Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 129-131

Neo aortoiliac system repair of burkholderia cepacia infected mycotic aneurysm with impending rupture


Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Achintya Sharma
Department of Vascular 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_78_17

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  Abstract 


Mycotic or infected aneurysms are focal vascular dilatations from inflammation or infection that results in weakening of the blood vessel wall. It poses a high risk of complications such as aneurysm rupture, uncontrolled sepsis, and extensive para-aortic infection. We report a case of a middle-aged man with a 2-week history of fever, abdominal pain, and backache. Computed tomography angiogram was done which showed infrasaccular aneurysm with impending rupture. The patient underwent neoaortoiliac system repair which was done by harvesting bilateral superficial femoral vein. We report a case of an infected mycotic aneurysm caused by Burkholderia cepacia, a Gram-negative lactose nonfermenting bacterium which is commonly seen in livestock and has not been reported earlier.

Keywords: Aorta, mycotic aneurysm, neoaortoiliac system


How to cite this article:
Sharma A, Pawar P, Raju R, Ayappan M K, Mathur K. Neo aortoiliac system repair of burkholderia cepacia infected mycotic aneurysm with impending rupture. Indian J Vasc Endovasc Surg 2018;5:129-31

How to cite this URL:
Sharma A, Pawar P, Raju R, Ayappan M K, Mathur K. Neo aortoiliac system repair of burkholderia cepacia infected mycotic aneurysm with impending rupture. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2021 Dec 7];5:129-31. Available from: https://www.indjvascsurg.org/text.asp?2018/5/2/129/231857




  Introduction Top


Infected aneurysm of abdominal aorta are relatively uncommon, accounting for only 18% of all mycotic aneurysms. Overall, gram -positive organisms accounts for 60% of mycotic aneurysms. We report a case caused by gram negative lacotse non fermenting bacterium which is rarely associated with mycotic aneurysm.


  Case Report Top


A 55-year-old male came with a history of fever for 2 weeks, abdominal pain radiating to the lower back, with loss of appetite, nausea, and vomiting. He consulted a general practitioner and was placed on oral antibiotics for suspected colitis, without significant improvement.

The patient came to the emergency room after being treated for 5 days by the general physician. Systemic review was otherwise unremarkable. The patient is a smoker with a history of hypertension.

On examination, the patient had temperature of 100°F and tachycardia. Abdominal assessment showed tenderness in the epigastric region and right iliac fossa. Pulsatile mass was not felt clinically. The ultrasonography abdomen showed prostatic abscess with mild collection in the abdomen.

Preliminary investigations showed elevated white cell count 23.7 × 109 cells/L, and serum alkaline phosphatase 246 U/L was positive for nitrites and leukocytes. Patient's hemoglobin is 12.4 g/dL, and coagulation profile was unremarkable. Initial blood culture was negative. The patient was placed on empirical antibiotics (cefoperazone and vancomycin) with coverage of both Gram-positive and Gram-negative organisms. Echocardiogram did not show evidence of infective endocarditis. The patient was taken for emergency computed tomography scan which showed saccular infrarenal aneurysm with impending rupture. [Figure 1]: Illustrates that infra- renal aorta and common ilac artery is aneurysmal and there is a collection around the origin of common iliac artery.
Figure 1: Infrarenal saccular aneurysm measuring 3.2 cm × 2 cm on the right side, 2.8 cm × 2 cm on the left side, hypodense cystic collection

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The patient was planned for elective laparotomy, performed through midline incision. Infrarenal aorta was involved with hypodense cystic collection extending around the common iliac bifurcations, with impending rupture of the aneurysmal sac [Figure 2]. On the table, plan was made for neoaortoiliac system (NAIS) repair as general condition of the patient was stable. NAIS has been shown to be highly resistant to infection and with excellent long-term patency. Bilateral superficial femoral veins (SFVs) were harvested before cross-clamping the aorta, so as to reduce the ischemia time. Infrarenal proximal control and bilateral common iliac control were taken distally, and aneurysmal sac was opened and excised [Figure 3]. The retroperitoneal bed was debrided and washed thoroughly with saline. Using harvested bilateral SFVs, the neo-infrarenal aorta was created using pantaloons technique [Figure 4]. Proximal anastomosis to infra renal aorta was done with 3-0 prolene and both the common iliac artery were repaired with 5-0 prolene and the graft was reinforced with omentum [Figure 5]. Postoperatively, the patient was shifted to Intensive Care Unit and kept on higher antibiotics (cefoperazone and vancomycin) and prophylactic anticoagulation. The tissue wall biopsy showed the presence of rare Gram-negative organism Burkholderia cepacia, for which our antibiotic coverage was adequate.
Figure 2: Impending rupture of aneurysmal sac

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Figure 3: Aneurysmal sac opened and thrombus evacuated

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Figure 4: Bilateral superficial femoral vein harvested and infrarenal aorta conduit made by pantaloon technique

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Figure 5: After anastomosis and neoaortoiliac system

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  Discussion Top


Infected aneurysms of the abdominal aorta are relatively uncommon, accounting for only 18% of all mycotic aneurysms, and among aortic locations, aneurysms of the suprarenal aorta are less frequent than those of infrarenal origin.[1] A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition as it has a natural history of rapid rupture and death.[2] It carries a high risk of complications, especially those with underlying sepsis and extensive para-aortic infection. Symptoms are frequently minimal during the early stages, and a high index of suspicion is essential to make the diagnosis.

Mycotic aneurysm results from systemic bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic plaque acting as a culture medium. These emboli usually lodge at the sites of arterial division, particularly in the femoral and superior mesenteric arteries. Rarely, organisms may colonize the intact vascular wall through the vasa vasorum, where the arterial wall is weakened by a local suppurative process which results in aneurysm formation.[3]

Risk factors include (1) endothelial damage caused by atherosclerosis including preexisting aneurysm and (2) antecedent infection including bacteremia, which appears to be similar in our case having prostatic abscess.[4] Opinion was taken from an urologist and the patient was managed conservatively on antibiotics.

Mycotic aneurysms are defined by the presence of two or more of the following features: sepsis (fever, leukocytosis, and pain), positive blood culture, positive culture from the aneurysmal wall, or characteristic radiological appearance (including irregular aortic wall, rapid growth rate, or saccular appearance of the aneurysm). Negative blood cultures and absence of fever do not exclude the diagnosis when the patient has presented with signs of infection and had characteristic radiological findings but had already been commenced on antibiotics.[5] Despite improved patient selection, refined surgical technique, and postoperative management, morbidity and morbidity remain high. Thirty-day operative mortality is 10%, with a 5-year mortality rate of 30%–50%. The strongest predictors of mortality in various series were operative blood loss of 3 L, infection with Candida glabrata, and American Society of Anesthesiologists Class 4.[6] Thirty-day major amputation rates range from 2% to 7.4%, with a 5-year limb salvage rates ranging between 89% and 96%. Early occlusion of the grafts is rare, with 4% undergoing thrombosis within the first 30 days; 5-year primary patency ranges from 75% to 91%, with secondary patency approaching 91% at 5 years.[5],[6],[7] The durability of the NAIS reconstruction is unparalleled, with patency rates as described here. Aneurysmal degeneration has also been a concern that has failed to be borne out with long-term follow-up.

B. cepacia is rarely associated with mycotic aneurysm. It is found in 0.5%–1% of cases, primarily in immunocompromised patients and pneumonia. Our patient did not have any evidence of above. From our search, all the reported Burkholderia mycotic aneurysms are caused by Burkholderia pseudomallei[8] and we could not find any cause by B. cepacia.

B. cepacia is a member of a group known as B. cepacia complex. It comprises nine different recognized genomovars, including Burkholderia multivorans, Burkholderia cenocepacia, Burkholderia stabilis, Burkholderia vietnamiensis, Burkholderia dolosa, Burkholderia ambifaria, Burkholderia anthina, and Burkholderia pyrrocinia. B. cepacia complex may cause “cepacia syndrome” which is a form of progressive necrotizing pneumonia. It is commonly seen in cattle and livestock. Co-trimoxazole is the drug of choice for the treatment of infections caused by B. cepacia along with ceftazidime and meropenem, alone or in combination with other antibiotics. It is innately resistant to various antimicrobial agents including polymyxins, aminoglycosides, chloramphenicol, and beta-lactams. Mechanisms conferring resistance include efflux pumps, production of beta-lactamases, and other modifying enzymes, as well as modification of antibiotic targets.


  Conclusion Top


Mycotic aneurysms are rare but are serious, life-threatening pathologies. Burkholderia is a rare pathogen. All reported cases are with B. pseudomallei, and we found none with B. cepacia. In situ repair of such aortoiliac aneurysm with NAIS is described here and likely durable and resistant to recurrent infections.

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.
Lussier N, Girouard Y, Chapleau D. Mycotic aneurysm of suprarenal aorta: Case report and literature review. Can J Surg 1999;42:302-4.  Back to cited text no. 1
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2.
Sörelius K, Mani K, Björck M, Sedivy P, Wahlgren CM, Taylor P, et al. Endovascular treatment of mycotic aortic aneurysms: A European multicenter study. Circulation 2014;130:2136-42.  Back to cited text no. 2
    
3.
Chan YC, Morales JP, Taylor PR. The management of mycotic aortic aneurysms: Is there a role for endoluminal treatment? Acta Chir Belg 2005;105:580-7.  Back to cited text no. 3
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4.
Papadimitriou D, Tachtsi M, Koutsias S, Pitoulias G, Mpompoti T. Mycotic aneurysm of the infrarenal aorta. Vasa 2003;32:218-20.  Back to cited text no. 4
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5.
Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer H, Eidt JF, et al. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg 2009;50:30-9.  Back to cited text no. 5
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6.
Daenens K, Fourneau I, Nevelsteen A. Ten-year experience in autogenous reconstruction with the femoral vein in the treatment of aortofemoral prosthetic infection. Eur J Vasc Endovasc Surg 2003;25:240-5.  Back to cited text no. 6
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7.
Ehsan O, Gibbons CP. A 10-year experience of using femoro-popliteal vein for re-vascularisation in graft and arterial infections. Eur J Vasc Endovasc Surg 2009;38:172-9.  Back to cited text no. 7
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8.
Bodilsen J, Vammen S, Fuursted K, Hjort U. Mycotic aneurysm caused by Burkholderia pseudomallei in a previously healthy returning traveller. BMJ Case Rep 2014;2014. pii: bcr2013202824.  Back to cited text no. 8
    


    Figures

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



 

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