Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 194-197

Emergency endovascular management of ruptured mycotic aneurysm of the iliac artery using “bare stent-graft technique”


Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. S Roshan Rodney
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_92_18

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  Abstract 


Mycotic aneurysm of the aortoiliac region remains a life-threatening condition, especially if an aneurysm has already ruptured by the time of surgery. The mortality is increased further when it is associated with Salmonella infections, especially in the presence of risk factors for atherosclerosis. We report a case of a 50-year-old man who presented with ruptured mycotic aneurysm of the left common iliac artery secondary to infection with Salmonella paratyphi. He underwent emergent endovascular repair of the aneurysm with the “bare stent-graft technique.” Postoperative recovery was eventful. This case demonstrates that it is possible to safely manage mycotic aneurysms by endovascular means, following targeted perioperative antibiotic therapy.

Keywords: Aneurysm, endovascular, mycotic, salmonella


How to cite this article:
Rodney S R, Anand V, Vishnu M, Raj S, Chaudhari H, S Sravan C P, Lende V, Davra D, Jain PK, Vishal H, Krishna K S, Nishan B. Emergency endovascular management of ruptured mycotic aneurysm of the iliac artery using “bare stent-graft technique”. Indian J Vasc Endovasc Surg 2019;6:194-7

How to cite this URL:
Rodney S R, Anand V, Vishnu M, Raj S, Chaudhari H, S Sravan C P, Lende V, Davra D, Jain PK, Vishal H, Krishna K S, Nishan B. Emergency endovascular management of ruptured mycotic aneurysm of the iliac artery using “bare stent-graft technique”. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Sep 19];6:194-7. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/194/265786




  Introduction Top


Mycotic aneurysms are rare with an incidence of 0.06%–0.65%.[1] The most common sites are thoracic and abdominal aorta with involvement of lower extremity arteries being rare. Mycotic aneurysm of the aortoiliac region remains a life-threatening condition especially if the aneurysm has already ruptured at the time of presentation. Endovascular treatment plays a definitive role in the treatment of ruptured infected aneurysm in patients at prohibitive risk for open surgery.[2]


  Case Report Top


A 50-year-old male patient, ex-smoker, recently diagnosed diabetic, hypertensive, and history of ischemic heart disease with cardiomyopathy presented to our institute with complaints of fever for 2 weeks with left flank pain and abdominal distension for 1 day. On admission, he was hypotensive and anemic. Blood investigations showed a leukocyte count of 14.8 × 109/l, hemoglobin of 8.7 g/dl, and C-reactive protein of 15.17 mg/dl with deranged liver function tests. Ultrasound abdomen showed retroperitoneal hematoma of size 20 cm × 15 cm in the left psoas region confirmed with contrast-enhanced computed tomography (CT) scan which also showed a 3.3 cm × 3.5 cm × 4.2 cm size ruptured saccular aneurysm arising from the left distal common iliac artery (CIA) and ulcerated plaque in proximal CIA and 80%–90% stenosis in the proximal external iliac artery (EIA) with severe atherosclerotic vascular disease involving all arteries [Figure 1] and [Figure 2].
Figure 1: Computed tomography angiogram of left common iliac artery saccular aneurysm

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Figure 2: Axial sections with dimensions of the aneurysm

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He was treated in an emergent basis. Using a retrograde femoral approach, a 7F sheath was placed. Control angiogram displayed an irregularly shaped aneurysm of the distal CIA with contrast extravasation and significant stenosis in the proximal CIA and EIA [Figure 3]. A bare-metal self-expanding stent (7 mm × 150 mm) was deployed initially to the common and EIA atherosclerotic lesions [Figure 4] and to stop aneurysmal inflow, a (8 mm × 60 mm) stent graft was advanced through a 9F sheath which was replaced for the 7F sheath from the ipsilateral common femoral artery and deployed into the first stent at the level of the aneurysm [Figure 5]. Control angiography showed total exclusion of the inflow of the aneurysm [Figure 6]. His blood culture was positive for  Salmonella More Details paratyphi. Postoperatively, all peripheral pulses of the left lower limb were palpable. Postoperative period was uneventful, and the patient was discharged on 3rd postoperative day with appropriate culture-specific intravenous antibiotics for 6 weeks, but he had an acute coronary syndrome for 3 weeks following discharge and expired.
Figure 3: Digital subtraction angiography showing leaking left common iliac artery aneurysm

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Figure 4: Bare-metal self-expanding stent implantation

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Figure 5: Stent graft (8 mm × 60 mm) deployment inside the bare-metal stent

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Figure 6: Angiogram showing complete aneurysm exclusion

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  Discussion Top


Mycotic aneurysm was first described by Osler in 1885.[3] Early diagnosis of mycotic aneurysms is challenging because the clinical manifestations are nonspecific. Clinically, apparent mycotic aneurysms are often at an advanced stage of development or are associated with complications, such as rupture.[3] Diagnosis is based on the imaging findings of the aneurysm and positive results of bacterial culture or the support of arterial wall histological examination. Reports about mycotic aneurysms had decreased gradually since the widespread use of antibiotics. Currently, the most common cause of mycotic aneurysms is Staphylococcus aureus, followed by Salmonella. Salmonella infections are predominantly detected in atherosclerotic lesions, whereas S. aureus infections mainly occur in intravenous drug abusers.[4],[5]

Mycotic aneurysms can develop from (a) hematogenous spread of infectious microemboli into the vasa vasorum of a normal caliber artery or a preexisting aneurysm, (b) infection of a preexisting intimal defect by circulating infectious agent, (c) contiguous involvement of the vessel from an adjacent source of sepsis, or (d) direct infectious inoculation of the vessel wall at the time of vascular trauma. Infection causes destruction of the arterial wall with subsequent formation of a pseudoaneurysm. An infected aneurysm rapidly enlarges, leading to fatal rupture due to sustained systemic arterial pressure.[4],[5],[6]

Salmonella with its strong affinity for larger blood vessels leads to aneurysm formation due to necrosis and rupture of atherosclerotic vessel wall. If the mycotic aneurysm is not treated, the incidence of fatal prognosis is extremely high. Kam et al. reported that >53% of Salmonella-infected aneurysm ruptured.[7] Hsu et al. reported that the mortality was approximately 16%–44%.[8]

Multidetector CT angiography is the current imaging modality of choice for the evaluation of suspected infected aneurysms. Its advantages include rapid examination with three-dimensional reconstruction of vascular anatomy for surgical or endovascular treatment planning and simultaneous identification of any associated complications.[9]

The gold standard treatment of patients with a mycotic aneurysm is open surgery with resection of the infected aneurysm, extensive local debridement, and revascularization by in situ reconstruction or extra-anatomic bypass. Nowadays, especially during the last decade, there is a shift toward endovascular repair for hemodynamically unstable patients with a ruptured mycotic aneurysm because of the high mortality and morbidity associated with open surgical treatment. To prevent postoperative recurrence, the recommended intravenous antibiotic therapy should be prolonged until 6 weeks after surgery, especially in patients with endovascular repair, but there is no general consensus on the optimal duration of antibiotic therapy.[3],[10]

The major concern regarding endovascular stent-graft repair to mycotic aneurysms is persistent infection or reinfection of the graft fabric with the fact that endovascular repair does not allow for surgical debridement of the infected tissues, and that the presence of a foreign body in an infected area presents a risk of continued infection despite antibiotic treatment.[1]

Nevertheless, this case report confirms the feasibility of endovascular repair of ruptured mycotic aneurysm of the CIA. This may be a valuable and lifesaving option, which can be performed quickly and safely in patients with a life-threatening condition and precludes the need for a difficult, prolonged high-risk procedure with significant mortality in the emergency setting.

To our knowledge, this is the first case of mycotic iliac artery aneurysm with underlying atherosclerotic steno-occlusive disease treated with this “bare stent-graft technique.”


  Conclusion Top


Diagnosis of mycotic aneurysm requires a high index of suspicion. Evidence-based conclusions with regard to a endovascular treatment of mycotic aneurysms cannot be drawn due to the paucity of published reports and lack of large patient series. Endovascular repair can be considered a valuable and lifesaving option of such ruptured infected aneurysms in an emergency setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
Joshi S, Mitta N. Mycotic aneurysm of iliac artery: A rare complication of Salmonella infection. Indian J Vasc Endovasc Surg 2014;1:26-8.  Back to cited text no. 2
  [Full text]  
3.
Guo Y, Bai Y, Yang C, Wang P, Gu L. Mycotic aneurysm due to salmonella species: Clinical experiences and review of the literature. Braz J Med Biol Res 2018;51:e6864.  Back to cited text no. 3
    
4.
McCready RA, Bryant MA, Divelbiss JL, Chess BA, Chitwood RW, Paget DS, et al. Arterial infections in the new millenium: An old problem revisited. Ann Vasc Surg 2006;20:590-5.  Back to cited text no. 4
    
5.
Cohen PS, O'Brien TF, Schoenbaum SC, Medeiros AA. The risk of endothelial infection in adults with Salmonella bacteremia. Ann Intern Med 1978;89:931-2.  Back to cited text no. 5
    
6.
Soravia-Dunand VA, Loo VG, Salit IE. Aortitis due to Salmonella: Report of 10 cases and comprehensive review of the literature. Clin Infect Dis 1999;29:862-8.  Back to cited text no. 6
    
7.
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. 7
    
8.
Hsu RB, Chen RJ, Wang SS, Chu SH. Infected aortic aneurysms: Clinical outcome and risk factor analysis. J Vasc Surg 2004;40:30-5.  Back to cited text no. 8
    
9.
Sanada J, Matsui O, Arakawa F, Tawara M, Endo T, Ito H, et al. Endovascular stent-grafting for infected iliac artery pseudoaneurysms. Cardiovasc Intervent Radiol 2005;28:83-6.  Back to cited text no. 9
    
10.
Luo Y, Zhu J, Dai X, Fan H, Feng Z, Zhang Y, et al. Endovascular treatment of primary mycotic aortic aneurysms: A 7-year single-center experience. J Int Med Res 2018;46:3903-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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