Article

New Bacteriological Patterns in Primary Infected Aorto-iliac Aneurysms: A Single-centre Experience

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Abstract

To assess causative pathogens and surgical outcomes in patients with primary infected aorto-iliac aneurysms at our institution. Retrospective study of patients treated at a university hospital between 1992 and 2009. We identified 26 patients (median age, 63 years) with primary infected aneurysms on the aorta (descending thoracic, n = 2; thoraco-abdominal, n = 3; suprarenal, n = 2; infrarenal, n = 15) or iliac arteries (n = 4). Among them, 22 were symptomatic, including 13 with ruptured aneurysms. The causative organisms, identified in 25/26 patients, were Campylobacter fetus, n = 6; Streptococcus pneumoniae, n = 4; Listeria, n = 3; Salmonella, n = 2; Mycobacterium tuberculosis, n = 2; Staphylococcus aureus, n = 1; and other, n = 7. Immune suppression was a feature in 10 (38.4%) patients. Revascularisation was performed in situ in 23 patients (10 allografts, eight grafts, three superficial femoral veins, and 2 stentgrafts) and by extra-anatomic bypass in three patients. Hospital mortality was 23% (in situ group, 17.4%; extra-anatomic group, 66.7%; χ(2)(Yates), P = 0.24). During follow-up in the 20 survivors (median, 48.5 months), there were two non-infection-related deaths (five and 24 months) and six (30%) vascular complications. The bacteriological spectrum of primary infected aorto-iliac aneurysms was wider than previously reported. The availability of new diagnostic tests and increased prevalence of immunosuppression may explain this finding.

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... In the absence of appropriate treatment, they pose a risk to life due to the danger of rupture and sepsis. Currently, surgery coupled with appropriate antibiotic therapy represents a reliable treatment to achieve satisfactory results [2][3][4][5]. In this article, we describe the case of a massive tuberculous aneurysm of the left common iliac artery complicated by skin necrosis adjacent to the abdominal mass, which presents a challenge for restoring arterial continuity as well as for skin closure in an infected environment. ...
... Iliac aneurysms are often asymptomatic (55 %), but they present a high risk of rupture in the absence of appropriate treatment, and the risk is increased with a mycotic origin [1,2,17]. Currently, surgery combined with appropriate antibiotic therapy or antituberculous treatment according to the etiology represents a reliable treatment for achieving satisfactory results [4,5,7,17]. Surgical treatment of iliac artery aneurysms is indicated for a diameter of 30 mm or greater [18]. ...
... In this case, the greater saphenous vein, superficial femoral vein, or cephalic vein may be used. If not available, some centers recommend the use of cryopreserved allografts to reduce operative time and minimize the risk of infection [4]. Restoring arterial continuity using an end-toend arterial anastomosis remains a good approach, although it is not always viable and depends on the extent of the arterial lesion and offers the advantage of avoiding the use of in situ grafts. ...
Article
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Introduction and importance Tuberculosis is re-emerging globally, including in Morocco. Common iliac artery aneurysms induced by tuberculosis are very rare and severe due to the risk of infection and hemorrhage, making treatment choice crucial. Only a few cases have been reported in the literature. Case presentation In this article, we report a new case involving a 54-year-old man admitted to the emergency department of the university hospital for skin necrosis in the groin area with a pulsating mass in front and altered general condition, associated with night fevers that led to a chest X-ray revealing miliary tuberculosis. An emergency CT angiography showed a false aneurysm of the left common iliac artery, measuring 55 mm in diameter. The patient underwent resection of the friable portion of the iliac artery and restoration of arterial continuity through an end-to-end arterial anastomosis. Histological analysis of the surgical samples confirmed the tuberculous origin of the false aneurysm. The patient was placed on anti-tuberculous treatment, and the postoperative course was uneventful. After 6 months, the patient was asymptomatic, and the iliac axis was patent on the follow-up CT angiography. Clinical discussion Mycotic aneurysms are rarely reported, including in the carotid, iliac, femoral, and popliteal arteries. Contamination of the artery by the tuberculous mycobacterium results either from direct extension of the infection through contact with an adjacent focus or from hematogenous dissemination. Based on published cases, the evolution after appropriate medical and surgical treatment is generally favorable; however, the choice of therapy and the approach to restoring arterial continuity—vein versus prosthesis—are not well represented in the literature and depend on clinical and radiological contexts. The mortality rate remains high, with reported causes of death including aneurysmal rupture and septicemia. Conclusion The combination of anti-bacillary treatments and antibiotics, along with either open or endovascular surgery, represents the optimal therapeutic choice to ensure good outcomes and effective disease control.
... Primary distant site of infection could be determined by blood culture or culture of aneurysmal content, or usually both, although results could be negative [1]. Blood cultures are positive in about 62% to 75% of the cases [3,4]. Positive cultures from aneurysm wall or surrounding tissues are also positive in 85% of patients [4]. ...
... Blood cultures are positive in about 62% to 75% of the cases [3,4]. Positive cultures from aneurysm wall or surrounding tissues are also positive in 85% of patients [4]. ...
... Infection of native aorta occurs predominantly in males with a mean age of above 60 [1,2,[4][5][6][7][8][9][10]. The most common pathogen in Europe is Staphylococcus aureus, whereas the most common one in Asian countries is non-typhoid Salmonella species [5][6][7][8][9]. ...
Article
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Mycotic aneurysms are infective aneurysms of native aorta. Pathogenesis is by septicaemic seeding of distant site infection to susceptible atherosclerotic aortic wall. Staphylococcus aureus is the most common causative organism in Western countries, whereas non-typhoid Salmonella species are more common in Asian countries. Mycotic aneurysms are usually diagnosed by infective clinical picture, with or without positive blood cultures, imaging techniques and intraoperative findings. Current standard treatment is open surgical repair, while newer modalities such as endovascular repair are being examined. Lack of randomised, controlled trials highlights the requirement of national and international registry for mycotic aneurysms.
... Studies from Asian countries such as Taiwan, Thailand and Singapore 1,3,7,8,11,18,20 reported that Salmonella species were the major causative bacteria, accounting for 50-80 per cent of detected pathogens. Reports from European countries 2,4,5,10,17,19 demonstrated that Gram-positive cocci were the most frequent, accounting for 30-60 per cent of isolated organisms. The present study revealed the recent aetiological trend in Japan: Gram- b Freedom from aorta-related mortality positive cocci and Gram-negative rods were each responsible in almost half of the patients, and Salmonella species were less common. ...
... Preoperative blood cultures are often negative, sometimes making diagnosis more difficult. The rate of positive blood cultures was 44.4 per cent in the present study, whereas that reported in the literature ranges from 40 to 80 per cent 4,5,7,[9][10][11][18][19][20][21] . The moderate positivity rate may be attributable partly to empirical antibiotic administration before the bacteriological diagnosis. ...
... The results of this study have demonstrated that current surgical practice for the disease in Japan consisted of in situ graft replacement in 62.5 per cent, extra-anatomical bypass in 6.6 per cent, and EVAR in 26.2 per cent of the patients. Open revascularization concomitant with resection of aneurysmal and surrounding tissues has been the treatment of choice for primary infected aortic aneurysms [2][3][4]16,[18][19][20][21] . In situ arterial reconstruction is often preferred to extra-anatomical bypass, owing to the risks of aortic stump rupture and graft occlusion 2,19-21 . ...
Article
Background: Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined. Methods: A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR). Results: Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639 days. Cumulative overall survival rates at 30 days, 90 days, 1 year, 3 years and 5 years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P < 0.001). Propensity score-matched analyses demonstrated no significant differences between EVAR and in situ graft replacement in terms of 3-year all-cause and aorta-related mortality rates (P = 0.093 and P =0.472 respectively). Conclusion: In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.
... Usually, organisms suspected to be involved in spondylitis or iliopsoas abscesses are Staphylococcus aureus, Streptococcus spp., Mycobacterium tuberculosis (when the origin is skeletal infection) and Escherichia coli (when the origin is the urinary tract or the bowel [7]). During septic aortic aneurysm [8], Salmonella spp., Staphylococcus aureus and Streptococcus spp., but also Campylobacter fetus, Listeria monocytogenes, Mycobacterium tuberculosis, Aspergillus spp., and Brucella spp. could be involved. ...
... In our patient, all of these pathogens had been excluded by microscopic examination, culture and serological testings. In a study of 26 patients treated for septic aneurysm, Coxiella burnetii was isolated in one case [8], and in 2 of 25 patients with septic aortic aneurysms in another study [9]. To our knowledge no guidelines exists asking for a mandatory research for Q fever. ...
... To our knowledge no guidelines exists asking for a mandatory research for Q fever. Serology has to be done facing a negative result for all other research [8]. Coxiella burnetii seems to be rare in septic aneurysm and ask for a systematic research to avoid delay for appropriate treatment that negatively impacts on global outcome as our patient. ...
... In contrast, Brossier et al. reported that Campylobacter spp. and Streptococcus pneumoniae are the two most common pathogens in infected aneurysms [13]. ...
... We included patients who were diagnosed with infected aneurysm from 2005 to 2019. In contrast, studies with an in-hospital mortality of higher than 20% included patients who were diagnosed in the 1990s [4,6,7,9,13,25]. The mortality of both aortic aneurysm and sepsis have decreased over time, partly due to progressions in the treatment of both conditions [26,27]. ...
Article
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Background It is challenging to diagnose infected aneurysm in the early phase. This study aimed to describe the clinical and microbiological characteristics of infected aneurysm, and to elucidate the difficulties in diagnosing the disease. Methods Forty-one cases of infected aneurysm were diagnosed in Nagasaki University Hospital from 2005 to 2019. Information on clinical and microbiological characteristics, radiological findings, duration of onset, and type of initial computed tomography (CT) imaging conditions were collected. Factors related to diagnostic delay were analyzed by Fisher’s exact test for categorical variables or by the Wilcoxon rank-sum test for continuous variables. Results Pathogens were identified in 34 of 41 cases; the pathogens were Gram-positive cocci in 16 cases, Gram-negative rods in 13 cases, and others in five cases. Clinical characteristics did not differ in accordance with the identified bacteria. At the time of admission, 16 patients were given different initial diagnoses, of which acute pyelonephritis (n = 5) was the most frequent. Compared with the 22 patients with an accurate initial diagnosis, the 19 initially misdiagnosed patients were more likely to have been examined by plain CT. The sensitivities of plain CT and contrast-enhanced CT were 38.1% and 80.0%, respectively. Conclusions In cases of infected aneurysm, diagnostic delay is attributed to non-specific symptoms and the low sensitivity of plain CT. Clinical characteristics of infected aneurysm mimic various diseases. Contrast-enhanced CT should be considered if infected aneurysm is suspected.
... catheterization), prior infections like IE with septic emboli, periodontal infection, immunocompromised state, atherosclerosis and preexisting aneurysm [45][46][47][48][49][50][51][52]. The infectious organisms are primarily bacterial (Staphylococcus species, Salmonella species, Streptococcus species, Escherichia coli), although Treponema pallidum (previously a common cause), Mycobacterium and fungal species can also cause mycotic aneurysms [45][46][47][48][49][50][51][53][54][55][56][57][58]. Positive cultures support the diagnosis, but negative cultures do not exclude the possibility. ...
... Mycotic aneurysms can occur anywhere, but intracranial arteries are the most frequently affected, followed by visceral arteries and upper or lower extremity arteries [55,59]. Infectious aortitis can also occur [53,55,[57][58][59]. Diagnosis is made with computed tomography angiography, although magnetic resonance angiography is acceptable if intravenous contrast is contraindicated. ...
Article
While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.
... Before the popularized use of antibiotics, nonhemolytic Streptococcus species have once been the most common infectious organisms; subsequently, they account for less than 10% of infection cases after the advent of the antibiotic era [5,36]. Currently, in Western countries, Staphylococcus species are generally the most common pathogens, accounting for 28-71% of cases based on published literatures [13,37,38]. It is also noteworthy that methicillin-resistant Staphylococcus aureus (MRSA) prevalence is continuously rising, and some reports indicated MRSA as the most dominant pathogen [39,40]. ...
... Furthermore, the bacteriological spectrum may also be broader than that expected [37]. A recent report on endovascular treatment of infected aortic aneurysms from a European multicenter study revealed that 62% of the cases had a positive blood culture in which 20% was Staphylococcus species, 12% Salmonella species, and 11% Streptococcus species; approximately 19% were caused by other microorganisms [42]. ...
Chapter
Infected aortic aneurysms are surgical urgencies, requiring prompt management to avoid the development of catastrophic complications. Although traditional open surgery composed of radical debridement and aortic reconstruction remains the gold-standard, many favorable results of the endovascular repair strategy have been reported. In this chapter, the etiology, bacteriology, clinical manifestation, and diagnostic criteria of infected aortic aneurysms will be discussed in detail at first, followed by a comprehensive review of both traditional open surgery and endovascular repair, based on current evidences and the authors’ institutional experience. Along with long-term oral antibiotic suppression and aggressive adjunctive procedures, endovascular repair for uncomplicated infected aortic aneurysms could be a definite treatment alternative to traditional open surgery in the endovascular era.
... 1,6 High positive rates of cultures from blood or surgical specimens have been reported. 3,5,7 Staphylococcus aureus and Salmonella species were predominantly reported as the most common causative organisms. [1][2][3][4][5][6]9 Brossier et al. also reported a wider bacteriological spectrum including Campylobacter fetus, Listeria monocytogenes, and Mycobacterium tuberculosis. ...
... [1][2][3][4][5][6]9 Brossier et al. also reported a wider bacteriological spectrum including Campylobacter fetus, Listeria monocytogenes, and Mycobacterium tuberculosis. 7 In the present case, although blood cultures were negative, probably due to the antibiotic treatment prior to admission, 3,5,6 the clinical evidence including persistent inflammatory laboratory data, fever, and abdominal symptoms as well as radiological findings led us to make an early diagnosis. Growth and morphological change of the aneurysm were clearly revealed on CT carried out on the 10th hospital day. ...
Article
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Case: We report a case of an infected iliac artery aneurysm complicated by an aortocaval fistula. Outcome: A 74-year-old-man was admitted with fever, chills, general fatigue, and appetite loss. The patient was diagnosed with an infected iliac artery aneurysm, which was controlled with antibiotics preoperatively. During hospitalization, deep vein thrombosis developed with a pulmonary embolism resulting from an aortocaval fistula. The patient was successfully operated on with in situ autologous vein graft reconstruction. Conclusion: An infected iliac artery aneurysm with aortocaval shunt has rarely been reported. We successfully treated the patient with a combination of appropriate i.v. antibiotics and surgical resection.
... Staphylococcus aureus, Salmonella, and Streptococcus pneumoniae are among the most commonly identified causative organisms; however, the spectrum of infections has been found to be quite extensive. 2,3 Traditional treatment consists of immediate and longterm intravenous antibiotic therapy with open surgical repair (OSR) and an extra-anatomic or in situ bypass. A growing body of evidence also supports the role for endovascular approaches such as endovascular aortic repair (EVAR), particularly in comorbid states precluding immediate surgery, as immediate risk mitigation or indeed as a palliative measure. ...
Article
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Objective This retrospective case series reports the 15-year experience of the endovascular management of mycotic aortic and iliac aneurysms (MAAs) at a tertiary referral center in the United Kingdom. Materials and Methods The patients were identified through advanced searches in picture archiving and communication system (PACS) and electronic patient records. Data were retrieved and recorded in a structured spreadsheet including demographic details, symptoms and comorbidities, endovascular techniques employed and graft types, as well as treatment outcomes including 30-day mortality, 1-, 3-, and 5-year survival, aneurysm resolution percentage, and rates of re-intervention and complications. Statistical Analysis Descriptive statistics summarized the demographic and clinical characteristics, presenting them as means for continuous variables and frequencies/percentages for categorical variables. Results Of the 15 included patients, 73.3% (11/15) and 26.7% (4/15) were males and females, respectively, with a mean age of 64 years. Imaging revealed diverse anatomical involvement, with MAA in the descending thoracic (6/15), suprarenal and juxtarenal (5/15), infrarenal (3/15), and common iliac arteries (1/15). The 30-day mortality rate was 6.7% (1/15), while 1-, 3-, and 5-year survival rates from time of initial intervention were 57.1% (8/14), 38.5% (5/13), and 30.8% (4/13), respectively, with 1 case only just having undergone 1-month follow-up (performed in July 2023). The average mycotic aneurysm size was 47 mm (range: 19–80 mm), of which 33.3% (5/15) presented with rupture. The average sac size reduction following treatment was 31%, with 5/15 cases demonstrating complete resolution. Four cases required re-intervention due to persistent endoleak, sac re-expansion secondary to delayed endoleak, or stent occlusion. Persistent or recurrent graft infection was observed in 53.3% (8/15) of cases. Two cases required surgical re-intervention for stent occlusion. Conclusion Our findings reinforce the role of endovascular interventions in MAA acute management, showcasing immediate survival benefits. Late complications and frequent re-interventions emphasize the importance of vigilant surveillance.
... Infected aneurysms involving the aorta and iliac arteries, although extremely rare, can occur in the course of brucellosis (Herrick et al., 2014;Willems et al., 2022). If left untreated, aneurysms can rupture quickly, causing severe bleeding and even death (Müller et al., 2001;Luo et al., 2003;Brossier et al., 2010;Jiang et al., 2023). In 2022, Willems and colleagues published a review on aortic and iliac involvement in brucellosis, wherein they conducted PubMed, Web of Science, and AccessMedicine searches and identified (Ramachandran Nair et al., 2019) cases with an overall mortality rate of 22% (Willems et al., 2022). ...
Article
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Objective: Brucellosis, the most common bacterial zoonosis, poses a serious threat to public health in endemic regions. Cardiovascular complications of brucellosis, mostly pericarditis or endocarditis, are the leading cause of brucellosis-related death. Complications involving the aorta and iliac arteries are extremely rare but can be life-threatening. Our objective was to identify and review all reported cases of aortic and iliac involvement in brucellosis to provide a deep, up-to-date understanding of the clinical characteristics and management of the disease. Methods: Online searches in PubMed, Web of Science, China National Knowledge Infrastructure, and the Chinese Wanfang database were conducted to collect articles reporting cases of brucellosis with aortic and iliac artery involvement. All data in terms of patient demographics, diagnostic methods, clinical manifestations, and treatment regimens and outcomes were extracted and analyzed in this systematic review. Results: A total of 79 articles were identified, reporting a total of 130 cases of brucellosis with aortic and iliac artery involvement. Of the 130 cases, 110 (84.5%) were male individuals and 100 (76.9%) were over 50 years old. The patients had an overall mortality rate of 12.3%. The abdominal aorta was most commonly involved, followed by the ascending aorta, iliac artery, and descending thoracic aorta. Arteriosclerosis, hypertension, and smoking were the most common comorbidities. There were 71 patients (54.6%) who presented with systemic symptoms of infection at the time of admission. Endovascular therapy was performed in 56 patients (43.1%), with an overall mortality rate of 3.6%. Open surgery was performed in 52 patients (40.0%), with an overall mortality rate of 15.4%. Conclusion: Aortic and iliac involvement in brucellosis is extremely rare but can be life-threatening. Its occurrence appears to be associated with the male gender, an older age, arteriosclerosis, and smoking. Although the number of reported cases in developing countries has increased significantly in recent years, its incidence in these countries may still be underestimated. Early diagnosis and therapeutic intervention are critical in improving patient outcomes. Endovascular therapy has become a preferred surgical treatment in recent years, and yet, its long-term complications remain to be assessed.
... They are reported at about 1% of all aortic aneurysms, 3 and the bacteria most frequently causing these infections were Salmonella sp., Staphylococcus sp., and Streptococcus sp. 1,6 The mycotic aortic-iliac aneurysms caused by Brucella are extremely rare. By 2022, only 51 cases have been reported in English literature (Table S1, Appendix S1 [Supplementary Material]). ...
Article
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Purpose Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms. Materials and Methods The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed. Results Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak. Conclusion EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms. Clinical Impact Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%–40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.
... 4,5 Common bacterial pathogens include Staphylococcus aureus, Streptococcus pneumoniae, and non-typhoidal Salmonella followed by other gram-negative organisms such as Escherichia coli, Klebsiella, and Pseudomonas spp. 6,7 Most TAAs are clinically asymptomatic and are identified incidentally upon imaging examination. The initial symptoms are generally secondary to an aortic dissection or rupture that follows hypertension, Marfan syndrome, and Turner syndrome, often being the leading cause of death. ...
Article
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Background A thoracic aortic aneurysm (TAA) is a known condition seen in cardiovascular practice. A TAA rupture and postoperative infection may result in death. Preoperative infections leading to death are extremely rare. Case Study A 62-year-old Chinese female was admitted to The First Hospital of Hebei Medical University with a two-day history of abdominal pain. She was diagnosed with a TAA rupture and underwent immediate surgery. The preoperative urine analysis indicated that the positive bacteria and white blood cell count suggested a urinary tract bacterial infection. The patient was administered the empiric antibiotics, cefazolin; however, her blood pressure continued to drop during the perioperative period and she died of uncorrectable acidosis 8 h after the operation. On the second day after death, both the blood and urine cultures were positive for Pseudomonas aeruginosa. Conclusion Given that this patient with a TAA rupture died of uncorrected acidosis caused by preoperative infection, it is important to evoke the diagnosis in the context of TAA. Routine laboratory indicators are valuable factors for surgeons and physicians in assessing a patient’s condition and improving their prognosis.
... have been reported in less than 10%. 20,21 This could be linked to lifestyle improvement and dietary rules, and Salmonella spp. tend to remain predominant in developing countries or in the West Indies. ...
Article
Introduction: In situ reconstruction (ISR) with autologous veins is the preferred method in infectious native aortic aneurysms (INAA) or vascular (endo)graft infection (VGEI). However, access to biological substitutes can prove difficult and lacks versatility. This study evaluates survival and freedom from reinfection after ISR of INAA/VGEI using the Antimicrobial InterGard Synergy graft combining silver and triclosan. Methods: From February 2014 to April 2020, 86 Antimicrobial grafts were implanted for aortic infection. The diagnosis of INAA/VGEI and reinfection was established based on the MAGIC criteria. Survival was analyzed using the Kaplan-Meier method and log-rank p-values. Results: The Antimicrobial graft was implanted in 32 cases of INAA, 28 of VGI, and 26 of VEI. Median age was 69.0 (IQR: 62.0;74.0), with a history of coronary artery disease (n=21; 24.4%), chronic kidney disease (n=11; 12.8%), cancer (n=21; 24.4%), and immunosuppression (n=27; 31.4%). Imaging showed infiltration (n=14; 16.3%), air (n=10; 11.6%), and rupture (n=16; 18.6% including 22 aorto-enteric fistulae (AEnF)). Symptoms included fever (n=37; 43.0%), shock (n=11; 12.8%), and pain (n=47; 54.7%). Repair was undertaken through a midline laparotomy in 75 cases (87.2%) and coeliac cross-clamping in 19 (22.1%), supra-renal in 26 (30.2%), plus celiac trunk (n=3), mesenteric (n=5), renal (n=13) or hypogastric (n=4) artery reconstruction and omental flap coverage (n=41; 48.8%). For AEnF, the gastrointestinal tract was repaired using direct suture (n=14; 16.3%) or resection-anastomosis (n=8; 9.3%). Causative organisms were identified in 74 patients (86.0%), with polymicrobial infection in 32 (37.2%) and fungal co-infection in 7 (8.1%). Thirty-day and in-hospital mortality were 14.0% and 22.1% (n=12 and 19 respectively, 3 INAA (9.4%), 7 VGI (25.0%) and 9 VEI (34.6%)). Seventy patients (81.4%) had a post-operative complication, 44 (51.2%) of whom returned to the operative room. The 1 and 2-year survival rates were 74.0% (95%CI: 63.3-82.1) and 69.8% (95%CI: 58.5-78.5). Survival was significantly better for INAA vs VGEI (p=.01) and worse for AEnF (p=.001). Freedom from reinfection was 97.2% (95%CI: 89.2-99.3) and 95.0% (95%CI: 84.8-98.4) with 6 reinfections (7.0%) requiring 2 radiological/6 surgical drainage and 2 graft removals. Primary patency was 88.0% (95%CI: 78.1-93.6) and 79.9% (95%CI: 67.3-88.1) with no significant difference between INAA and VGEI (p=.16). Conclusion: ISR of INAA or VGEI with the Antimicrobial graft showed encouraging early mortality, comparable to the rates found in femoral vein (9-16%) and arterial allograft (8-28%) studies, as well as mid-term reinfection. The highest in-hospital mortality was noted for VEI including nearly 50% of AEnF.
... In the pre-antibiotic era, gram-positive cocci implicated in endocarditis (e.g., Staphylococcus, Streptococcus) were the most common organisms isolated from MTAA. However, in the post-antibiotic era, gram-negative organisms account for up to 40% of cases of MTAA, with Staphylococcus, Streptococcus, and non-typhoidal Salmonella species being the most common pathogens [17,[51][52][53][54][55][56][57][58][59][60][61][62][63]. Furthermore, in western countries, Staphylococcus aureus (28%), Salmonella spp. ...
Article
Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.
... AAA prevalence is negligible before the ages of 55-60 years, except for mycotic (MAA) and inflammatory aneurysms (InflAAA), which tend to affect younger patients [3,5]. Traditionally, Staphylococcus, Streptococcus, and Salmonella species have been considered the most frequent bacteria causing MAA, but the spectrum of other organisms is widening [6]. MAA and InflAAA make up about 1.3% and 4-7% of all AAAs, respectively [7,8]; diagnosis is based on a combination of clinical presentation, laboratory findings, and characteristics on computed tomography (CT) angiography [3,7,9]. ...
Article
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Background Inflammatory aneurysms and mycotic aneurysms make up a minority of abdominal aortic aneurysms. Mainly autoimmune mechanisms are proposed in the pathogenesis of inflammatory aneurysms, and it is not routine to check for infectious agents as disease culprits. Case presentation A 58-year-old European male with complaints of abdominal and back pain for 8 weeks was admitted after a semi-urgent computed tomography scan revealed an 85 mm inflammatory abdominal aortic aneurysm. The patient had normal vital signs, slightly elevated inflammatory markers, and mild anemia on admission. Clinical examination revealed a tender pulsating mass in his abdomen. His clinical condition was interpreted as impending rupture and urgent repair of the aneurysm was deemed necessary. Due to the patient’s relatively young age and aneurysm neck morphology, open aortic repair was preferred. Preoperatively, the aneurysm appeared inflamed, with fibrous wall thickening and perianeurysmal adhesions. Aneurysm wall biopsies were sent to histopathological and microbiological diagnostics. Routine cultures were negative, but 16S rRNA gene real-time polymerase chain reaction was positive and Borrelia afzelii was identified by DNA sequencing of the polymerase chain reaction product . B. afzelii was also identified by sequencing the polymerase chain reaction product of a Borrelia- specific groEL target. Immunoglobulin G and M anti- Borrelia antibodies were present on serological analysis. Histopathological analysis displayed loss of normal aortic wall structure and diffuse infiltration of lymphocytes and plasma cells. The patient had an uneventful recovery and was discharged after 1 week to a regional rehabilitation facility. Though the patient fares clinically well and inflammatory markers had normalized, antimicrobial treatment with doxycycline continues at 3 months follow-up due to remaining radiologic signs of inflammation. Conclusions Borrelia infection in the setting of acute aortic pathology is a rare entity. To our knowledge, this is the first case report to demonstrate a mycotic abdominal aortic aneurysm as a rare manifestation of Lyme disease. Aortic wall biopsies and real-time polymerase chain reaction analysis of the specimen were essential for accurate diagnosis. This finding may contribute to the understanding of the etiology of inflammatory aneurysmal disease and abdominal aneurysms in general.
... Realizando una búsqueda bibliográfica en la base de datos científica PubMed, en idioma español e inglés, encontramos 32 casos reportados de aneurismas de la aorta abdominal infectados por C. fetus, desde los años 1971 a 2016, los que se resumen en la Tabla 1 5,7,9,11,13,15,[23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] . El 90% de los pacientes eran varones, la mayoría con comorbilidades. ...
Article
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Resumen La infección es una complicación infrecuente de los aneurismas de la aorta abdominal. Campylobacter fetus tiene un especial tropismo por el endotelio vascular y ha sido reportado como causa de infección de aneurismas aórticos. Este tipo de infección es de alta mortalidad por lo que el reconocimiento temprano con el inicio precoz de terapia antibacteriana efectiva es clave. Además del tratamiento médico, puede requerirse cirugía, la que tiene una alta letalidad en pacientes inestables y con comorbilidades. Comunicamos el caso clínico de un adulto mayor con un aneurisma de aorta abdominal infectado por C. fetus. Dado su compromiso del estado general y antecedentes cardiovasculares se decidió tratamiento médico con imipenem, con una buena respuesta clínica y microbiológica, sin recurrencia de los síntomas. También se presenta una revisión de los casos publicados.
... The organisms with the greatest affinity for the aortic wall are Staphylococcus and Salmonella spp. [5]. Salmonella is less prevalent in comparison but has been reported in up to 15% of cases with bacteremic seeding of atherosclerotic plaque proposed [6][7]. ...
Article
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A mycotic aneurysm is a localised dilatation of an artery due to destruction of the vessel wall by infection. Diagnosis is based on clinical, microbiological, and radiological findings. Typical management includes antibiotic therapy and open surgical debridement with or without revascularisation. This case of mycotic aortic aneurysm highlights the utilisation of endovascular grafts in the treatment of such pathology. This may improve both short and long term morbidity and mortality as compared to open intervention.
... 42 Other publications reported results of deep vein conduits, i.e., neo-aorto-iliac system, silver coated polyester graft, or cryopreserved homografts, but only in individual patients. 34,36 There was no evidence regarding the superiority of one prosthetic material over another. The use of in situ reconstruction with omental pedicle wrapping has been reported with few IRCs (n ¼ 1/ 147 [0.7%]). ...
... Many studies have already reported cases of mycotic aneurysms with negative blood culture results. [4][5][6][7] These cases may account for misdiagnosis and deaths confirmed through autopsy. Furthermore, the sensitivity of blood culture for Salmonela was reported to be only 66% (95% CI 56-75%) compared to bone marrow culture. ...
Article
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INTRODUCTION: Ruptured mycotic aortic aneurysm is a rare and life-threatening condition. An early and proper initiation of antibiotics aside from aneurysmal repair is of paramount importance. The typhidot IgG and IgM may help with this dilemma, especially when the blood culture is negative and during the waiting period for the the aortic sample result. CASE: A 47-year-old male Filipino with type 2 diabetes mellitus presented with severe back pain for one month and intermittent fever for three weeks. Complete blood count showed anemia and leukocytosis with predominance of neutrophils. On computed tomography of the aorta, a segmental calcification and wall discontinuity in the right posterolateral wall of the infrarenal abdominal aorta with heterogenous collection of blood in the retroperitoneal region was seen and aortic rupture secondary to mycotic aneurysm was considered. He underwent emergency abdominal aortic aneurysm repair with debridement, antibiotic lavage, aortoiliac grafting, anastomosis and omental packing. The typhidot IgG and IgM test was positive and was given ceftriaxone 2gm/IV every 24 hours for six weeks. Blood cultures did not reveal significant growth of any pathogen. The aortic wall culture showed heavy growth for salmonella species sensitive to ceftriaxone, confirming and guiding the management. He was then discharged improved. CONCLUSION: A mycotic aneurysm secondary to salmonella should be one of the considerations in an adult male diabetic presenting with prolonged fever, abdominal and back pain with or without a tender pulsatile mass. The Typhidot test is an easy and affordable test that allows rapid detection of salmonella infection. Early surgical intervention and antibiotics are the treatment of choice
... 42 Other publications reported results of deep vein conduits, i.e., neo-aorto-iliac system, silver coated polyester graft, or cryopreserved homografts, but only in individual patients. 34,36 There was no evidence regarding the superiority of one prosthetic material over another. The use of in situ reconstruction with omental pedicle wrapping has been reported with few IRCs (n ¼ 1/ 147 [0.7%]). ...
Article
Objectives: The aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes. Methods: A systematic literature review was performed using the search terms mycotic and infected aortic aneurysms in the MEDLINE and ScienceDirect databases, published between January 2000 and September 2018. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinised regarding surgical technique, aortic segment involved, pre- and post-operative antibiotic regimens, survival and infection related complications (IRCs), and factors associated with adverse or favourable outcomes. Results: Twenty-eight studies, with a total of 963 patients, were included. All publications were observational, retrospective studies. Patient and study heterogeneity, along with missing data, precluded meta-analyses. Overall treatment consisted of open surgical repair (OSR; n = 556 [58%]), endovascular aortic repair (EVAR; n = 373 [39%]), and medical treatment alone (n = 34 [3%]). OSR was the dominant surgical technique prior to 2010, shifting to EVAR thereafter. For MAAs located in the abdominal aorta, EVAR was associated with better short term survival than OSR. Antibiotic treatment for more than six months post-operatively was associated with better survival, but there was no consensus on the length of treatment. MAAs were complicated by IRCs in 21%, irrespective of surgical technique, of which 46%-70% were fatal. The most consistently reported factors associated with adverse outcomes were increasing age, rupture, suprarenal abdominal aneurysm location, and non-Salmonella positive culture. Conclusions: With few exceptions, the literature mainly consists of small, retrospective single centre studies. Standardised reporting is needed to increase comparability of studies. EVAR appears to be associated with superior short term survival without late disadvantages, compared with OSR. This suggests that EVAR can be an acceptable alternative to OSR. However, MAA treatment should always be tailor made and planned individually, and general recommendations are in vain. IRCs pose a significant threat to patients after MAA repair and require further investigation.
... Surgical site infection after a cardiothoracic operation makes patients vulnerable to vascular arteriopathy that can lead to development of an MP. 5 Coagulase-positive S. aureus remains the most commonly isolated pathogen and was the presumed causative organism in our case. [8][9][10][11] Most case series support surgical excision of the infected aorta and prolonged antibiotic therapy as the preferred treatment of MP. 1,12 Diagnosis of an MP relies on a high degree of clinical suspicion as patients often present with nonspecific clinical manifestations, such as repeated febrile illness, weight loss, chest or back pain, and malaise. 1,2 Laboratory studies including complete blood cell count, inflammatory markers, and blood cultures may suggest an underlying infection. ...
Article
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Mycotic pseudoaneurysms (MPs)rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.
... To date only 18 cases of infectious aortitis due to L. monocytogenes have been described. Of these, 2 occurred in the context of thoracic aortic aneurysms [25,26], 9 in abdominal aortic aneurysms [27][28][29] and 7 in endovascular aortic graft [30][31][32][33]. Our case is, to the best of our knowledge, the first case of L. monocytogenes abdominal periaortitis associated with a vascular graft. ...
Article
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Background Endograft infection is a rare but extremely dangerous complication of aortic repair (25–100% of mortality). We describe here the first case of Listeria monocytogenes abdominal periaortitis associated with a vascular graft. We also discuss the differential diagnosis of periaortitis and provide a literature review of L. monocytogenes infectious aortitis. Case presentation Nine months after endovascular treatment of an abdominal aortic aneurysm (abdominal stent graft), a 76-year-old man was admitted for severe abdominal pain radiating to the back. Laboratory tests were normal apart from elevated C-reactive protein (CRP). Injected abdominal computed tomography (CT) showed infiltration of the fat tissues around the aortic endoprosthesis and aneurysmal sac expansion; positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a hypermetabolic mass in contact with the endoprosthesis. Blood cultures were negative. At surgical revision, an infra-renal peri-aortic abscess was evident; post-operative antibiotic therapy with ciprofloxacin and doxycycline was started. Cultures of intraoperative samples were positive for L. monocytogenes. Results were further confirmed by a broad-range polymerase chain reaction (PCR) and next-generation sequencing. Antibiotic treatment was switched to intravenous amoxicillin for 6 weeks. Evolution was uneventful with decrease of inflammatory parameters and regression of the abscess. Conclusion An etiologic bacterial diagnosis before starting antibiotic therapy is paramount; nevertheless, culture-independent methods may provide a microbiological diagnosis in those cases where antimicrobials are empirically used and when cultures remain negative.
... The standard treatment consists in combining antibiotics with aggressive debridement of the infected tissue [2]. The organisms with the greatest affinity for the arterial wall, Staphylococcus spp and Salmonella spp, remain the most common [3]. ...
... Because infectious aortic aneurysm has different treatment strategy with the non-infectious cause, precise diagnosis is necessary. Gram positive and negative bacteria had been the most common micro-organisms causing aortic infections (2), and Campylobacter fetus, Listeria, and Coxiella have been reported in the single center (3). Mycobacterium tuberculosis, Treponema pallidum and fungi rarely infect the aorta, but their frequency is increasing due to the immunosuppressed patients (4). ...
Article
We present the case of thoracic aortic aneurysm associated with the tuberculous pleural effusion. An 82-year-old woman underwent emergency stent graft under a diagnosis of dissecting thoracic aortic aneurysm. Preoperative computed tomography revealed right pleural effusion supposed to the hemothorax caused by the dissecting aneurysm. But, the effusion was sanguineous color fluid and it was determined to result from pulmonary tuberculosis. The medical team was exposed to the pulmonary tuberculosis; fortunately no one became infected. Physicians should be aware of the possibility of an infected aortic aneurysm and prepare for pathogen transmission.
... Esses aneurismas podem se formar devido a uma infecção pré-existente ou podem ser secundariamente infectados. Os principais agentes encontrados nesses aneurismas são Salmonella sp (40%) Staphylococus aureus e Streptococcus sp 3,4 . ...
Article
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Resumo Os aneurismas de aorta abdominal infecciosos (AAAIs) são raros e apresentam uma alta mortalidade devido à septicemia e ao risco de ruptura. A opção terapêutica consagrada consiste na correção aberta com ressecção do aneurisma, debridamento e reconstrução com veia autóloga. Mais recentemente, alguns grupos vêm relatando séries de casos nas quais se realizou tratamento endovascular. Em ambas as opções, a antibioticoterapia adjuvante é imperativa. Relatamos um caso ilustrativo em que o tratamento de escolha foi a cirurgia aberta com reconstrução utilizando-se veia autóloga.
Book
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The book "Vascular Surgery: Procedures, Complications and Recovery'' was written by a team of vascular, cardiac, and neurosurgeons working mainly in The East Slovak Institute of Cardiovascular diseases but also Luis Pasteur University Hospital in Kosice, Slovakia. The book is addressed to students of medicine and also as fundamental principles of vascular surgery for residents of different surgical specializations. Vascular surgery has been rapidly developing in the last decades. Although the first successful arterial reconstructions appeared at the beginning of the 20th century, the active management of arterial diseases had developed since the 1950s when new techniques of arterial surgery were established. The first attempt at vascular reconstruction was performed by Alexis Carrel, a French surgeon who was awarded the Nobel Prize in Medicine in 1912 for inventing the modern vascular suture, which is used even nowadays. Significant development of vascular surgery brought the introduction of prosthetic grafts by Vorhees in 1952. That enabled De Backey to resect an abdominal aortic aneurysm and replace it with a synthetic graft in 1955. Seldinger performed the first angiography with the catheter in 1952, and Gruntzig in 1974 was the first who did percutaneous transluminal angioplasty and started the modern era of endovascular treatment. Since this time, an important development in the treatment of vascular diseases has been observed. Nowadays, vascular surgeons solve the most severe cases of arterial diseases, solve complications of endovascular therapy, or are a part of hybrid procedures, which are a combination of surgical and endovascular treatment. In the first chapter, elementary clinical examinations, imaging methods, and also surgical techniques are described. Aortic disorders, which are the most severe vascular diseases, are analyzed in the second, third, and fourth chapters. Open aortic surgery is technically the most challenging part of vascular surgery and is associated with the highest mortality. Open aortic surgery is now being replaced by endovascular procedures due to lesser invasivity and mortality. The fifth chapter is dedicated mainly to the surgery of carotid arteries. Stenosis of the internal carotid artery is one of the reasons for stroke. Carotid endarterectomy that removes atherosclerotic plaque from the carotid bifurcations is an effective prevention of stroke in patients with stenosis of the internal carotid artery. The sixth chapter analyses the problem of surgery of peripheral arteries as peripheral arterial occlusive disease or acute limb ischemia. Both conditions can lead to major amputations and lifelong disability. The seventh chapter analyses vascular trauma that may lead to severe bleeding or limb ischemia; both situations require almost immediate diagnosis and treatment. Peripheral artery trauma is treated mainly by open surgery, while the treatment of aortic injury is mostly endovascular. Basic types of vascular access and problems of venous disorders are described in the eighth chapter. Venous diseases are not so life-threatening but much more common compared to arterial. The last chapter deals with complications and recovery that are inevitable for an excellent surgical outcome.
Article
Background Endovascular repair of mycotic aneurysms is a viable option in patients deemed high risk for open repair, with complex repair using parallel stent grafting described in cases of both mycotic thoracic aneurysms as well as mycotic para-visceral abdominal aneurysms. We present the case of a mycotic suprarenal aneurysm with endovascular repair including combined proximal and distal 4-vessel parallel stent grafting. Case Report The patient is a 76-year-old male who presented with malaise, back pain, fever, and chills. Work-up was pertinent for leukocytosis and blood cultures positive for Group B streptococcus. Computed tomography (CT) imaging revealed a suprarenal mycotic aneurysm extending from the origin of the superior mesenteric artery to the bilateral renal arteries, as well as associated periaortic and retroperitoneal fat stranding. Aorta proximal and distal to the aneurysm was normal. We performed an endovascular repair using a 10-centimer length, 31 to 26 millimeter tapered thoracic stent graft. Parallel grafts were placed from proximal approach into the celiac and superior mesenteric arteries, and from distal approach into bilateral renal arteries using balloon-expandable covered stents. His postoperative course was unremarkable, and he was discharged on the second post-operative day. He completed a six-week course of intravenous antibiotics and continues oral antibiotics for long-term prophylaxis. At the four-year follow-up, he remained asymptomatic with CT imaging showing patent stent grafts without evidence of endoleak. Conclusions Complex endovascular repair of mycotic aneurysms using a combination of a thoracic covered stent and parallel stent grafts extending from both proximal and distal approaches can be a viable alternative in selected patients deemed high risk for open repair. Further follow-up will be needed to determine long-term outcomes.
Article
Objective Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards. Methods A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses. Results Seventy patients (60 men [86%], median age 68 years [range 59 – 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan–Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 – 93.0) and 71.7% (95% CI 59.2 – 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 – 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0–66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 – 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 – 33.9), 4 (OR 14.9, 95% CI 1.7 – 129.3), and CKD (OR 32.0, 95% CI 1.2 – 821.5) were related to 90 day mortality. Conclusion Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn.
Article
Objective: The aim of our systematic review and meta-analysis was to demonstrate the clinical outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infective native aortic aneurysms (INAAs). Methods: MEDLINE, Embase, and Cochrane Databases were searched for articles reporting OSR and/or EVAR repair of INAA. The methodological quality of included studies was assessed by the Newcastle-Ottawa scale and Moga-Score. Random-effects models were used to calculate the pooled measures. Results: A total of 34 studies were included, with 22 studies reporting OSR alone, 6 studies reporting EVAR alone and 6 comparative studies for INAAs. The pooled estimates of infection-related complications (IRCs) were 8.2% (95% CI 4.9%-12.2%) in OSR cohort and 23.2% (95% CI 16.1%-31.0%) in EVAR cohort. EVAR was associated with a significantly increased risk of IRCs compared with OSR during follow-up (OR 1.9, 95% CI 1.0-3.7). As for survival outcomes, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality in OSR cohort were 11.7% (95% CI 7.7%-16.1%), 21.6% (95%CI 16.3%-27.4%) and 28.3% (95% CI 20.5%-36.7%; I2=50.47%), respectively. For EVAR cohort, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality were 4.9% (95% CI 1.1%-10.4%), 9.4% (95% CI 2.7%-18.7%) and 22.2% (95% CI 12.4%-33.7%), respectively. EVAR was associated with a significantly decreased of 30-day mortality (OR 0.2, 95% CI 0.1-0.6). However, no difference was found between EVAR and OSR in 3-month (OR 0.2, 95% CI 0-1.1), 1-year all-cause mortality (OR 0.4, 95% CI 0.1-1.1) or aneurysm-related mortality (OR 1.4, 95% CI 0.5-3.9). Moreover, no difference of incidence of reintervention was observed (OR 2.6, 95% CI 0.9-7.7; I2=53.7%) between two groups. Conclusions: EVAR could provide better short-term survival than OSR in patients with INAAs. However, patients undergoing EVAR suffered from higher risks of IRCs. EVAR could be considered as an alternative for low-risk patients with well-controlled infections or patients considered high-risk for open reconstruction.
Article
Objective There remains a controversy regarding the use of endovascular aneurysm repair (EVAR) versus open aneurysm repair (OAR) for infected abdominal aortic aneurysms (AAA). This study aimed to investigate the comparative outcomes of EVAR and OAR for the treatment of infected AAAs. Methods We conducted a systematic review and meta-analysis using MEDLINE and EMBASE databases through May 2021. We included the studies describing both EVAR and OAR for the treatment of infected AAA. Primary endpoints were rates of recurrent infection and related rupture/death. Perioperative and 1-year mortality as well as readmission/re-intervention were also analyzed. Results Fourteen observational studies describing a total of 1203 patients (EVAR, 359 [29.8%]; OAR, 844 [70.2%]) were eligible for qualitative analyses. Baseline characteristics demonstrated diabetes mellitus (33.2%), fever at presentation (71.6%), rupture at diagnosis (26.1%), and positive blood cultures (52.5%). Mean follow-up period ranged from 12–40 months. EVAR became more prevalent in recent years (32.4%, 2016-2020) compared to the former period (13.8%, 2010-2015, p < .0001). Fenestrated, branched or concomitant visceral debranching EVAR were performed in 6.1% of cases. In OAR, surgical debridement was consistently performed, in-situ reconstruction was applied in 82.2%, and omental flap in 51.5%. In 9 studies considered for quantitative analyses, patients background (EVAR, 264 vs. OAR, 274patients) were statistically balanced. The crude rates of recurrent infection and related rupture/death were 13.6% (95% confidence interval [CI] 8.8%–18.5%) and 4.9% (95% CI 1.8%–8.0%), respectively. The pooled analyses depicted significantly higher rates of recurrent infection after EVAR compared to OAR (relative risk [RR] 2.42; 95% CI 1.80–3.27; p < .0001; I² = 0%). Recurrent infection-related rupture/death (RR 1.51; 95% CI 0.70–3.23; p = .29; I² = 0%), perioperative death (RR 0.80; 95% CI 0.39–1.65; p = .55; I² = 35%), 1-year mortality (hazard ratio 1.12; 95% CI 0.97–1.28; p =.13; I² = 0%) and readmission or re-intervention (RR 1.16; 95% CI 0.74–1.82; p =.52; I² = 0%) were not statistically different between the 2 groups. Funnel plots showed no evidence of publication bias. Sensitivity analyses of leave-one-out meta-analysis confirmed higher rates of recurrent infection after EVAR. Conclusions EVAR has become more prevalent as initial treatment for infected AAAs. Although operative and 1-year survival is similar between OAR and EVAR, recurrent infection is more frequent after EVAR. This limitation should be weighed in selecting patients for EVAR in infected AAA. Postoperative graft and infection surveillance are critical especially after EVAR.
Article
The management of abdominal aortic aneurysms (AAA) has evolved significantly with the advent of endovascular strategies. Thus, there has been a decline in the number of open AAA repairs once an endovascular option is available. There have also been reports of successful endovascular management of infective native aortic aneurysms (INAA) [1], previously called mycotic aneurysms [2]. The rarity of this condition makes its management a challenging one as there are no standard guidelines. The European Society of Vascular Surgery has suggested that the nomenclature be changed from mycotic aneurysms as this can be misleading to standardise reporting [1]. The authors’ present a case of a 67-year old male who presented during the peak of the Corona Virus pandemic with constitutional gastrointestinal symptoms. He was subsequently diagnosed with an INAA and successfully managed with open Neo-Aorto Iliac System reconstruction with a homograft [3]. The report highlights various strategies used in the surgical approach and their benefits in the management of INAA. Furthermore, a literature review of Streptococcus (Streptococcus agalactiae) species as a rare cause of INAA and how these cases were managed are also highlighted.
Article
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Peripheral artery mycotic aneurysms are rare occurrences. In this case, we review a 52-year-old lady with poorly controlled diabetes who developed a spontaneous left superficial artery mycotic aneurysm. She underwent excision and subsequent extra-anatomic bypass with a great saphenous vein graft. She had full functional recovery after a short period of rehabilitation. 1. Introduction The term mycotic aneurysm, first coined by Osler in 1885, refers to localized, irreversible arterial dilatation due to destruction of the vessel wall by infection [1]. This may occur in a previously healthy artery or may be due to secondary infection of a preexisting aneurysm. Various risk factors including direct arterial injury, antecedent infection, preexisting conditions resulting in impaired immunity, or atherosclerotic disease predispose patients to mycotic aneurysms [2]. In this case, we reviewed a 52-year-old lady with poorly controlled diabetes who developed a spontaneous left superficial femoral artery (SFA) mycotic aneurysm. 2. Case Report A 52-year-old lady with hypertension, diabetes, and asthma presented with a one-week history of left groin pain. The pain started insidiously and was localized to the left groin. She was otherwise well and asymptomatic prior to this. There was no history of preceding trauma. Of note, she had a dental extraction procedure two weeks prior to this. She was only on inhaled corticosteroids for her asthma, without any systemic corticosteroids. On examination, she was found to have a tender left upper thigh mass that measured about . Other than this, her lower limb neurovascular examination did not reveal any abnormalities. She did not have any features of distal emboli or splinter hemorrhages. Initial blood investigations revealed a total white cell count of /L as well as a raised C-reactive protein of 247.7 mg/L. Her diabetic control was also poor with a glycosylated hemoglobin level of 15.4%. Initial blood cultures were also taken which did not reveal any microbes. She underwent an urgent computed tomographic (CT) angiogram of the lower limbs which revealed a thin wall eccentric saccular pseudoaneurysm arising from the proximal third of the left SFA measuring cm with a gas containing intramuscular fluid collection seen. Mass effect from the collection and pseudoaneurysm was compressing the adjacent femoral vein causing central intraluminal filling defects, suspicious of deep venous thrombosis (Figure 1). (a)
Article
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Listeria monocytogenes‐caused primary infected abdominal aortic aneurysm is a very rare disease. Aortic wall tissue sampling is essential for confirmation of diagnosis. Surgical repair and long‐term antibacterial treatment are crucial for management. Listeria monocytogenes‐caused primary infected abdominal aortic aneurysm is a very rare disease. Aortic wall tissue sampling is essential for confirmation of diagnosis. Surgical repair and long‐term antibacterial treatment are crucial for management.
Article
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Background Helicobacter cinaedi is rarely identified as a cause of infected aneurysms; however, the number of reported cases has been increasing over several decades, especially in Japan. We report three cases of aortic aneurysm infected by H. cinaedi that were successfully treated using meropenem plus surgical stent graft replacement or intravascular stenting. Furthermore, we performed a systematic review of the literature regarding aortic aneurysm infected by H. cinaedi. Case presentation We present three rare cases of infected aneurysm caused by H. cinaedi in adults. Blood and tissue cultures and 16S rRNA gene sequencing were used for diagnosis. Two patients underwent urgent surgical stent graft replacement, and the other patient underwent intravascular stenting. All three cases were treated successfully with intravenous meropenem for 4 to 6 weeks. Conclusions These cases suggest that although aneurysms infected by H. cinaedi are rare, clinicians should be aware of H. cinaedi as a potential causative pathogen, even in immunocompetent patients. Prolonged incubation periods for blood cultures are necessary for the accurate detection of H. cinaedi.
Article
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Mycotic aneurysm caused by Campylobacter is rare. The patient was a 65-year-old man and his chief complaint was low back pain. He had no past history of diabetes, steroid use nor malignant disease. Contrast-enhanced computed tomography demonstrated multiple saccular aneurysms of the abdominal aorta and right common iliac artery. Preoperative blood culture revealed Campylobacter. Imipenem was started and elective surgery was performed. Using an ePTFE graft, Y grafting and omental transfer was performed. His postoperative course was uneventful.
Chapter
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Abdominal aortic aneurysms (AAAs) are a significant cause of death in the Western world. Endovascular aneurysm repair (EVAR) is becoming the prevalently used procedure to repair AAAs (versus the traditional approach of open surgery). In cases of infrarenal AAAs, there is a risk of the renal arteries being blocked by the stent graft (SG) inserted to repair the aneurysm. In these cases, two additional SGs termed”chimney” stent grafts (CSGs) are inserted into the renal arteries in parallel with the main SG to exclude this hazard. In this study, the hemodynamics of an infrarenal AAA endovascularly repaired by a system of SGs using the “chimney” technique is investigated. Two AAA models are analyzed using computational fluid dynamics (CFD, Ansys Fluent)—a healthy abdominal aorta and an abdominal aorta post”chimney” endovascular aneurysm repair (ChEVAR) with a CSG inserted into each renal artery in parallel with the aortic SG. Results indicate that CSGs induce stagnation zones downstream the renal arteries yet mild and confined overall flow and wall shear stress (WSS) modifications. The flow regime remains principally laminar. The study findings indicate the limited hemodynamic modifications of the ChEVAR procedure and thus further support its merit.
Article
Mycotic aneurysm is a life-threatening disease often caused by Salmonella, Staphylococci and Streptococci species. Interestingly, Escherichia Coli (E. Coli) is described as a rare causative agent. We report the case of a patient who developed a mycotic aortic and ruptured left iliac aneurysm due to E. Coli. The patient developed a secondary aortic graft infection due to a mesenteric ischemia with fecal peritonitis. A literature overview of the current knowledge on mycotic aortic aneurysms specifically due to E. Coli is discussed including the clinical characteristics of patients, the management of the disease and the post-operative outcomes.
Article
Background: Listeria monocytogenes-associated endovascular infections are not well characterized. Methods: Retrospective study of 71 culture-proven cases reported to the French National Reference Center for Listeria from 1993 to 2018. Results: Seventy-one cases were identified: 42 with vascular aneurysms/prosthetic infections, 27 with endocarditis, 2 with both. Fifty-eight were men (82%); median age was 75 years [46-92]; 93% reported co-morbidities (66/71), including 50% with immunosuppressive conditions. Vascular infections consisted of infected aneurysms (68%) or prosthetic graft infections (32%); vascular rupture was reported in 25/42 (60%). Tissue samples grew L. monocytogenes in 98% (43/44) and blood cultures in 64% (27/42). Endocarditis cases involved prosthetic or native valves or intracardiac devices in respectively 62% (18/29), 28% (8/29) and 10% (3/29). Infected valves were aortic (62%, 16/26), mitral (31%, 8/26) or both (8%, 2/26); 38% patients required surgery; 45% displayed heart failure; 17% had concomitant neurolisteriosis. In-hospital mortality in vascular infections was 12% (5/42) and 41% (12/29) for Lm-associated endocarditis. Conclusions: Endovascular listeriosis is a rare but severe infection. It manifests as vascular infections and endocarditis, mostly in older patients with vascular or cardiac valve prosthetic devices and co-morbidities. Mortality in Lm-associated endocarditis is twice higher than with other pathogens, requiring prompt recognition and treatment.
Article
Résumé Les anévrismes tuberculeux de l’artère iliaque commune sont rares. Quelques cas seulement ont été rapportés dans la littérature. Nous en rapportons un nouveau cas chez un homme de 47 ans admis pour douleurs abdominales et fièvre persistante. L’anévrisme était évoqué à l’écho-doppler et confirmé à l’angioscanner. Le patient a bénéficié d’un pontage extra-anatomique fémorofémoral croisé à l’aide d’une prothèse en dacron et d’une ligature section de l’artère anévrismale. Les suites opératoires étaient marquées par une dyspnée fébrile en rapport avec une miliaire tuberculeuse découverte à la radiographie du thorax. L’analyse histologique des pièces opératoires avait permis de confirmer l’origine tuberculeuse de l’anévrisme. Le patient était mis sous antituberculeux et les suites opératoires étaient simples. Avec un recul de 4 mois, le patient était asymptomatique et le pontage était bien perméable.
Article
There are few reports of abdominal aortic aneurysm (AAA) infection with Campylobacter fetus. We report a case of AAA infected with C. fetus, in which the aneurysm rapidly expanded. A 65-year-old man initially presented with the chief complaint of high fever and severe lumbar pain. Contrast-enhanced computed tomography (CECT) on arrival showed a 43-mm fusiform AAA with a slightly thickened aortic wall, suggestive of either an inflammatory or an infected AAA. The symptoms improved with antibiotic administration for three days. However, the C-reactive protein level remained high. Two sets of blood cultures collected on admission revealed the presence of C. fetus on day 13. CECT on day 14 showed that the AAA had rapidly expanded to 55 mm in diameter. We diagnosed an AAA infected with C. fetus, and performed replacement in situ surgery using a rifampicin-bonded graft, due to the high risk of rupture. At the 5-month follow-up, the patient was symptom-free and follow-up CT was uneventful.
Article
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Mycotic abdominal aortic aneurysms (MAAAs) are rare entities accounting for 0.65–2% of aortic aneurysms. Campylobacter fetus has a tropism for vascular tissue and is a rare cause of mycotic aneurysm. We present a 73-year-old male patient with contained rupture of a MAAA caused by C. fetus, successfully treated with endovascular aortic repair (EVAR) and antibiotics, which is not previously described for this aetiology. Although open surgery is the gold standard, EVAR is nowadays feasible and potentially represents a durable option, especially in frail patients.
Article
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We report a surgical case of infected thoracic aortic aneurysm. Before arrival of the cryopres- erved aortic allograft, the patient had hemoptysis resulting from aneurysm rupture. Therefore endovascular stent grafting was urgently performed three days prior to in situ allograft implantation. Palliative stent grafting prevented circulatory collapse and stabilized the patient until successful allograft implantation. © 2009 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
Article
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The authors report a case of Campylobacter fetus subsp. fetus gastro-intestinal infection and bacteremia with poly-arthritis, mainly of the hip, in a French patient simultaneously suffering from cirrhosis of the liver. The outcome was eventually favorable, however only after a trial of ineffective pefloxacin-gentamicin therapy. The authors suggest: (i) gentamicin should not be given alone in C. fetus subsp. fetus infections, and (ii) pefloxacin should not be given if antibiotic sensitivities data are not available. The inconclusive reliability of disk diffusion tests for C. fetus subsp. fetus should be recognized.
Article
Mycotic aortic aneurysm caused by Klebsiella pneumoniae (K. pneumoniae) is extremely rare and 3 cases of K. pneumoniae-induced mycotic aortic aneurysm are present, 2 of which were located in the aortic arch and the other in the suprarenal abdominal aorta. Urgent surgery was performed for 2 cases because of impending aneurysmal rupture and progressive septic shock, whereas elective surgery was performed after radical antibiotic chemotherapy for the other case. In-situ reconstruction with rifampicin-bonded prosthetic grafts was performed, and no infective complications have occurred in any of the cases.
Article
Endovascular grafts have rapidly evolved as a minimally invasive treatment for a variety of acute and chronic disorders of the thoracic aorta. Application of this technology at a single center is reported. Between 1998 and 2007, 197 patients underwent thoracic endovascular aortic repair. Primary indications included degenerative aneurysms (n = 121), type B aortic dissection (n = 44), mycotic aneurysms (n = 9), traumatic disruptions (n = 9), intramural hematoma (n = 5), pseudoaneurysm (n = 4), and miscellaneous pathology (n = 5). An analysis of patient demographics, periprocedural records, complications, reinterventions, and survival was conducted. Thirty-day mortality was 6%, which was lowest among patients undergoing treatment for a degenerative thoracic aortic aneurysm (2.4%, 3 of 121). Major adverse events included stroke in 3%, spinal cord ischemia in 2%, peripheral vascular repair in 4.5%, renal failure in 4.5%, and open conversion in one patient (0.5%). Both preoperative serum creatinine (odds ratio 1.44, 95% CI 1.02 to 2.04, p = 0.039) and number of endograft components (odds ratio 1.43, 95% CI 1.01 to 2.01, p = 0.043) were predictors of major adverse events. Kaplan-Meier analysis revealed a reduction in late survival among patients with preoperative creatinine >or=1.8 mg/dL (p < 0.001). One- and 5-year intervention-free survivals were 77%+/-3% and 41%+/-6%, respectively. Thoracic endovascular aortic repair represents an effective treatment for a variety of pathologic states. But the risk-benefit analysis for thoracic endovascular aortic repair should carefully consider the extent of disease, pathologic condition, and renal function.
Article
We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.
Article
Untreated infectious thoracic aortic pathology (ITAP) has a dismal prognosis. Despite its high rates of morbidity in this setting, conventional open repair remains the gold standard therapy. Understanding the limitations of open repair, we describe outcomes for one of the largest series of ITAP treated with thoracic endovascular repair. Of 170 patients undergoing thoracic endovascular repair (1993 to 2008), 20 presenting with ITAP were identified. Indications for intervention included aortobronchial (n = 10), aortoesophageal (n = 2), or aortocutaneous fistulae (n = 1), or mycotic aneurysms (n = 7). Underlying disease included fusiform aneurysm (n = 1), saccular aneurysm or pseudoaneurysm (n = 18), or dissection (n = 1). Four patients had ITAP from infected grafts. Follow-up was 100% complete (mean, 28.6 months). Median age was 73 years. A history of immunosuppression was present in 4; concurrent malignancy was present in 5. Arch repair was needed in 8; total descending, in 6. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Causes of in-hospital mortality (n = 3; 15.0%) included refractory hypoxemia (n = 1) and sepsis from tracheoesophageal fistula (n = 1) or pneumonia (n = 1). Dialysis was needed in 2; none sustained postoperative stroke or paraplegia. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients, with 3 attributed to recurrent ITAP. There was a trend for recurrence of ITAP when thoracic endovascular repair was originally performed in an infected graft (p = 0.08). At last imaging follow-up, 14 patients had a healed aorta. Treatment with thoracic endovascular repair for ITAP can be accomplished with acceptable results. Late mortality is frequently related to underlying comorbidities, rather than complications from the aortic disease itself, suggesting that thoracic endovascular repair is an appropriate palliative therapeutic option in this high-risk cohort.
Article
Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.
Article
Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare and life-threatening disease. We report a single-center experience of three patients treated with a combination of surgical aortic replacement and prolonged antituberculosis therapy. The first case is a 34-year-old woman with a suprarenal abdominal aortic aneurysm, the second case is a 77-year-old man with an infrarenal abdominal aortic aneurysm and a right psoas abscess, the third case is a 37-year-old woman with an infrarenal abdominal aortic aneurysm. All patients had a favorable outcome with a mean follow-up of 6.2 years (range, 6 months-10 years). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.
Article
Infected aneurysm of the aorta is almost always fatal without undergoing aortic resection. Medical treatment was attempted selectively in patients who were considered too high risk for surgery. We review our experience with 22 patients treated without undergoing aortic resection over 12 years. Retrospective chart review. Between 1995 and 2007, 22 cases of infected aortic aneurysms treated without undergoing aortic resection during the first admission were included. There were 17 men with a median age of 76 years (range, 35 to 88 years). Of 18 pathogens isolated, the most common responsible microorganism was nontyphoid Salmonella in 11 followed by Staphylococcus aureus in five. The site of infection was thoracic in eight and abdominal in 14. The hospital mortality rate was 50%, and the aneurysm-related mortality rate after long-term follow-up was 59%. The event-free survival rate at one year was 32%. Of 11 patients with Salmonella infection, eight patients have lived beyond 30 days and six were event-free after one year. Of 11 patients with non-Salmonella, four patients have lived beyond 30 days and only one was event-free after one year. The overall aneurysm-related mortality rate was 36% in Salmonella infected patients and 82% in non-Salmonella infected patients. Clinical results of medical treatment using current antibiotics in patients with infected aortic aneurysm were poor. Traditional surgical excision of infected aortic aneurysms with revascularization remains the gold standard and should be attempted except in high risk patients.
Article
The primary objective of this study was to compare the efficacy of a collagen silver-coated polyester graft, InterGard, with a gelatin-sealed graft, Gelsoft, both soaked in rifampin, for resistance to direct bacterial contamination in an animal model. The second objective was to confirm the lack of inflammation from silver acetate. Vascular grafts, 6 mm in diameter, were implanted in the infrarenal aorta of 28 dogs. Intravenous cefamandole (20 mg/kg) was injected intraoperatively in all dogs. The dogs were divided into three groups. Group I included 12 dogs. Six dogs received silver grafts and six dogs received gelatin-sealed grafts, all soaked with rifampin. Grafts implanted in group I were directly infected with methicillin-resistant Staphylococcus aureus (MRSA). Group II included also six silver grafts and six gelatin-sealed grafts, all soaked with rifampin. Dogs of group II were directly infected with Escherichia coli. Group III comprised four dogs, which received gelatin unsealed grafts, directly infected with MRSA, the control group. All dogs were followed by regular clinical examination, including blood cultures. Grafts in groups I and III and in group II were harvested at 30 days and 10 days, respectively. Bacterial analyses were performed on the explanted grafts. Histology was performed on both the tissue samples and the anastomotic sites of the harvested grafts. In group I, no grafts were infected with MRSA, irrespective of graft type. In group II, no silver grafts were infected with E. coli, whereas one (16.6%) of six gelatin-sealed grafts was infected (p = 0.317). In group III, three (75%) of the four grafts were infected with MRSA. The infection rate in the silver grafts and the gelatin-sealed grafts soaked in rifampin in group I compared with the unsealed gelatin grafts in group III was statistically significantly different (p < 0.05). There was no statistically significant difference in the inflammation score, obtained by histological analysis, between rifampin-soaked silver and Gelsoft grafts in either group I or group II. There were signs of necrosis at the anastomoses in three (25%) gelsoft grafts of 12 in groups I and II. There were no clinical or biological signs of inflammation from use of silver-coated grafts. These results indicate that collagen silver-coated grafts and gelatin-sealed grafts, both soaked in rifampin, provide resistance against MRSA and E. coli. There was a trend toward better resistance but without statistical significance against E. coli from the rifampin silver graft compared with the rifampin-soaked Gelsoft graft, without signs of inflammation from InterGard silver grafts.
Article
Few reports of aortoiliac aneurysms infected by Campylobacter fetus are available. We report five cases and review previous reports, with a view to describing the clinical pattern, treatment options, and outcome of this infection. During a 10-year period, 21 patients were diagnosed with C fetus infection in the Department of Clinical Microbiology, five of whom had an infected arterial aneurysm. We retrospectively reviewed their medical charts. Diagnosis was made on the basis of clinical presentation, computed tomography scan, perioperative findings, and identification of C fetus in at least one blood culture or culture from an aneurysm specimen. Late outcome of surviving patients was assessed by telephone interview. We identified four aortic aneurysms and one hypogastric aneurysm. All patients were seen in an emergency setting. Five had fever and abdominal pain, and three had contained rupture. Campylobacter fetus was found in blood cultures of four patients and in the aneurysm specimen of one patient. Three patients were treated by open repair and two by endovascular repair. One patient treated endovascularly died from septic shock due to C fetus at 2 weeks. One patient treated by open surgery underwent reoperation for persistent infection. The remaining patients were cured, but one died at 5 months of an unrelated cause. All surviving patients received long-term antibiotic therapy. Campylobacter fetus infection of aortoiliac aneurysms is a serious condition with a high rate of rupture. However, long-term success can be obtained with prompt surgical treatment and an appropriate antibiotic regimen. The benefits of stent grafts remain debatable.
Article
Twenty-seven patients with mycotic aneurysms of the aorta and its major branches were operated on between 1969 and 1991. There were 24 males and three females ranging in age from 6 to 84 years (mean age for adults 63 years). Sixteen of the 27 (59%) aneurysms were ruptured and in situ repair was undertaken in 20 (74%) patients. The mean follow-up was 5.8 years (range: 8 months to 16 years). Four patients (15%) died during the hospital stay and 23 survived. There were eight late deaths, two of which were a direct result of the aneurysm. The estimated 1- and 5-year survival rates were 62 and 36%, respectively. Extra-anatomic reconstruction is the method of choice for the majority of patients with mycotic aneurysm of the infrarenal abdominal aorta and iliac arteries. In situ repair after an extensive debridement of the aneurysmal wall and all infected tissue combined with antibiotic therapy is a satisfactory method of treating mycotic aneurysms of other locations, and for a highly selected group of patients with infrarenal mycotic aortic aneurysms.
Article
Twenty-five infected infrarenal aortic aneurysms operated on between 1968 and 1989 were reviewed. They were classified into post-embolic (mycotic) aneurysms (group I), infective aortitis (group II), and infected atherosclerotic aneurysms (group III). Aortoduodenal fistulas were found in eight patients and aortocaval in two. Five patients were operated on in a state of shock, and 12 had preoperative positive blood cultures. Surgical procedures included in situ reconstruction of the aorta (n = 21) and extra-anatomic bypass associated with aneurysmal resection (n = 4). In 19 patients, prostheses were covered with omental flaps, and antibiotics were continued for more than 6 weeks in all patients. In patients who underwent in situ reconstruction, three deaths were related to the initial surgery. All surviving patients were regularly followed up, and none showed any sign of late septic recurrence. In patients who underwent extra-anatomic bypass, two died in the postoperative period, one underwent reoperation 2 years after the initial surgery, and the last patient is doing well. Positive postoperative blood cultures (n = 4) revealed persistent sepsis: two cholecystitis, one spondylitis, and one aortic infection. An exhaustive review of the literature was performed; clinical, bacteriologic, and operative features and results were analyzed; prognostic factors were evaluated; and a practical therapeutic approach was suggested. The importance of preoperative diagnosis, complete resection, debridement of infected tissues, omental flap coverage, and long-term antibiotic therapy with regular computerized tomographic scanning follow-up is stressed.
Article
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.
Article
Infected aortic aneurysms are a rare (1.3% of all abdominal aortic aneurysms) but life-threatening disease. At present controversy continues about the specific diagnosis and the best surgical management. We present one case of infected aortic aneurysm treated with in situ reconstruction with cryopreserved arterial homograft. He was a 50-year-old man with recent history of pneumococcal meningitis who is readmitted because he suffered a stroke and during physical examination a pulsatile abdominal mass was discovered. Blood cultures were done and the result was repeatedly negative. Radiological studies were performed: the abdominal CT scanning showed a non ruptured 5 cm infrarenal aortic aneurysm with irregular wall and in the aortography it appeared eccentric, multilobulated with a clear neck in an otherwise normal size aorta but with some arteriosclerotic lesions. The diagnosis of infected aneurysm was suspected and the patient received antibiotic therapy and was operated on: aneurysm resection with wide debridement of surrounding tissues and in situ aortic replacement with aortobifemoral cryopreserved arterial homograft. Cultures of the aneurysm wall and contents were negative but aneurysm wall biopsy suggested an infected aortic aneurysm. The postoperative course was uneventful and antibiotics were continued for 6 weeks. The patient is doing well 7 months after surgery without signs of recurrent infection and normal appearance of the cryopreserved arterial homograft. We conclude that specific diagnosis of infected aortic aneurysms is essential for correct treatment but may be difficult, in these cases a history of infection supported by radiologic findings and aneurysm wall biopsy are of great value. Cryopreserved arterial homografts constitute a good alternative to prosthetic grafts for in situ reconstructions in the treatment of infected aortic aneurysms, decreasing the risk of re-infection or septic complications.
Article
Background: In situ treatment of artery/graft infection has distinct advantages compared to vessel excision and extra-anatomic bypass procedures. Based on animal studies of a rifampin-soaked, gelatin-impregnated polyester graft that demonstrated prolonged in vivo antibacterial activity, this antibiotic-bonded graft was used selectively in patients for in situ treatment of low-grade Gram-positive prosthetic graft infections or primary aortic infections not amenable to excision and ex situ bypass. Methods: In a 5-year period (1995-1999), 27 patients with prosthetic graft infection (aortofemoral, n = 18, femorofemoral, n = 3; axillofemoral, n = 1) or primary aortic infection (mycotic aneurysm, n = 3; infected AAA, n = 2) underwent excision of the infected vessel and in situ replacement with a rifampin soaked (45-60 mg/ml for 15 min) gelatin-impregnated polyester graft. All prosthetic graft infections were low grade in nature, caused Gram-positive bacteria (Staphylococcus epidermidis, 16; Staphylococcus aureus, 5; Streptococcus, 1), and were treated electively. Patients with mycotic aortic aneurysm presented with sepsis and underwent urgent or emergent surgery. Results: Two (8%) patients died-1 as a result of a ruptured Salmonella mycotic aortic aneurysm and the other from methicillin-resistant S. aureus infection following deep vein replacement of an in situ replaced femorofemoral graft. No amputations or late deaths as the result of vascular infection occurred in the 25 surviving patients. Two patients developed recurrent infection caused by a rifampin-resistant S. epidermidis in a replaced aortofemoral graft limb and were successfully treated with graft excision and in situ autogenous vein replacement. Eighteen patients remain alive and clinically free of infection after a mean follow-up interval of 17 months. Conclusions: In situ replacement treatment using a rifampin-bonded prosthetic graft for low-grade staphylococcal arterial infection was safe, durable, and associated with eradication of clinical signs of infection. Failure of this therapy was the result of virulent and antibiotic-resistant bacterial strains.
Article
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. 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. 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. 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.
Article
Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.
Article
The first isolation methods for the detection of Listeria spp. were generally based on the direct culture of samples on simple agar media, but isolation of the pathogenic Listeria monocytogenes was difficult. In time, new techniques were developed, based on a variety of selective and elective agents in isolation and enrichment media, which gained better and quicker results. Current reference methods allow the recovery of L. monocytogenes from a variety of foods with relative ease. However, more comparative studies are needed to select one horizontal method. It is suggested that the procedure of the International Organization for Standardization is a good base for such comparisons.
Article
In this prospective study we analyzed the immediate and midterm outcome in patients with abdominal aorta infection (mycotic aneurysm, prosthetic graft infection) managed by excision of the aneurysm or the infected vascular prosthesis and in situ replacement with a silver-coated polyester prosthesis. From January 2000 to December 2001, 27 consecutive patients (25 men, 2 women; mean age, 69 years) with an abdominal aortic infection were entered in the study at seven participating centers. Infection was managed with either total (n = 18) or partial (n = 6) excision of the infected aorta and in situ reconstruction with an InterGard Silver (IGS) collagen and silver acetate-coated polyester graft. Assessment of outcome was based on survival, limb salvage, persistent or recurrent infection, and prosthetic graft patency. Twenty-four patients had prosthetic graft infections, graft-duodenal fistula in 12 and graft-colonic fistula in 1; and the remaining 3 patients had primary aortic infections. Most organisms cultured were of low virulence. The IGS prosthesis was placed emergently in 11 patients (41%). Mean follow-up was 16.5 months (range, 3-30 months). Perioperative mortality was 15%; all four patients who died had a prosthetic graft infection. Actuarial survival at 24 months was 85%. No major amputations were noted in this series. Recurrent infection developed in only one patient (3.7%). Postoperative antibiotic therapy did not exceed 3 months, except in one patient. No incidence of prosthetic graft thrombosis was noted during follow-up. Preliminary results in this small series demonstrate favorable outcome with IGS grafts used to treat infection in abdominal aortic grafts and aneurysms caused by organisms with low virulence. Larger series and longer follow-up will be required to compare the role of IGS grafts with other treatment options in infected fields.
Article
Q fever may lead to serious complications in chronically infected patients. We report two cases of psoas abscess due to Coxiella burnetii associated with lumbar osteomyelitis secondary to an aortic aneurysmal infection. Diagnosis was based on serology, and PCR detected C. burnetii DNA in an abscess sample.
Article
Campylobacter fetus subspecies fetus is an opportunist Gram-negative bacillus, which is known to be a cause of systemic infections, mainly in immunocompromised patients. We report a C. fetus bacteremia and cellulitis complicating a venous access port infection in a patient with acquired immunodeficiency syndrome (AIDS). This bacillus seems to have a predilection for the vascular endothelium and its isolation is difficult. Physicians should be aware of C. fetus infection in patients with vascular devices. Microbiologists should accurately isolate this organism from clinical specimens by modifying incubation techniques and performing molecular biology. The prognosis seems to be improved by a prolonged betalactam antibiotic regimen, especially amoxicilline plus clavulanic acid. In HIV infected patients, quinolones that were successful in our case, should be used with caution because of increasing resistance to antibiotics.
Article
Pathology of infected aortic aneurysm and its clinical correlation have rarely been reported. Between 1995 and 2005, 48 patients with infected aortic aneurysm underwent in situ graft replacement. Twenty-five patients had a suprarenal and 23 patients had an infrarenal infection. The most common responsible pathogen was nontyphoid Salmonella in 32 patients (67%). During operation, gross pus was present in 26 patients (54%). On pathological examination, aortic atherosclerosis was present in all cases, acute suppurative inflammation was present in 31 patients (65%), and bacterial clumps were present in five patients (10%). Positive culture of the aneurysm wall was present in 14 patients (29%). There were 10 patients with prosthetic graft infection (21%) and 12 patients with aneurysm-related death (25%). Although statistically insignificant, local purulent infection with positive culture of the aneurysm wall, gross pus during operation, or acute suppurative inflammation on pathology tended to be associated with high risk of prosthetic graft infection and aneurysm-related death. In conclusion, infected aortic aneurysm occurred in patients with aortic atherosclerosis. On pathology, acute suppurative inflammation was present in the majority of cases but bacterial clumps were not commonly present. Local purulent infection tended to be associated with high risk of prosthetic graft infection and aneurysm-related death.
Article
Mycotic aortic aneurysm caused by Klebsiella pneumoniae (K. pneumoniae) is extremely rare and 3 cases of K. pneumoniae-induced mycotic aortic aneurysm are present, 2 of which were located in the aortic arch and the other in the suprarenal abdominal aorta. Urgent surgery was performed for 2 cases because of impending aneurysmal rupture and progressive septic shock, whereas elective surgery was performed after radical antibiotic chemotherapy for the other case. In-situ reconstruction with rifampicin-bonded prosthetic grafts was performed, and no infective complications have occurred in any of the cases.
Article
Surgical treatment for mycotic aortic aneurysms is not optimal. Even with a large excision, extensive debridement, in situ or extra-anatomical reconstruction, and with or without lifelong antibiotic treatment, mycotic aneurysms still carry very high mortality and morbidity. The use of endovascular aneurysm repair (EVAR) for mycotic aortic aneurysms simplifies the procedure and provides a good alternative for this critical condition. However, the question remains: if EVAR is placed in an infected bed, what is the outcome of the infection? Does it heal, become aggravated, or even cause a disastrous aortic rupture? In this study, we tried to clarify the risk factors for such an adverse response. A literature review was undertaken by using MEDLINE. All relevant reports on endoluminal management of mycotic aortic aneurysms were included. Logistic regressions were applied to identify predictors of persistent infection. A total of 48 cases from 22 reports were included. The life-table analysis showed that the 30-day survival rate was 89.6% +/- 4.4%, and the 2-year survival rate was 82.2% +/- 5.8%. By univariate analysis, age 65 years or older, rupture of the aneurysm (including those with aortoenteric fistula and aortobronchial fistula), and fever at the time of operation were identified as significant predictors of persistent infection, and preoperative use of antibiotics for longer than 1 week and an adjunct procedure combined with EVAR were identified as significant protective factors for persistent infection. However, by multivariate logistic regression analysis, the only significant independent predictors identified were rupture of aneurysm and fever. EVAR seems a possible alternative method for treating mycotic aortic aneurysms. Identification of the risk factors for persistent infection may help to decrease surgical morbidity and mortality. EVAR could be used as a temporary measure; however, a definite surgical treatment should be considered for patients present with aneurysm rupture or fever.
Article
Infected aneurysm of the thoracic aorta is rare and can be fatal without surgical treatment. We review our experience with 32 patients during a 12-year period. Retrospective chart review. Between 1995 and 2007, 32 patients (24 men, 8 women) with infected aneurysms of thoracic aorta were treated at our hospital. Their median age was 74 years (range, 50-88 years). Of the 28 pathogens isolated, the most common responsible microorganism was nontyphoid Salmonella in 16 (57%), followed by Staphylococcus aureus in four (14%) and Mycobacterium tuberculosis in three (11%). The site of infection was the aortic arch in 13 patients, proximal descending thoracic aorta in 10, and distal descending thoracic aorta in 9. Seven patients had medical treatment alone, and 25 patients underwent in situ graft replacement. The hospital mortality rate of medical treatment alone was 57%, and the hospital mortality rate of in situ grafting was 12%. Of the 22 operated-on survivors, there were 11 late deaths, four of which were aneurysm-related. The aneurysm-related mortality rate in operated-on patients was 28%. Of 16 patients with infection caused by nontyphoid Salmonella, 13 patients underwent in situ grafting, with a hospital mortality rate of 8% and aneurysm-related mortality rate of 31%. Infected aneurysm of the thoracic aorta was uncommon. The clinical results of in situ grafting were improving. Nontyphoid Salmonella was the most common responsible microorganism, and the prognosis of infection caused by Salmonella was not dismal. Outcomes of other management strategies, such as endovascular stenting, need to be compared with these results.
Infections à Campylobacter. Encyclopédie Médico Chirurgicale.
  • Cabie A.
  • Bouchaud O.
  • Coulaud J.P.
Cabie A, Bouchaud O, Coulaud JP. Infections à Campylobacter. Encyclopédie Médico Chirurgicale. Paris: Elsevier; 1996.
Campylobacter fetus bacteremia and cellulitis complicating a venous access port infection in an HIV infected patient
  • C Rapp
  • P Imbert
  • R Fabre
  • J D Cavallo
  • T Debord
Rapp C, Imbert P, Fabre R, Cavallo JD, Debord T. Campylobacter fetus bacteremia and cellulitis complicating a venous access port infection in an HIV infected patient. Med Mal Infect 2007;37:284e6.