in hypotension requiring inotropic support (total leucocyte count 42,000). History revealed pain abdomen radiating to back with continuous fever for the last 3 weeks. He was diagnosed as pyelonephritis with left hydronephrosis and treated symptomatically. With deterioration in condition, a repeat computed tomography (CT) scan confirmed a large infected aortic aneurysm with multiple abscesses in the retroperitoneum [Figure 1]. Since the patient was in frank sepsis with pus in the abdomen, exploration of abdomen, and removal of the septic component was considered as the priority in the treatment. Unlikely patient would get stabilized with medical treatment and endografting. Hence, he was planned for an emergency surgical procedure. After ureteric stenting, radical excision of the infrarenal infected aortic aneurysm with ligation of infrarenal aorta and both common iliac arteries [Figure 2]. The aortic stump was closed with prolene sutures and was covered with prevertebral fascia and with a layer of omentum. Retroperitoneum was thoroughly debrided and washed followed by axillo bifemoral bypass with 8 mm polytetrafluoroethylene ringed synthetic graft [Figure 3]. Both the procedures were done in the same sitting. Immediate postoperative period was stromy with hypotension and acidosis. He remained on mechanical ventilation for 2 days. On 3rd day onward, he showed good recovery and was off inotropes mechanical ventilation, with normal kidney and liver functions and palpable pedal pulses [Figure 4]. Specimen grew E. Coli for which appropriate long term antibiotics were continued for 6 weeks. He is doing good since then and now its been close to 18 months in the follow-up.
Figure 1: Computed tomography scan: Large infected aortic aneurysm

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Figure 2: Large infected aortic aneurysm involving distal aorta and both iliac arteries

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Figure 3: Extra-anatomical bypass with synthetic graft (axillo bifemoral bypass)

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Figure 4: Computed tomography angiogram: Patent axillo bifemoral bypass

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  Discussion Top


The prevalence of infected aortic aneurysm comprises 0.7%–2.6% of all cases of aortic aneurysm, and despite, the recent improvements in surgical techniques and antibiotic therapy, mortality rate ranges from 16% to 44%.[1],[2],[3] Early diagnosis and surgical intervention plus prolonged antibiotic therapy are essential for survival.[1],[2],[3]

The presence of primary aortic infection should be suspected in patients with fever, pain, leukocytosis, immunosuppression, and a saccular aneurysm located in unusual aortic location. The diagnosis is best confirmed by CT of the abdomen which shows thickening of aortic wall anteriorly and laterally. Other findings that point toward an infective pathology are unusual location, saccular morphology, fat stranding, and gas bubbles.

Surgical management consisted of wide debridement of necrotic tissue, copious irrigation, and either in situ graft replacement or extra-anatomic bypass.

Bacteriological examination of pus revealed E. coli as the offending organism which is in contrast to most studies that report Salmonella and S. aureus as the dominant infecting organisms. A prolonged course of antibiotics, for at least 3 months after discharge, has been recommended. White blood cell count and C-reactive protein are to be monitored regularly to assess the occurrence of reinfection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
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. 2
    
3.
Fillmore AJ, Valentine RJ. Surgical mortality in patients with infected aortic aneurysms. J Am Coll Surg 2003;196:435-41.  Back to cited text no. 3
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