Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 184-186

Treatment of infected aortic aneurysms: Case reports and review of the literature


1 Department of Vascular and Endovascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
2 Department of Vascular Surgery, Sri Ramachandra Medical University, Chennai, Tamil Nadu, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Pranay Pawar
Department of Vascular and Endovascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_1_19

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  Abstract 


Management of infected aortic aneurysms remains one of the most challenging clinical problems for the vascular surgeon, as they are rare and difficult to treat. Curative treatment is achieved by removal of all infected native tissue followed by a vascular reconstruction. Endovascular repair can also be used as a “bridge therapy” to reduce the mortality in these patients.

Keywords: Infected aortic aneurysms, mycotic aortic aneurysms, neo-aortoiliac system


How to cite this article:
Pawar P, Jagan J, Raju R, Ayyappan M K, Mathur K. Treatment of infected aortic aneurysms: Case reports and review of the literature. Indian J Vasc Endovasc Surg 2019;6:184-6

How to cite this URL:
Pawar P, Jagan J, Raju R, Ayyappan M K, Mathur K. Treatment of infected aortic aneurysms: Case reports and review of the literature. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Nov 15];6:184-6. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/184/265770




  Introduction Top


Infected aortic aneurysms comprise a minority of all aortic aneurysms (0.65%–2%). They are potentially lethal and their management remains challenging due to their rapidly progressive clinical course and fatal outcomes. The recommended treatment policy is open repair with surgical resection of the infected aorta, extensive debridement of the infected tissue, and aortic reconstruction with either in situ graft or extra-anatomic bypass.[1] We describe two cases of infected aortic aneurysms that were managed at our center.


  Case Reports Top


Case 1

A 54-year-old man presented with low-grade fever and lower abdominal pain for 10 days before admission. He was under treatment at a nearby clinic and was referred due to worsening of the abdominal pain. On examination, his pulse rate was 120/min, blood pressure was 140/60 mmHg, and his temperature was 100°F. His systemic examination was unremarkable and his distal pulses were palpable. His preliminary investigations revealed a total leukocyte count (TLC) of 23,700 and a C-reactive protein (CRP) of 5.6 with a normal two-dimensional (2-D) echo. His computed tomography angiogram (CTA) revealed well-defined peripherally enhancing collection of size 7.5 cm × 8.8 cm × 6 cm at the distal abdominal aorta just proximal to the bifurcation with two saccular aneurysms (3.3 cm × 2.0 cm × 3.2 cm and 2.8 cm × 1.4 cm × 3.4 cm) at the level of this collection. A prostatic collection of 6–10 cc was also noted. A diagnosis of an infected aortic aneurysm was made, and the patient was empirically started on cefoperazone-sulbactam and vancomycin and was taken up for a laparotomy the following day. A midline laparotomy was performed, and after taking proximal and distal controls, the aneurysm was opened. There was a large cystic mass with purulent fluid and large lymph nodes surrounding the aorta. The mass and the aorta were excised, and a thorough debridement and lavage of the area was performed. Simultaneously, the right femoral popliteal vein was harvested and was fashioned into a pantaloon aortobiiliac graft. The proximal anastomosis was performed with 4–0 prolene and the distal iliac with 5–0 prolene. The graft was covered with omentum and the abdomen was closed in layers. The tissue and blood culture both grew Burkholderia cepacia, for which appropriate sensitive antibiotics were started. This case was published in the same journal at an earlier date[2] [Figure 1] and [Figure 2].
Figure 1: Computed tomography angiogram depicting a bilobed infrarenal saccular aneurysm

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Figure 2: Creation of the neo-aortoiliac system bypass graft

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Case 2

A 51-year-old man presented with low-grade fever and abdominal pain for 3 weeks. He was diagnosed with typhoid fever and had completed the treatment course at another hospital. On presentation, his pulse rate was 120/min, blood pressure was 110/70 mmHg, and temperature was 102°F. His baseline investigations showed a TLC of 17,300 with a CRP of 5.2 and a normal 2-D echo. His systemic examination was unremarkable and his distal pulses were normal. His CTA revealed an irregular nodal mass measuring 3.6 cm × 3.0 cm × 2.5 cm in the distal abdominal aorta just proximal to the bifurcation with a 1.0 cm × 0.8 cm saccular outpunching present in the mass. A working diagnosis was made of an infected aortic aneurysm, and the patient was started on ceftriaxone and vancomycin in view of his history of enteric fever. After a week of antibiotic therapy, the patient was taken up for a midline laparotomy. The operative findings were of a 4 cm × 5 cm nodal mass with a saccular aneurysm of the infrarenal aorta. The affected part was excised, and a thorough debridement was done after proximal and distal controls. An aortobiiliac bypass was performed with a rifampicin-soaked dacron graft. The tissue culture grew Citrobacter species and sensitive antibiotics were continued for 6 weeks [Figure 3] and [Figure 4].
Figure 3: Computed tomography angiogram depicting a saccular infrarenal aortic aneurysm

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Figure 4: Implantation of a rifampicin-soaked dacron graft

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  Discussion Top


Sir William Osler first reported infected aortic aneurysms in 1885 and used the misnomer term mycotic to describe the appearance of fresh fungal vegetation on the intimal surface of an aortic aneurysm in a patient with bacterial endocarditis.[3] Infected aortic aneurysms comprise a minority of all aneurysms but continue to be challenging to treat due to delayed presentations with rupture, complex aneurysms in immunocompromised hosts and controversy over the ideal treatment.

There are four types of infected aortic aneurysms based on etiology:

  1. Microbial arteritis with aneurysm formation due to noncardiac origin bacteremia or contiguous spread of a localized infection
  2. Posttraumatic infected pseudoaneuryms
  3. Infection of preexisting aneurysms from bacteremia
  4. Infected aneurysms from septic emboli.[4]


Since the introduction of antibiotics, the predominant organisms Streptococcus pyogenes, pneumococcus, and Enterococcus species have become less common, and Staphylococcus aureus and  Salmonella More Details species have become the dominant infecting organisms. Salmonella species exhibit a more virulent course due to their ability to invade the normal intima and cause early aneurysm rupture.[5]

The gold standard of treatment is resection, debridement of infected tissues, and graft replacement either by in situ or by extra-anatomic bypass. Many adjunctive procedures such as (a) omental or pedicled muscle flap to isolate the graft, (b) biologic materials such as a homograft or a vein graft, and (c) a silver-coated or antibiotic-soaked dacron graft have been proposed to avoid recurrent infection.[6]

The neo-aortoiliac system bypass was described by Clagett. During this procedure, the infected material is removed and is replaced by a graft constructed from the femoral and popliteal veins. The advantages of this procedure are that there is no synthetic material introduced, which minimizes the risk of recurrent infection, there is no risk of blowout associated with a blind suture closure of the aorta in an infected surgical field, and secondary occlusion of the reconstruction is rare due to a high arterial volume flow and low thrombogenicity.[7]

Over the last decade, endovascular aneurysm repair (EVAR) of thoracic and abdominal aortic aneurysms has become widely accepted. However, reports on mycotic aortic aneurysms have been controversial. Semba et al. were the first to describe EVAR of three mycotic aneurysms. Compared with open repair, the unresected infected aneurysm sac and the surrounding tissue may cause persistent sepsis and late prosthetic graft infection, are the major concerns after EVAR. On the other hand, usage of a stent graft does not preclude later open repair, and in a situation of impending rupture, it could be used as a “bridge to surgery” and EVAR rapidly stops aneurysm expansion and has relatively less hemodynamic instability, which is a primary risk factor for mortality in open repair.[1],[8],[9]

Targeted antibiotic treatment leads to significant decrease in the mortality rate, and maximum effort should be made to identify the infectious agent. It is appropriate to continue the antibiotic treatment for 4–8 weeks after surgery, and in cases of Salmonella, a treatment period of at least 6 months is advised.[10]


  Conclusion Top


Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. Early diagnosis and aggressive treatment personally tailored to the patient will ensure favorable outcomes in this disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luo CM, Chan CY, Chen YS, Wang SS, Chi NH, Wu IH, et al. Long-term outcome of endovascular treatment for mycotic aortic aneurysm. Eur J Vasc Endovasc Surg 2017;54:464-71.  Back to cited text no. 1
    
2.
Sharma A, Pawar P, Raju R, Ayappan M, Mathur K. Neo aortoiliac system repair of Burkholderia cepacia infected mycotic aneurysm with impending rupture. Indian J Vasc Endovascular Surg 2018;5:129.  Back to cited text no. 2
    
3.
Macedo TA, Stanson AW, Oderich GS, Johnson CM, Panneton JM, Tie ML, et al. Infected aortic aneurysms: Imaging findings. Radiology 2004;231:250-7.  Back to cited text no. 3
    
4.
Guo Y, Xu T, Wang C, Wang J. Aortic dissection with aneurysm associated with Salmonella infection. Eur J Inflamm 2017;15:98-101.  Back to cited text no. 4
    
5.
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. 5
    
6.
Aoki C, Fukuda W, Kondo N, Minakawa M, Taniguchi S, Daitoku K, et al. Surgical management of mycotic aortic aneurysms. Ann Vasc Dis 2017;10:29-35.  Back to cited text no. 6
    
7.
Nordanstig J, Törngren K, Smidfelt K, Roos H, Langenskiöld M. Deep Femoral Vein Reconstruction of the Abdominal Aorta and Adaptation of the Neo-Aortoiliac System Bypass Technique in an Endovascular Era. Vascular and endovascular surgery 2019;53:28-34.  Back to cited text no. 7
    
8.
Semba CP, Sakai T, Slonim SM, Razavi MK, Kee ST, Jorgensen MJ, et al. Mycotic aneurysms of the thoracic aorta: Repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1998;9:33-40.  Back to cited text no. 8
    
9.
Sedivy P, Spacek M, El Samman K, Belohlavek O, Mach T, Jindrak V, et al. Endovascular treatment of infected aortic aneurysms. Eur J Vasc Endovasc Surg 2012;44:385-94.  Back to cited text no. 9
    
10.
Ting AC, Cheng SW, Ho P, Poon JT. Endovascular stent graft repair for infected thoracic aortic pseudoaneurysms – A durable option? J Vasc Surg 2006;44:701-5.  Back to cited text no. 10
    


    Figures

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



 

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