Suprarenal mycotic aortic aneurysm: surgical management and follow-up

A case is reported of a rare 7 cm saccular mycotic aneurysm that developed in the suprarenal abdominal aorta of a severely atherosclerotic 63-year-old man from presumed hematogenous inoculation of an atherosclerotic plaque. At operation a right axillobifemoral artery bypass graft was performed along with autotransplantation of the left kidney to the left common iliac vessels and the suprarenal aorta was ligated, excised, and widely debrided. The patient recovered and was in good health for 6 months when sudden occlusion of his axillofemoral graft required thrombectomy for limb salvage and to preserve renal function. Elective thoracoaortic to bilateral iliac artery bypass was successfully undertaken 8 months after the initial operation. However, the patient suffered a fatal myocardial infarction 2 weeks after operation. At autopsy a well-perfused nephrosclerotic kidney, healed aortic ligation, and no graft infections were found.     

Autologous superficial femoral vein for the repair of suprarenal mycotic aneurysms: a preferred conduit?--a case report.

The authors report a patient who presented with a ruptured mycotic aneurysm that destroyed the posterior segment of the suprarenal perimesenteric aorta. Initial in-line repair with a rifampin-soaked Dacron prosthetic patch failed 14 days postoperatively with recurrent hemorrhage. At reoperation, the aorta was repaired with a superficial femoral/popliteal vein interposition graft; a segment of superficial femoral/popliteal vein was also used in-line to revascularize the superior mesenteric and celiac arteries. The patient survived with no evidence of recurrence at 8 months postoperatively.     

Suprarenal Clostridium septicum Aortitis with Rupture and Simultaneous Colon Cancer

We report a case of combined colon cancer and Clostridium septicum aortitis involving the suprarenal abdominal aorta with rupture. An 82-year-old male presented with fever, abdominal pain, and back pain associated with constipation. He was successfully treated by in situ aortic graft placement with polytetrafluroethylene and concomitant colon resection. Only 20 other cases of C. septicum mycotic aneurysm, aortitis, or aortic dissection have been reported. Concomitant surgical treatment for Clostridium aortitis or mycotic abdominal aortic aneurysm and colon cancer can be accomplished successfully in selected cases when the diagnosis of both conditions is made preoperatively.     

Clostridial mycotic aneurysm of the suprarenal abdominal aorta

Clostridial mycotic aneurysms are unusual. We therefore record a fatal case of a ruptured clostridial mycotic aneurysm of the suprarenal aorta which developed several weeks after the resection of a segment of gangrenous small bowel.     

Mycotic aneurysm of the suprarenal aorta secondary toStreptococcus pneumoniae: An unusual pathogen

Mycotic aneurysms of the suprarenal aorta are rare lesions, accounting for less than 1% of aortic reconstructions for aneurysmal disease. The bacteriology of these lesions differs from the infrarenal aneurysms and primarily consists of Gramnegative organisms. We report an unusual case of an 87-year-old man successfully treated for a ruptured mycotic suprarenal aortic aneurysm caused byStreptococcus pneumoniae. We have not seen a previously reported case where this pathogen has been associated with a suprarenal mycotic aneurysm. The unique bacteriology of these aneurysms is reviewed along with theories of etiology and their classification. The current management of these aneurysms is summarized.     

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.     

Implantation of antibiotic-releasing carriers and in situ reconstruction for treatment of mycotic aneurysm.

Four patients with mycotic aneurysm of the extracranial carotid artery, the innominate artery, the ascending aorta, and the infrarenal aorta were treated with local implantation of antibiotic-releasing carriers after resection of the aneurysm, excision of all infected tissue, and in situ reconstruction by prosthetic graft replacement in two patients and patch plasty in two patients. The patient with a mycotic aneurysm of the ascending aorta was operated on again 1 month after the first operation because of a second mycotic aneurysm located on the aortic arch. No early or late signs of recurrent infection were seen on clinical and laboratory postoperative follow-up done between 9 and 16 months or on duplex scan or computed tomography done at these times. Implantation of antibiotic-releasing carriers after débridement of all infected tissue and in situ reconstruction for treatment of mycotic aneurysm was performed successfully in four patients with this life-threatening condition.     

Source of elastin-degrading enzymes in mycotic aortic aneurysms: bacteria or host inflammatory response?

Elastolytic matrix metalloproteinases play a central role in the development of chronic atherosclerotic aortic aneurysms, but mycotic aortic aneurysms are a distinct and unusual form of aneurysm disease caused by bacterial infection. Mycotic aortic aneurysms follow a more rapid and unpredictable course than chronic aneurysm disease and they exhibit a predilection for the suprarenal aorta, further implying unique pathophysiologic mechanisms. The purpose of this study was to examine the nature and source of elastin-degrading enzymes in mycotic aortic aneurysm. Bacterial isolates and aortic tissues were obtained from four consecutive patients undergoing surgical repair of suprarenal mycotic aortic aneurysm. Using an in vitro 3H-labeled elastin degradation assay, elastin-degrading enzyme activity was only observed in the bacteria-conditioned medium from an isolate of Pseudomonas aeruginosa. Elastin-degrading enzyme activity in the aortic tissue homogenate of this patient was abolished by the serine protease inhibitor, phenylmethylsulfonyl fluoride, but it was not suppressed by the metalloproteinase inhibitor, ethylenediamine tetraacetic acid (EDTA). In contrast, elastin-degrading enzyme activity in the bacterial-conditioned medium was decreased by about half by both phenylmethylsulfonyl fluoride and EDTA. Elastin substrate zymography revealed two phenylmethylsulfonyl fluoride-inhibitable elastin-degrading enzyme activities in the aortic tissue homogenate that corresponded to human neutrophil elastase (approximately 30 kDa) and its stable complex with alpha 1-proteinase inhibitor (approximately 80 kDa), but no activity attributable to Pseudomonas elastase, a 33-kDa metal-dependent enzyme. Human neutrophil elastase was readily detected throughout mycotic aortic aneurysm tissues by immunohistochemistry, but elastolytic metalloproteinases were only occasionally observed. The results of this study suggest that the elastin-degrading enzyme produced in mycotic aortic aneurysm are largely serine proteases of host neutrophil origin, rather than elastases produced by the infecting microorganisms or the macrophage-derived metalloproteinases typically observed in atherosclerotic aneurysm disease. Further studies will be needed to extend these findings to a larger number of patients with mycotic aortic aneurysm and those caused by additional microorganisms.     

In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-impregnated Dacron grafts: A preliminary case report

Treatment of mycotic aortic aneurysm by excision and extraanatomic bypass is difficult to apply when the infectious process involves the visceral arteries. On the basis of experimental studies in our laboratory that demonstrated prolonged antistaphylococcal activity of rifampin-bonded, gelatin-impregnated Dacron grafts after implantation in the arterial circulation, this conduit was successfully used for in situ replacement of a native aortic infection in two patients. Both patients had fever, leukocytosis, abdominal or back pain, and a computed tomographic scan that demonstrated contained rupture of a mycotic aneurysm. Preoperative computed tomography guided aspiration and culture of periaortic fluid from one patient grew Staphylococcus aureus. Treatment consisted of prolonged (6 weeks) culture-specific parenteral antibiotic therapy, excision of involved aorta, oxychlorosene irrigation of the aortic bed, and restoration of aortic continuity by in situ prosthetic replacement. A preliminary right axillobifemoral bypass was performed in the patient who had an infection involving the suprarenal and infrarenal aorta. In both patients intraoperative culture of aorta wall recovered S. aureus. Patients were discharged at 20 and 21 days. Clinical follow-up and computed tomographic imaging of the replacement graft beyond 10 months after surgery demonstrated no signs of residual aortic infection. In the absence of gross pus and frank sepsis, the use of an antibiotic-bonded prosthetic graft with antistaphylococcal activity should be considered in patients who have arterial infections caused by S. aureus when excision and ex situ bypass are not feasible. (J Vasc Surg 1996;24:472-6.)     

Resection of Suprarenal Aortic Aneurysm With Autotransplantation of the Kidney

This is a report of a patient with renovascular hypertension associated with a suprarenal aortic aneurysm that was treated by nephrectomy, resection of the aneurysm and autotransplantation of the kidney. The autografted kidney was preserved on the Mox-100 perfusion-preservation apparatus for over four hours, during which time the aneurysm was resected and replaced with a Dacron bifurcated graft. The authors believe this is the safest method for the management of aneurysms of the suprarenal aorta, especially when associated with renovascular disease, and it deserves wider application in treating major renovascular disease.     

Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases

OBJECTIVE: A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition, threatening life, organs, and limbs. With regard to the aortic segment involved, repair by either in situ replacement or extra-anatomic reconstruction can be quite challenging. Even when surgery has been successful, the prognosis is described as very poor because of the weakened health status of the patient who has developed this type of aneurysm. The aim of our study was to find out whether any progress could be achieved in a single center over a long time period (18 years) through use of surgical techniques and antiseptic adjuncts. MATERIAL AND METHODS: From January 1983 to December 1999, a total of 2520 patients with aneurysms of the thoracic and abdominal aorta and iliac arteries underwent surgery for aortic or iliac replacement at our institution. During that period, 33 (1.31%) of these patients (mean age, 64.3 years) were treated for mycotic aneurysms of the lower descending and thoracoabdominal (n = 13), suprarenal (n = 4), and infrarenal (n = 10) aorta and iliac arteries (n = 6). Twenty (61%) of these 33 patients had histories of various septic diseases; in the other 13 (39%), the etiology remained uncertain. Preoperative signs of infection, such as leukocytosis and elevated C-reactive protein, were found in 79% of the patients, and fever was apparent in 48%; 76% of the patients complained of pain. At the time of surgery, eight (24%) mycotic aneurysms were already ruptured, and 20 (61%) had penetrated into the periaortic tissues, forming a contained rupture. Five (15%) aneurysms were completely intact. The predominant microorganisms found in the aneurysm sac were Staphylococcus aureus and Salmonella species. Careful debridement of all infected tissue was essential. In the infrarenal aortic and iliac vascular bed, in situ reconstruction was performed only in cases of anticipated "low-grade" infection. Alternative revascularization with extra-anatomic procedures (axillobifemoral or femorofemoral crossover bypass graft) was carried out in eight of 16 cases. All four suprarenal and all 13 mycotic aneurysms of the thoracoabdominal aortic segment were repaired in situ. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics. RESULTS: In-hospital mortality was 36% (n = 12). Because of the smallness and heterogeneity of the sample, we could not demonstrate significant evidence for any influence of aneurysm location or type of reconstruction on patients' outcome. However, survival was clearly influenced by the status of rupture. During long-term follow-up (mean, 30 months; range, 1-139 months), 10 patients (48%) died-one (4.8%) probably as a consequence of the mycotic aneurysm, the others for unrelated reasons. Eleven patients (52%) are alive and well today, with no signs of persistent or recurrent infection. CONCLUSIONS: A mycotic aneurysm of the aortic iliac region remains a life-threatening condition, especially if the aneurysm has already ruptured by the time of surgery. Although the content of the aneurysm sac is considered septic, as was proved by positive cultures in 85% of our patients, in situ reconstruction is feasible and, surprisingly, was not more closely related to higher morbidity and mortality in our series than ligation and extra-anatomic reconstruction, although most of the aneurysms repaired in situ were located at the suprarenal and thoracoabdominal aorta. We assume that our operative mortality rate of 36%, which relates to a rupture rate of 85%, could be substantially lowered if the diagnosis of mycotic aneurysm were established before rupture.     

Suprarenal stent perforation after endovascular abdominal aortic aneurysm repair

A 66-year-old man with an abdominal aortic aneurysm previously repaired with an endovascular stent graft presented to our facility with worsening midabdominal and back pain. Previous postoperative surveillance computed tomography scans were unremarkable, showing excellent stent-wall apposition and a shrinking aneurysm sac; however, imaging done on his arrival identified a contained rupture at the level of the celiac artery containing a perforating suprarenal stent. We repaired this rupture with a surgeon-modified fenestrated stent graft. To our knowledge, this is the first reported case of penetration of the native aorta by a suprarenal stent in the absence of infection or trauma.     

Cardiac reoperation in a patient with osteogenesis imperfecta: a case report.

A case of a 40-year-old man with dehiscence of the prosthetic aortic valve and recurrence of mycotic aneurysm of the left ventricular outflow tract with osteogenesis imperfecta is presented. He had an operation of aortic valve replacement and direct closure of the mycotic aneurysm for infective endocarditis twenty-one months ago. We performed reoperation of prosthetic aortic valve, patch closure of the mycotic aneurysm and graft replacement of the ascending aorta. He was complicated with multiple fractures of bilateral scapla and dislocation of left shoulder one postoperative day. Fortunately, cardiac reoperation was performed successfully in this patient despite anticipated difficulties with tissue friability with osteogenesis imperfecta.     

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.     

Computed tomography-detected abnormalities following conventional abdominal aortic aneurysm (AAA) repair

PURPOSE: To determine how time since the operation influences vascular abnormalities following conventional infrarenal abdominal aortic aneurysm (AAA) repair.METHODS: In 47 patients computed tomography was performed 1 to 12 years following the aneurysm repair. Aortic diameters at different levels were measured and other abnormalities recorded.RESULTS: Significant correlation was found between time since operation and diameter of the suprarenal aorta (R=0.51, P<0.001) but not with aortic neck diameter (R=-0.10, P=0.48) or diameter of the prosthetic graft (R=0.07, P=0.66). However, measured diameters of graft and aortic neck showed a significant positive correlation (R=0.40, P=0.005).CONCLUSIONS: Dilatation of the suprarenal aorta has a different pattern from aortic neck dilatation. The latter showed correlation with the diameter of the prosthetic graft. This may be of interest for future design of endovascular stent-grafts.     

Distal repair using the frozen elephant trunk technique to treat an extended mycotic aneurysm of the aortic arch

We reported successful distal repair using the frozen elephant trunk technique to treat a mycotic aneurysm extending from the ascending aorta to the descending aorta. A blood culture sample was positive for Escherichia coli, and total arch replacement with a rifampicin-bonded graft covered the omental pedicle flap.     

Novel visceral reconstruction for paravisceral aortic aneurysm complicated with aortoiliac occlusion

Visceral ischemia is a serious factor in the postoperative morbidity and mortality of suprarenal aortic reconstruction. We report a case of a patient who underwent surgical repair for a paravisceral aortic aneurysm complicated with aortoiliac occlusion, using a novel visceral reconstruction. Prior to proximal anastomosis of the aorta, we reconstructed visceral arteries by bypass grafting to the superior mesenteric artery and right renal artery (RA), using a straight 12-mm prosthetic graft originating from the intact descending aorta. During the visceral reconstruction, selective cold crystalloid perfusion of the RA was performed. We then underwent the proximal anastomosis of the aorta just below the celiac trunk using a Y-shaped prosthetic graft 18×10?mm in diameter, in keeping the adequate visceral perfusion. Finally, a femoro-femoral bypass was performed with an 8-mm Gore-Tex Vascular Graft, and the left limb of the Y-shaped graft was sewn onto the side of this prosthetic graft. Postoperative computed tomography (CT) identified the successful repair of the aneurysm without any complications. Our novel visceral reconstruction could allow the surgeon to provide a physiological perfusion of visceral organs and prevent the potential visceral ischemia, during suprarenal aortic reconstruction.     

Acute and chronic dissections of the abdominal aorta: clinical features and treatment

We report seven cases of dissection of the abdominal aorta. Three patients had acute back pain, whereas four patients had more chronic courses. In six cases, as a result of the palpation of a pulsatile abdominal mass, clinical diagnosis was an atheromatous aneurysm. Angiography and CT scanning demonstrated a dissected abdominal aorta and a normal thoracic aorta. Six patients with an infrarenal dissection were treated by replacement of the aorta with a Dacron prothesis, and one patient with an suprarenal dissection was treated conservatively. With a mean follow-up of 3 years, all patients were alive and free of symptoms. These results favor graft replacement in case of infrarenal aortic dissection and more selective surgical indications in suprarenal aortic dissection.     

Aneurysmal change at or above the proximal anastomosis after infrarenal aortic grafting.

We conducted a retrospective review of all patients undergoing repair of abdominal aortic aneurysm at or above the proximal anastomosis of a previous infrarenal aortic graft between 1986 and 1991. Infected grafts and patients with suprarenal aneurysms present at the time of the original graft were excluded. Twenty-one patients, 19 men and two women, were included. The original indication for surgery was aneurysm in 14 patients and occlusive disease in seven; the mean interval from initial surgery to presentation was 10 years (range, 3 to 23 years). Twelve lesions were anastomotic false aneurysms, and nine were true aneurysms beginning in the proximal juxta-anastomotic aorta. Fourteen patients had an asymptomatic abdominal mass. Seven patients had symptoms of acute expansion (three), rupture (three), or thrombosis (one). True aneurysm and symptomatic presentation were correlated with aneurysm as the original indication for surgery. Repair was accomplished by an interpositional graft in 13 and graft replacement in eight. Seven patients required suprarenal anastomosis or renal and visceral reconstruction. Five operative deaths (24%) occurred, including two of three patients with rupture (67%) and two of seven patients (28%) in the suprarenal group. The mortality rate for elective repair with an infrarenal anastomosis was 11%. Two additional late deaths occurred during the follow-up period.     

Rupture of an extended mycotic aneurysm of the descending thoracic aorta in a multiple myeloma patient undergoing anti-myeloma therapy

Infectious complications in patients with multiple myeloma remain the main cause of mortality because of disease-related immunodeficiency. A mycotic aortic aneurysm caused by Burkhoderia cepacia, which has been recognized as nosocomial pathogen in immunocompromised populations, is very rare and only few cases have been reported in the literature. We describe an unusual case of a ruptured mycotic aneurysm of the descending thoracic aorta with a DeBakey IIIb aortic dissection caused by Burkhoderia cepacia in a patient with active multiple myeloma during chemotherapy with anti-myeloma agents. Successful treatment of this mycotic aneurysm included appropriate antibiotic therapy and replacement of the aortic arch and the descending aorta for the extensive debridement of all infected aortas. This was followed by the wrapping of a prosthetic graft with a well-vascularized tissue flap of the greater omentum and of the latissimus dorsi muscle.