11-Year Experience with Anatomical and Extra-anatomical Repair of Mycotic Aortic Aneurysms

BACKGROUND: We have reviewed our management, of both ruptured and non-ruptured, abdominal and thoraco-abdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs. METHODS: Data regarding presenting symptoms, investigations, operative techniques and outcome, were collected on patients treated at a singe centre over 11 years. RESULTS: There were 11 men and four women, with a median age of 70 years (range, 24-79). All but one patient were symptomatic and six had a contained leak on admission. In six patients no organisms were identified in either blood or tissue cultures. Pre-operative CT identified; four infra-renal, four juxta-renal, three (Crawford thoraco-abdominal) type IV, three type III and one type II, aortic aneurysms. Thirteen were repaired with in situ prostheses and two required axillo-femoral prosthetic grafts. There were four early deaths. All surviving patients have been followed-up for a median duration of 38 months (range 1/2-112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection. CONCLUSIONS: In the absence of uncontrolled sepsis, repair of mycotic aortic aneurysms using prosthetic grafts can achieve durable results.     

Mycotic aortic aneurysms treated by endovascular repair: initial experience in a single center

Introduction: Mycotic aortic aneurysm (MAA) is an uncommon cause of aneurysmal aortic disease. However, it may have an aggressive presentation and a complicated early outcome. Endovascular aneurysm repair (EVAR) of MAA is emerging as an alternative to open repair (OR) for the treatment of these aneurysms, particularly in high-risk surgical patients. We report a single-center experience with the endovascular management of mycotic aortic aneurysms.

Material and methods: Two mycotic abdominal aortic aneurysms were treated with an endovascular stent graft at Centre Hospitalier Régional du Val de Sambre, Belgium. The mean follow-up was 15 months. Technical success was achieved in all two patients. CT-scan follow up showed shrinkage of the aneurysm sac, with no evidence of infection along the stent graft and no signs of endoleakage in all patients. One patient died during the follow-up period from a cause unrelated to the aneurysm.

Conclusion: EVAR is an effective and safe option and might be a suitable alternative to OR in the absence of predictors of poor prognosis for the treatment of non-complicated forms of MAA.     

Endovascular stent graft repair of mycotic aneurysms of the thoracic aorta

Traditional open surgical repair for mycotic aneurysms of the thoracic aorta is associated with significant morbidity and mortality. Endovascular repair has been reported as an alternative treatment in patients with mycotic thoracic aneurysms. This article reports our experience of endovascular stent graft placement in three patients with mycotic aneurysms of the thoracic aorta and compares the results with similar reports on the literature.     

Repair of a Mycotic Aneurysm of the Infrarenal Aorta in a Patient with HIV,Using a Palmaz Stent and Autologous Femoral Vein Graft

With the widespread use of endovascular surgery, aneurysms can be managed selectively with the use of stent grafts. Standard treatment of mycotic aneurysms usually requires resection and extraanatomic bypass. Although stent graft repair of a mycotic femoral aneurysm with autologous graft has been reported, we present a case of an infrarenal mycotic aneurysm in a patient with the human immundeficiency virus (HIV) that was successfully treated with a novel endovascular approach.     

经股动脉带膜支架腔内搭桥治疗动脉瘤的初步应用

目的 探讨带膜支架腔内治疗动脉瘤的临床意义。方法 应用进口及自制带膜支架,在透视下经股动脉放置在动脉瘤的恰当位置上,实现动脉瘤的腔内搭桥。结果 ４例胸主动脉瘤,１例累及肾动脉、肠系膜上动脉及腹腔动脉的腹主动脉瘤及１例髂动脉瘤应用直筒状带膜支架;５例肾动脉下腹主动脉瘤应用分叉状带膜支架腔内治疗,即刻效果满意。随访３～１９个月,定期ＣＴ及ＭＲＡ检查。５例术后５～８ｄ出现延迟性发热。１例术后３个月发现有     

Extra-anatomic revascularization and aortic exclusion for mycotic aneurysms of the infrarenal aorta and iliac arteries in an Asian population

OBJECTIVES: To study the clinical presentation, management and eventual outcome of patients with mycotic abdominal aortic aneurysms managed with aortic exclusion and extra-anatomic reconstruction. DESIGN: A retrospective chart review of 18 cases treated at a single institution. METHODS: Medical records of 18 patients admitted to our institution from October 1997 to July 2006 with a diagnosis of mycotic abdominal aortic aneurysms were reviewed. In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered. Seventeen patients had surgical debridement, aneurysm exclusion, and extra-anatomic reconstruction. The antibiotics were continued in the postoperative period for 6 weeks. RESULTS: Immunosuppression was present in 72%, with diabetes mellitus present in 56%. Salmonella sp was the causative organism in 72% of cases. Most patients presented late, with a 67% incidence of contained rupture. Seventy-two percent needed early or emergency surgery with less than 1 week of preoperative antibiotics. Disease-specific mortality was 39% (7/18). There was 1 late death during the mean follow-up period of 34 +/- 26 months. One patient with an infrarenal aneurysm arising relatively close (neck, 2 cm) to the renal arteries died on table when proximal ligatures cut through the friable aortic wall, resulting in uncontrollable exsanguination. One third of patients on long-term graft surveillance developed mild to moderate stenosis at the anastomotic site. CONCLUSIONS: Empirical antibiotics must be started early, aiming to achieve 1 week of antibiotics prior to surgery. In the Asian population, 3 characteristics are apparent: (1) most patients are immunocompromised; (2) patients present late in the course of disease; and (3) Salmonella is usually responsible. Extra-anatomic bypass may provide a safe option for revascularization of mycotic aneurysms of the iliac arteries and infrarenal aorta.     

Aorto-enteric fistula development secondary to mycotic abdominal aortic aneurysm following intravesical bacillus Calmette–Guerin (BCG) treatment for transitional cell carcinoma of the bladder

INTRODUCTIONIntravesical BCG-instillation for bladder cancer is considered safe but is not without risk. While most side-effects are localised and self-limiting, the development of secondary vascular pathology is a rare but significant complication.PRESENTATION OF CASEA 77-year-old male presented with a mycotic abdominal aortic aneurysm and associated aorto-enteric fistula 18 months after receiving intravesical BCG-instillations for early stage transitional cell carcinoma.DISCUSSIONResponse rates to intravesical BCG for early stage transitional cell carcinoma are high. The procedure produces a localised inflammatory response in the bladder but the exact mechanism of action is unclear. The treatment is generally well tolerated but BCG-sepsis and secondary vascular complications have been documented.Mycotic abdominal aortic aneurysm with associated aorto-enteric fistula secondary to BCG is very rare. Few examples have been documented internationally and the extent of corresponding research and associated management proposals is limited.Surgical options include in situ repair with prosthetic graft, debridement with extra-anatomical bypass and, occasionally, endovascular stent grafting. Recommended medical therapy for systemic BCG infection is Isoniazid, Rifampicin and Ethambutol.CONCLUSIONCurrent screening methods must be updated with clarification regarding duration of anti-tuberculous therapy and impact of concomitant anti-tuberculous medication on the therapeutic action of intravesical BCG. Long-term outcomes for patients post graft repair for mycotic aneurysm are unknown and more research is required regarding the susceptibility of vascular grafts to mycobacterial infection.Recognition of the risks associated with BCG-instillations, even in immunocompetent subjects, is paramount and must be considered even several months or years after receiving the therapy.     

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

Objective

The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications.

Recurrent Sepsis from an Oral Focus and a Duodenal Fistula Following Allograft Repair of a Perforated Mycotic Aortic Aneurysm

Summary BACKGROUND: Perforated mycotic aortic aneurysms remain a major problem in vascular surgery. These patients continue to present a challenge to both the vascular surgeon and the medical microbiologist, although improvements in graft materials, transplant surgery and perioperative management have led to decreased mortality. METHODS: The case report summarizes the medical history of a 44-year-old male treated at our hospital for perforated Salmonella mycotic aneurysm and recurrent septic episodes. RESULTS: The patient suffered from recurrent septic episodes originating in the oral cavity and a duodenal fistula for more than five years following an alloplastic aortobiiliacal bypass. The pathogenesis, diagnostic approach and management of this case are discussed. CONCLUSIONS: Duodenal fistulae following aortic graft implantation are a rare, but serious complication, which will cause septic episodes and graft infection. This case demonstrates that a careful identification of the involved pathogens may aid the identification of the infectious focus.     

Mycotic embolism and embolomycotic aneurysms. Neglected lessons of the past.

During the past decade, nine patients with bacterial endocarditis have required management of mycotic emboli and/or aneurysms in this center. In these patients, 25 separate mycotic emboli or aneurysms were identified. Among these were four visceral, 11 lower extremity, one aortic, one hypogastric, and eight cerebral lesions. Multiple sites were involved in seven of the nine patients (78%). Presenting symptoms were secondary to acute expansion of mycotic aneurysms in three patients and secondary to rupture of aneurysms in four patients. Mycotic emboli produced cerebral infarction in two patients and acute ischemia in six patients. Asymptomatic mycotic aneurysms of the middle cerebral, hepatic, hypogastric, and profunda femoris arteries and asymptomatic emboli to the profunda femoris and tibial arteries were found during angiographic study. Management included resection alone (7 aneurysms), resection and graft replacement (2 aneurysms and 2 emboli), embolectomy (2), or observation. There was no mortality or loss of limb in these patients. This experience underscores the frequent multiplicity of mycotic emboli and/or aneurysms and stresses the importance of empiric angiographic survey to exclude silent yet potentially lethal visceral and cerebral mycotic foci in patients with bacterial endocarditis and peripheral emboli or aneurysms.     

���ý���������΢��ǻ�ڸ���������Stanford B�ͼв㶯����

目的　探讨StanfordB型夹层动脉瘤的微创腔内隔绝术治疗的价值及应用经验。方法　采用进口器具治疗 2 6例StanfordB型夹层动脉瘤 ,术前精确评估 ,正确选择移植物 ,DSA监控下将移植物导入裂口位置 ,使假腔与真腔隔绝。结果　 2 6例中 ,移植物置入全部成功 ,无术中死亡或中转开胸手术 ;术中内漏 3例 ,术后 3天左上肢动脉血栓形成 1例 ,胸骨后疼痛 1例 ,腹股沟切口延迟愈合 2例 ,术后 6天心梗猝死 1例。中期结果示假腔内血栓形成率为 89 5 %。结论　度过急性期 3周的StanfordB型夹层动脉瘤为腔内隔绝术的手术适应证 ,螺旋CT为术前评估的最佳方法 ,术中应准确定位左锁骨下动脉开口 ,远端裂口宜分期行腔内隔绝术。腔内隔绝术微创、安全、方法简单、疗效确切 ,病人术后痛苦小 ,恢复快 ,在StanfordB型夹层动脉瘤有较大应用价值。     

Factors Affecting the Displacement Force Exerted on a Stent Graft after AAA Repair—An In vitro Study

OBJECTIVES: To investigate the distraction forces affecting grafts used to treat abdominal aortic aneurysms in an in vitro model. METHOD: Using a standard cardiac pump and a rigid plastic circulation system, distraction forces were measured with a gramometer attached to a PTFE graft while the pressure inside a rigid aortic sac was varied. RESULTS: If the pressure in the 'aneurysm sac' is maintained at the same level as the systemic pressure, the displacement force is zero. The displacement force is affected adversely by the level of systemic pressure, as this rises the displacement forces rise in an almost linear fashion. CONCLUSIONS: These observations may have important consequences for stent graft design and use in vivo pressurisation of a sealed sac may therefore not necessarily be an adverse event. Systemic hypertension is obviously important and its control may be necessary to prevent graft migration.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Cryopreserved Arterial Allografts for In situ Reconstruction of Infected Arterial Vessels

OBJECTIVE: To review our experience of using cryopreserved allografts for in situ reconstruction in the presence of infection involving the aorta, iliac or femoral arteries. DESIGN: Retrospective clinical study. METHODS: From 3/2000 to 8/2003 all patients with mycotic aneurysms or secondary infection following earlier prosthetic replacement were treated with cryopreserved human allografts. Forty-two patients, 39 (93%) with a prosthetic graft infection and 3 (7%) with a mycotic aneurysm of the abdominal aorta were treated. Six (14%) had aorto-enteric fistulas, 5 (12%) had ruptured aneurysms, and 2 also had vertebral destruction. The median follow-up time was 20 months (range 1-42 months). RESULTS: Thirty-day mortality was 14%. Three patients died due to multi-organ failure, two patients died from hypovolaemic shock due to allograft rupture and one from rupture of the native aorta. The overall mortality was 24% (four additional patients). Graft patency was 100% at 30 days and 97% at follow up in the survivors. The mean actuarial survival time was 32 months (95% CI=27-37 months). CONCLUSIONS: Cryopreserved allografts for the in situ reconstruction of infected arteries or grafts have acceptable intermediate results.     

分支型腔内支架人工血管治疗B型主动脉夹层

目的 应用主动脉-左锁骨下动脉分支型支架人工血管治疗累及左锁骨下动脉的主动脉弓部夹层。方法2004年2月至2005年1月，采用北京裕恒佳科技有限公司制作的血管腔内分支型主动脉支架人工血管治疗主动脉弓部B型夹层病人42例。原发破裂口位于左锁骨下动脉开口远侧2cm以内。分支型支架由主动脉支架和左锁骨下动脉支架组合而成。支架直径较相应支撑部位动脉直径增加15％～20％。治疗在血管造影室进行，分支型支架人工血管经送放器送入动脉，在透视下释放，植入主动脉弓和左锁骨下动脉。结果41例（98％）成功放置分支型支架41只和直筒型可弯曲支架人工血管5只；1例因左锁骨下动脉变形成角未能将送放器送入而改用直筒型支架治疗。夹层破裂口均被封闭，夹层真腔全部恢复正常直径。术后复查2例存在少量内漏。入路动脉无损伤，无死亡病例。术后病人均恢复正常活动。结论主动脉-左锁骨下动脉分支型支架人工血管易使用，适合修复破裂口位于左锁骨下动脉开口旁的主动脉弓部夹层，但长期效果还需进一步观察。     

Aorto-Iliac Stent Graft Infection Complicated by Endotension and Consequent Rupture of the Aneurysmal Sac: a Case Report

We present a case report of a bifurcated aorto-iliac stent graft infection two years after implantation. The initial procedure of implantation as well as the patient’s recovery was uneventful. Two years later the patient presented with a growing aneurysmal sac without a detectable endoleak and consequent rupture. Instead of graft explantation, we left the graft in situ and performed thorough debridement and an omentoplasty, because of the poor condition of the patient. A Staphylococcus species grew out of the cultures of the aortic wall. The patient recovered well without persistent infection and is still doing well after 43 months. This conservative approach might be an alternative in patients who are deemed to be at high risk for classic graft explantation and an extra-anatomic bypass or in situ bypass.     

New address of ARSMB/KVBMG The ARSMB — KVBMG Royal Association of the Medical Scientific Societies of Belgium Moves to Avenue Winston Churchill 11, box 30 — B-1180 Brussels (Uccle)

Aneurysm of the extracranial carotid artery is a rare condition; mycotic aneurysms are even less common. They always need surgical treatment to prevent possible rupture, embolisation or death. The literature before 1980 mentions ligation as the only treatment for mycotic aneurysms of the carotid artery, obviously with a high morbidity and mortality rate. We describe an 85-year-old male with a left carotid artery mycotic aneurysm. He presented with a history of Transient Ischaemic Attack (TIA) four weeks after a gastrointestinal infection. Resection of the aneurysm and interposition with autologous vein was performed. Escherichia coli was isolated from the excised tissue. Primary resection of the aneurysm with autologous vein interposition, in association with prolonged antibiotic therapy, is the preferred strategy. Prompt diagnosis and aggressive treatment is essential to prevent serious complications.     

Reoperations After Failure of Stent Grafting for Type B Aortic Dissection: Report of Two Cases

We describe our successful management of two patients who suffered complications after stent grafting for Type B aortic dissections. One patient was found to have stent-graft migration, which we treated with repeat aortic stent grafting, and the other patient had a proximal endoleak and total occlusion of the stent graft, which we treated with open surgical repair. We discuss the measures used to assist us in deciding on the most appropriate surgery, as well as the treatment alternatives.     

Mid-term results of an endovascular stent-graft by means of median sternotomy for distal aortic arch aneurysm

Migration and perigraft leakage are major problems after endovascular stent graft (EVG) by means of median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied to prevent these problems. We evaluate the mid-term results and the efficacy of anchoring sutures. The operation was performed on 19 men and 2 women with a mean age of 70 years (range, 59-81). The aneurysms were 19 true (12 fusiform, 7 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. EGVs were implanted by way of the aortic arch under retrograde cerebral perfusion in 13 patients and selective cerebral perfusion in 8. Total arch replacement was performed in 2 patients, and aortocoronary bypass grafting in 4. Anchoring sutures to fix the EVG were applied in 9 patients. The average follow-up period was 28 months (range, 2-56). There were no operative mortalities, but 1 paraplegia, 1 stroke, and 2 cases of temporary spinal cord dysfunction occurred. All aneurysms were thrombosed completely after surgery and reduced in diameter (66.9 +/- 17.4 mm to 57.3 +/- 15.7 mm, p < 0.0001). EVG-related complications arose in 4 patients. A chronic Type B dissection revealed impending rupture because of false lumen infection 1 year after operation, and redo surgery was performed. Migration occurred in 3 patients, all with fusiform aneurysms. One of these had a graft kink 1 year later. Another showed aneurysm enlargement with serous pleural effusion 3 years after operation. The third required redo surgery because of perigraft leakage at 3 years after surgery. There were 2 late deaths caused by stroke. There were no EVG-related complications in the 9 cases in which anchoring sutures were applied and in the 7 cases with saccular aneurysms. No spinal cord dysfunction occurred in 8 cases with low-flow antegrade perfusion by way of both axillary arteries while the aorta was opened. Logistic regression analysis showed significant relevance to complications of large aneurysms, greater than 80 mm in diameter. A large aneurysm tends to give rise to complications involving EVG migration. Anchoring sutures of EVG may prevent EVG-related complications.     

Lethal infection by Candida (Torulopsis) incospicua complicating orthotopic liver transplantation

We report here an uncommon case of deep infection by Torulopsis incospicua, associated with multibacterial sepsis and complicated by several mycotic aneurysms of hepatic artery, liver graft necrosis, and hepatic acute failure in a liver orthotopic transplant recipient. Two successive emergency liver transplants were needed, but fast relapses of infection and mycotic aneurysms were experienced. The patient died soon after the third liver transplant; disseminated mycosis was demonstrated by post mortem examination. In conclusion, fungal infection should be considered in cases of spontaneous hepatic artery rupture.