|Year : 2015 | Volume
| Issue : 1 | Page : 38-40
Mycotic Aneurysm: Case Series
Albert Abhinay Kota, Indrani Sen, Andrew Dheepak Selvaraj, Prabhu Premkumar, Sam Ponraj, Sunil Agarwal
Department of Vascular Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India
|Date of Web Publication||5-Mar-2015|
Dr. Albert Abhinay Kota
Department of Vascular Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Mycotic aneurysms are rare and usually occur secondary to embolization of septic foci. Early diagnosis is the crucial. They have high risk of rupture/complications and can pose a difficult management challenge especially in an acute setting. We describe the management of four patients with mycotic aneurysms in our case series.
Keywords: Endovascular treatment, infected aneurysm, mycotic aneurysm, surgical treatment
|How to cite this article:|
Kota AA, Sen I, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Mycotic Aneurysm: Case Series. Indian J Vasc Endovasc Surg 2015;2:38-40
| Background|| |
Infected aneurysms are classified into four categories based on their etiology. They include mycotic aneurysm, microbial arteritis, infected preexisting aneurysms and posttraumatic infected false aneurysms. 
| Case Report|| |
- Case 1: A 43-year-old male with alcohol-related decompensated chronic liver disease (Child Turcotte Pugh (CTP) class-C) underwent injection sclerotherapy and banding of the bleeding varices in 2010 and transjugular intrahepatic portosystemic shunt in 2011. In January 2014, he presented with worsening back pain and pulsatile mass around he umbilicus. On imaging, there was a 7 cm lobulated fusiform aneurysm of the infrarenal aorta with scalloping of the anterior L4 vertebral body [Figure 1]. Inflammatory markers like erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were elevated; however, the blood cultures were sterile. Trans-thoracic and trans-esophageal echocardiograms were normal. The options of open repair and endovascular treatment were discussed with the patient and treating hepatologist. He underwent endovascular aneurysm repair. At review, he was stable and doing well
- Case 2: A 45-year-old lady presented with fever, pain, pulsatile left thigh mass [Figure 2] with absent distal pulses. She had history of fever. She was diagnosed to have left superficial femoral artery (SFA) aneurysm with necrotizing soft tissue infection of the thigh and underwent emergency debridement, resection of the mycotic aneurysm and SFA to popliteal artery bypass using reversed saphenous graft [Figure 2]. Her postoperative period was uneventful. Culture grew beta-hemolytic Group A streptococcus
- Case 3: A 26-year-old male with infective endocarditis (Enterococcus on blood culture) was referred from a physician with lower abdominal pain. Evaluation revealed saccular left internal iliac mycotic aneurysm. He underwent percutaneous transluminal covered stenting of the aneurysm [Figure 3]. At review, he was asymptomatic
- Case 4: A 71-year-old male presented with severe low back pain with recurrent episodes of urinary tract infection. He was diagnosed to have infrarenal saccular mycotic aneurysm, underwent debridement of the infected aorta and open aneurysm repair using 14 mm tube Dacron graft. Culturew grew Enterococcus. Postoperatively, he developed ventilator-associated pneumonia, renal failure, pulmonary oedema and succumbed to multiorgan dysfunction on the 15 th postoperative day [Figure 4].
| Introduction|| |
Sir William Osler observed "fresh fungal vegetations" in infective endocarditis and introduced the term "mycotic aneurysm."  It is however a misnomer as the infected arterial aneurysm is commonly bacterial in origin. Mycotic aneurysms may be classified into primary or secondary. Primary is aneurysmal degeneration due to primary infective aortitis, and secondary is presence of preexisting aneurysm with secondary infection of the aneurysm wall due to septic embolization. Mycotic aneurysms have an incidence of 1-2% of all aortic aneurysms. ,,
| Discussion|| |
Etiology and risk factors
In the preantibiotic era, "syphilitic aortitis" was quite commonly seen. However, with the advent of increasing interventional arterial procedures and intravenous (IV) drug abuse, Gram-positive organisms like Staphylococcus and Streptococcus are often seen. In Asia, Salmonella is found to be the common etiological organism. Other rare organisms like Propionibacterium, Pseudomonas, Micrococcus, Candida, Aspergillus are also reported. ,,,,, In our series organisms isolated on cultures were Enterococci, Streptococci and one patient was culture negative.
The risk factors include interventional vascular procedures, infective endocarditis, immunosuppression, prior infections (lung, intra-abdominal sepsis, soft tissue and bone infections), IV drug abuse and preexisting aneurysms. ,,,,,
Clinical presentation and diagnosis
It is a rare but life-threatening condition. In the initial phase, the symptoms are usually nonspecific and include general malaise, fever. Symptoms like backache, abdominal pain, haemoptysis, neuropathy, sudden hypotensive shock, can be secondary to complications. ,,,,,,
Diagnosis is often clinical (past history of sepsis, interventions, fever, sudden increase in size of preexisting aneurysm) aided with increased inflammatory markers (ESR, CRP), positive microbiological cultures (negative blood cultures do not exclude mycotic aneurysm) and radiological evidence (saccular, eccentric and multilobulated with periaortic gas/fluid/inflammation). ,,
The cornerstone of management is having a high index of clinical suspicion and diagnosis. The options of management include open and endovascular with long-term antibiotics.
Open repair is the best option. Goals of surgical treatment include debridement of infected tissues (confirms the diagnosis and for sepsis control), resection of involved segment and reconstruction. If there is no gross perivascular infection in situ reconstruction using autogenous venous grafts, prosthetic grafts, cryopreserved allografts have been described. If there are gross periaortic infected tissues, extra-anatomic bypass has been advocated. Ligation, debridement without revascularization has also been done in few instances. The distal aortic stump is always closed in two layers and reinforced with omental pedicle as there is high risk for stump blowout. The use of long-term antibiotics is advocated ranging from 6 weeks to life long. ,,,,
Endovascular treatment option is also viable especially in setting when surgical risk is very high and has the advantage of being minimally invasive. It is advocated as the primary option but can also be used as a bridge therapy followed by definite open repair, as there is potential for the endo-graft to get secondarily infected and recurrent sepsis. The long-term benefits of primary endovascular therapy are not known. ,,,,,,
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]