Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report.

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.     

Mycotic aortocoronary saphenous vein graft aneurysm presenting with unstable angina pectoris

We report the case of a 60-year-old man with a history of coronary bypass surgery 20 years prior who had a fever, chest pain, and a mediastinal mass develop after a complicated postoperative course of abdominal aortic aneurysm resection. A mycotic aneurysm of the saphenous vein graft to his left anterior descending coronary artery was diagnosed based on blood culture results and visualization of the aneurysm before resection. A summary of the saphenous vein graft aneurysm and pseudoaneurysm cause, diagnosis, and management is detailed.     

Beware of Infection before Treating Aneurysms with Stent-grafts

A 51-year-old man with abdominal aortic aneurysm was treated endovascular placement of stent-grafts fabricated from expanded polytetrafluoroethylene and Z-stents. Exclusion of the aneurysm was achieved at the end of the procedure. However, a stent-graft infection developed two months after the procedure. We performed a surgical excision of the aneurysm with stent-grafts and an extra-anatomical reconstruction. The patient is alive and well after 4 years with no signs of infection. The preop angiography shows all features of a false aneurysm and the cultures at the open procedure revealed Salmonella. We must assume that the stent-graft has been implanted in a primarily mycotic aneurysm, even if there were no signs of infection initially.     

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.     

Superior mesenteric artery mycotic aneurysm in patients with left ventricular assist device support and intravenous drug abuse

Mycotic aneurysm of the superior mesenteric artery (SMA) is one of the complications associated with infective endocarditis. However, there are no previous case reports in the literature describing mycotic SMA aneurysm after left ventricular assist device (LVAD) implantation. We describe the case of a 31-year-old male diagnosed with congestive heart failure due to nonischemic dilated cardiomyopathy who underwent LVAD implantation for bridge to heart transplantation. The postoperative course was uneventful, and the patient was maintained on anticoagulation and antiplatelet therapy. There were no signs of pump failure or device-related infections. However, 7 months post-LVAD support, the patient complained of abdominal symptoms (nausea and vomiting) with low-grade fever. Computed tomography identified an aneurysmal change of the SMA (2.2 × 1.8 cm). There was no evidence of thrombus or septic vegetation inside the heart. Aneurysm and segmental small bowel resection was performed. Pathological study revealed typical findings of mycotic aneurysm with significant infiltration of inflammatory cells. The patient, however, expired due to concurrent brain hemorrhage. Postmortem study indicated no sign of pump thrombus or septic emboli inside the pump or inflow/outflow conduit. This case report presents a rare mycotic aneurysm that developed in the SMA after chronic LVAD support.     

A case report of ruptured mycotic aneurysm at the site of subclavian flap angioplasty]

Postoperative mycotic aneurysm of the thoracic aorta at the site of subclavian flap angioplasty (SFA) is very rare. A 6-year-old boy was admitted with a history of high fever for 10 days. He had undergone SFA at the age of 14 days and patch closure of VSD at 10 months. The chest X-ray film on admission revealed no abnormality. But, 7 days later, he suffered from frequent hemoptysis and chest X-ray film showed an abnormal mass shadow at the left upper lung field. Contrast enhanced CT scan and IV-DSA revealed a pseudoaneurysm of the aortic arch which had ruptured into the left upper lung. An extra-anatomical bypass was urgently made from the ascending aorta to abdominal aorta and the aneurysm was isolated by ligations of the aorta proximal and distal to the aneurysm. Aneurysmectomy combined with left upper lobectomy was carried out next day. Septic signs and hemoptysis dramatically improved after operation. Extra-anatomical bypass as a means of choice for the surgical treatment of the mycotic aneurysm greatly contributed to cure the severe ill patient. But a close follow up observation for the function of the graft is necessary.     

Abdominal infectious aortitis caused by Streptococcus pneumoniae: a case report and literature review

We report a case of a 75-year-old man who had been complaining of fever and pelvic pain for 3 weeks. First angio-computed tomography (CT) characteristics and blood culture led to suspicion of a pneumococcal-infected aortic aneurysm, which however was not confirmed by the surgeon. The abdominal infectious aortitis caused by Streptococcus pneumoniae was affirmed by a second angio-CT performed 7 days later. Without further delay, the patient underwent surgery for resection of mycotic aneurysm and in situ reconstruction with aortobiiliac homograft, in association with antibiotics. He died 10 days after the surgery as a result of severe sepsis in a polyvalent intensive care unit. This case report highlights the severity of this pathology. We reviewed the relevant literature related to Streptococcal pneumoniae mycotic aneurysm located in the abdominal aorta, including 29 more cases. Various microorganisms have already been associated with mycotic aneurysms, including S pneumoniae. Infectious aortitis remains a rare disease. It is extremely important to establish an early diagnosis but it may be delayed because clinical manifestations are usually nonspecific. However, if left untreated it is always lethal. Antibiotic in combination with complete surgical excision of the infected aorta is the treatment of reference. This therapeutic association dramatically improved patient survival.     

Observe and be guarded: the development and rupture of an abdominal aortic mycotic aneurysm in an afebrile hemodialysis patient with normal angiogram,and CT scan,and sterile blood cultures

Despite the increased risk factors and a high incidence of bacteremia in hemodialysis patients, the presence of mycotic aneurysms in the hemodialysis population is virtually unknown. Only two cases have been previously reported in this population. The diagnosis is usually made by angiogram, magnetic resonance angiography, or computed tomography (CT) in the presence of bacteremia dem-onstrated by positive blood culture. We report a case of mycotic aneurysm in an afebrile hemodialysis patient with sterile blood cultures for whom the diagnosis was made after no aneurysm was seen on abdominal ultrasound, CT scan, or magnetic resonance angiography. After a discussion of pathophysiology, we offer some insight into why so few mycotic aneurysms are reported in the hemodialysis population.     

Successful management of ruptured mycotic abdominal aortic aneurysm in a child

Mycotic aneurysm of the abdominal aorta is a serious disorder that generally carries a grave prognosis. A few survivors have been reported in adults but none in children. This report describes the successful management of ruptured mycotic abdominal aneurysm in a 10-year-old girl. The entire aneurysm was excised, and aortic continuity restored with low porosity bifurcated Dacron graft. With no macroscopic suppuration, we believe aortic continuity is a logical way to deal with this grave situation in children. Antibiotic cover was given pre and postoperatively for a total of six weeks. To our knowledge, this is the only surviving case in children in the literature. The pathogenesis and diagnosis of mycotic and infected aneurysm is discussed, and the literature has been reviewed.     

Customized endoluminal graft to treat a suspected saccular thoracoabdominal mycotic aneurysm

Open surgical repair of mycotic aneurysm is associated with a high surgical morbidity and mortality. The role of endovascular graft repair of mycotic aneurysm remains controversial because the graft material remains in contact with possibly infected tissue. We report an endovascular technique of customizing an abdominal endoluminal graft component to treat a suspected saccular thoracoabdominal mycotic aneurysm involving the takeoff of the celiac trunk.     

Cryptic mycotic abdominal aortic aneurysms: diagnosis and management

The incidence of cryptic mycotic abdominal aortic aneurysms has relatively increased since antibiotic therapy has become available. The causative organism is the salmonella group in about 50 per cent of cases. This diagnosis should be strongly entertained in patients with fever of unknown origin, vague abdominal pain, and progressive appearance of a pulsatile abdominal mass. Aortography may be helpful in establishing the diagnosis. Some postoperative graft infections may be due to unrecognized cryptic mycotic infection of the aorta and not from external contamination, as previously supposed. Construction of an axillofemoral bypass graft through clean tissue is advised for the successful treatment of the grossly infected infrarenal aortic aneurysm. Three surviving patients with cryptic mycotic abdominal aortic aneurysms are added to the sixteen surviving patients already reported in the literature.     

A case of ruptured mycotic cerebral aneurysm associated with repeated arterial narrowing and remission

The patient is a 23-year-old male in whom aortic valve regurgitation was pointed out at the age of about 13. From July 26, 1985 he developed a high fever of 39.7 degrees C and on August 5 he suddenly became unconscious with left hemiparesis. On August 10, his consciousness became further disturbed and he was admitted to this Department on the following day. Computed tomographic scan showed subarachnoid hemorrhage and a low density area in the right temporoparietal lobe. Carotid angiography (CAG) revealed an aneurysm 10 mm in size at the end of the horizontal portion of the right middle cerebral artery (MCA) and severe narrowing of the arteries, mainly the right MCA. A mycotic aneurysm due to bacterial endocarditis was diagnosed. In the CAG conducted on August 14, aneurysm had been almost disappeared, but arterial narrowing had been further increased. On September 4, there was a remission of the narrowing, but the aneurysm could again be visualized to be 7 mm in size, which increased to 14 mm on September 20. A neck clipping of the aneurysm and an aneurysmectomy were performed on September 27. Operative findings showed degeneration and thickening of the walls of the aneurysm and arteries with inflammatory reaction. An arterial blood culture conducted at the time of a recurrence of bacterial endocarditis demonstrated non-hemolytic Streptococcus. CAG conducted on November 1 showed remarkable narrowing of the right MCA, but CAG performed on April 1, 1986 showed the narrowing to be alleviated. There is a danger of rupture in mycotic aneurysm due to bacterial endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arteritis due to Salmonella with aneurysm formation: two cases.

Although arterial infection due to Salmonella is rare, it remains one of the most common causes of primary mycotic aneurysms. The presentation is one of sepsis, cultures positive for Salmonella and rapid expansion or rupture of the aneurysm. The authors' experience at Victoria Hospital, London, Ont., includes two cases of aneurysms infected with Salmonella--one aneurysm of the aorta and the other of the common femoral artery. Both patients were treated by excision of the aneurysm, extra-anatomic reconstruction in an area remote from the infected field and long-term administration of appropriate antibiotics. One patient was alive and well 36 months after resection. The other died of multiple organ failure 10 days after resection. From a review of the English and French literature since 1948, 64 cases of abdominal aortic aneurysms infected with Salmonella were found; half of the patients survived the perioperative period. The diagnosis of mycotic aneurysm must be considered in any patient with an aneurysm and culture specimens positive for Salmonella. The authors favour wide débridement of the infected aneurysm with extra-anatomic reconstruction. This view is supported by a review of the literature. The appropriate antibiotic therapy is bactericidal rather than bacteriostatic.     

Mycotic aneurysm presenting as acute pyelonephritis

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.     

Deep leg vein reconstruction for an isolated mycotic common iliac artery aneurysm in an HIV-positive patient

Isolated mycotic common iliac artery aneurysms are rare, and as such, there is no consensus opinion on management. Traditional surgical options include resection with extra-anatomic bypass, placement of allograft or antibiotic treated synthetic graft, or autogenous vein reconstruction. We report the case of a 46-year-old, human immunodeficiency virus-positive male who presented with a recurrent pneumonia and new onset of right lower quadrant abdominal pain associated with right lower extremity swelling. computed tomographic scan revealed an isolated 9.5 cm right common iliac artery aneurysm with no evidence of rupture. Preoperative blood cultures grew out Streptococcus pneumoniae. Operative repair included aneurysm resection and reconstruction using an autogenous femoropopliteal vein interposition graft from the ipsilateral thigh. The patient had an uneventful recovery with resolution of his lower extremity swelling and a normal duplex exam at follow-up. Large mycotic common iliac artery aneurysms can be successfully treated with aneurysm resection and reconstruction using an autogenous femoropopliteal vein conduit. This technique obviates the need for extra-anatomic bypass or other forms of reconstruction using prosthetic material.     

Diagnosis and management of aneurysms involving the superior mesenteric artery and its branches--a report of four cases

Aneurysms of the superior mesenteric artery (SMA) are an uncommon but lethal entity, which must be treated expeditiously to avoid mortality and high incidence of ischemic small bowel complications. In the past 7 years the authors have treated 4 patients with a variety of types of aneurysms involving the SMA and its branches at a university-based teaching hospital. The first was a mycotic SMA aneurysm as a result of septic mitral valve, the second a jejunal aneurysm in a patient with pancreatitis, the third a spontaneous dissection distal to a small SMA aneurysm with thrombus partially occluding the distal vessel, and the fourth an SMA aneurysm associated with the diagnosis of mesenteric insufficiency. All patients presented with abdominal pain. The diagnosis was made initially in 1 patient on plain abdominal films with a calcified aneurysm, on duplex scan in the second, and on computed tomography (CT) scans in the remaining 2. Treatment consisted of bowel resection and ligation of mycotic aneurysm in the first patient, of catheter embolization of jejunal aneurysm in the patient with pancreatitis, and of vein graft bypass in the patient with a large SMA aneurysm. The patient with SMA aneurysm and distal dissection with partially occluding thrombus received anticoagulation and is being followed up with serial CT scans. There were no deaths. One patient required bowel resection, which did not result in short gut syndrome. Improved abdominal duplex scanning and CT technology facilitates the diagnosis of mesenteric aneurysm. The broad spectrum of etiologies mandates that treatment be tailored to the individual patient, and it varies from endovascular techniques to traditional bypass surgery. Prompt diagnosis and treatment results in the lowest mortality rate and minimizes the prevalence of intestinal infarction.     

Mycotic abdominal aortic aneurysm induced by immunotherapy with bacille Calmette-Guérin vaccine for malignancy

Successful surgical treatment of a mycotic abdominal aortic aneurysm infected with Mycobacterium bovis is described. The infecting organism can be traced to an intraneoplastic injection of bacille Calmette-Guérin (BCG) vaccine into a cutaneous malignant melanoma nodule 14 months before aneurysm detection (17 months before operation). Treatment consisted of aneurysm excision, in situ prosthetic graft placement, and antituberculous medications. This patient represents the first reported case of BCG-induced mycotic aortic aneurysm.     

Mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum: a case report of surgical management and review of the literature

We report a surgical case of mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum. The patient was first treated with an in situ prosthetic graft replacement. When the infection recurred 5 weeks after the aortic surgery, the patient was successfully treated by transposition of rectus abdominis muscle flap around the graft. Only 19 cases of mycotic aneurysm or aortic dissection caused by Clostridium septicum have been reported. Ten of 12 patients who underwent vascular surgery survived, whereas all 7 patients who did not undergo surgery died. Surgical treatment should be undertaken since the surgical results seem satisfactory.     

MYCOTIC ANEURYSM PRESENTING AS ACUTE PYELONEPHRITIS

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.     

Mycotic aneurysm of the infrarenal aorta: surgical possibilities and results]

Between 1973 and 1990 eleven patients with mycotic aneurysm of the abdominal aorta underwent surgery. Extra-anatomic axillobifemoral bypass with aortic ligation and aneurysm excision was performed in 5 patients, and in situ reconstruction in 6. There were 3 early and 3 late deaths. Regardless of the type of operation, surgery of mycotic aneurysm is followed by severe postoperative complications with high the early and the late mortality rates.