Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 111-113

Endovascular aortic repair of mycotic abdominal aortic aneurysm with multiple systemic abscesses


Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Isesaki, Gunma, Japan

Date of Submission27-Aug-2021
Date of Acceptance03-Sep-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Takao Miki
Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Isesaki, Gunma
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_91_21

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  Abstract 


Mycotic abdominal aortic aneurysms (MAAAs) are rare, but severe aortic infection and subsequently infected aortic aneurysms can cause a lethal condition. The gold standard for treatment is resection, infected tissue debridement, and graft replacement. Despite meticulous surgical planning, the mortality rate after open surgical repair can reach 40%. Endovascular aortic repair (EVAR) is another treatment option because of its simplicity and low invasiveness. We report a case of symptomatic MAAA successfully treated with EVAR and antibiotic therapy. EVAR is valuable for postoperative physical recovery. Here, the endovascular approach was feasible, and an acceptable outcome could be obtained.

Keywords: Endovascular aortic repair, multiple systemic abscesses, mycotic abdominal aortic aneurysm


How to cite this article:
Miki T, Ohki S, Yasuhara K, Obayashi T. Endovascular aortic repair of mycotic abdominal aortic aneurysm with multiple systemic abscesses. Indian J Vasc Endovasc Surg 2022;9:111-3

How to cite this URL:
Miki T, Ohki S, Yasuhara K, Obayashi T. Endovascular aortic repair of mycotic abdominal aortic aneurysm with multiple systemic abscesses. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:111-3. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/111/340515




  Introduction Top


Mycotic abdominal aortic aneurysms (MAAAs) are rare,[1],[2] and the treatment of this fatal disease involves surgery and antibiotic therapy.[2] Conventional open repair, which includes the removal of aneurysms, blood flow reconstruction with anatomical or extra-anatomical routes, and debridement of infected periaortic tissues, is the gold standard, although it is associated with considerable morbidity and mortality.[1],[2],[3] EVAR has the substantial benefit of rapid aneurysmal exclusion, resulting in the prevention of rupture without a large incision and significant hemodynamic instability.[2],[3] We report a case of symptomatic saccular MAAA in a 63-year-old male with multiple systemic abscesses successfully treated with EVAR and antibiotic therapy.


  Case Report Top


A 63-year-old male consulted a hospital about right buttock pain and a high fever. Computed tomography (CT) revealed a large abscess in the right buttock and a saccular, infrarenal abdominal aortic aneurysm with a diameter of 21 mm. Because his CT scan 4 days after drainage indicated that the size of the aneurysm increased up to 35 mm in diameter [Figure 1]a, he was transferred to our hospital. On admission to our hospital, he had a high fever (38.7°C) with general weakness. Laboratory data showed an elevated white blood cell (WBC) count of 16,600/μL and a high C-reactive protein (CRP) level of 14.7 mg/dL. His serum albumin level was extremely decreased down to 1.3 g/dL. His blood culture was positive for methicillin-sensitive Staphylococcus aureus. The patient had multiple systemic abscesses (in the left sternoclavicular joint, dorsum of the left hand and foot, left ankle) with the same bacteria found in his blood culture. Consequently, he was diagnosed with MAAA. He was in a stable condition with only medical treatment of an intravenous administration of meropenem at a dose of 1 g every 8 h. However, he suddenly experienced excruciating abdominal back pain the day after hospitalization. Enhanced CT revealed an increase in the size of up to 42 mm in diameter [Figure 1]b and [Figure 1]c. We assessed the aneurysm as an impending rupture, and emergency surgical treatment was required. Considering the significant malnutrition, we decided to treat him with EVAR. Surgery under general anesthesia was performed immediately. According to his latest CT scan, the entry of the saccular MAAA could be completely closed with a straight leg stent graft with only one piece. Thus, we used the Excluder® (W. L. Gore and Associates, Flagstaff, AZ, USA) iliac extender. First, a 12 Fr sheath was placed at the right common femoral artery exposed by surgical cutdown. Then, a 4 Fr sheath was inserted at the left common femoral artery by percutaneous puncture, and a pigtail catheter was advanced through this sheath. Initial aortography using this catheter revealed that the entry of the MAAA cavity was located 55 mm below the lower-left renal artery and 20 mm above the aortic terminal [Figure 2]a. Then, the excluder iliac extender (PLL161407J) was delivered via the 12 Fr sheath. The pigtail catheter was placed in the cavity of the MAAA, followed by the deployment of the device with accurate adjustment of the bottom of the stent graft edge to the aortic terminal. After the injection of 1 g of dissolved vancomycin into the aneurysmal cavity via the pigtail catheter and the catheter's removal, a balloon touch-up was made. Completion angiography showed no endoleaks [Figure 2]b. The patient's postoperative course was uneventful with the disappearance of abdominal back pain and the improvement of laboratory data. An enhanced CT scan 5 days after surgery demonstrated that the MAAA was completely excluded and decreased in size [Figure 3]a. Antibiotic therapy was converted into the oral intake of rifampicin at a dose of 150 mg every 8 h and linezolid at a dose of 600 mg every 12 h. He was discharged on postoperative day 56, and he took oral antibiotic medication for half a year. No signs of recurrent infection or aneurysmal dilatation were observed for 3 years after EVAR [Figure 3]b.
Figure 1: The enhanced CT showed a saccular, infrarenal abdominal aortic aneurysm (a). Follow-up CT performed on the day after hospitalization revealed an increase in the size up to 42 mm in diameter (b and c). CT: Computed tomography

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Figure 2: The initial aortography indicated that the entry of the MAAA cavity existed 55 mm below the lower left renal artery and 20 mm above the aortic terminal (a). The completion angiography showed no endoleaks (b). MAAA: Mycotic abdominal aortic aneurysms

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Figure 3: The enhanced CT 5 days after surgery demonstrated that the MAAA was completely excluded and decreased in size (a). No signs of recurrent infection or aneurysmal dilatation were observed on follow-up CT scans for three years after the EVAR (b). CT: Computed tomography, MAAA: Mycotic abdominal aortic aneurysms, EVAR: Endovascular aortic repair

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  Discussion Top


MAAAs are rare but potentially fatal.[1],[2],[3],[4],[5] The incidence is estimated to be 0.65%–2% of all aortic aneurysms.[1] The treatment of MAAAs involves surgery and antibiotic therapy.[2] In terms of surgical management, open repair has long been regarded as the gold standard. However, over the last decade, EVAR has become widely accepted as a possible treatment option.[1],[2],[3],[4],[5] EVAR has an apparent advantage of rapid exclusion of the aneurysmal cavity and prevention of rupture, leading to significant hemodynamic stability without a large incision,[1],[2],[3] although it has a risk of difficulty in controlling the infection owing to the unresected infected aneurysmal sac and surrounding tissues remaining even after surgery.[1],[2] Moreover, MAAAs often causes general weakness, as in our case, which delays postoperative recovery and wound healing. From this point of view, EVAR, which requires minimum skin incision and blood transfer, has the potential to provide rapid physical improvement because it is less invasive. Moreover, the patient in our case had multiple abscesses, which could induce surgical site infection. Thus, we considered EVAR with a minimum surgical incision as appropriate in this case. Fortunately, because MAAA, in this case, had anatomically sufficient proximal and distal sealing length in the infrarenal abdominal aorta, only one piece of limb stent graft was needed for complete aneurysm exclusion. This was helpful for aortic clamping during open conversion. Quan et al. and Carlo et al. reported that EVAR should be considered as a bridging procedure to allow future definitive surgical treatment in some cases.[2],[4] It is important to contemplate a treatment plan including EVAR in anticipation of further possible open management.

As mentioned above, EVAR for the treatment of MAAAs has considerable usefulness. However, it still has a significant concern regarding the placement of a foreign body in an infected bed.[4],[5] This issue has been discussed in some reports. Luo et al. reported that preventing persistent infection, which leads to premature death due to fatal infectious complications, was the key to successful endovascular treatment of MAAAs,[1] and Quan et al. advocated that it might be important to start with preoperative, preferably broad-spectrum, antibiotic treatment.[2] In our case, the patient started intravenous administration of broad-spectrum antibiotics, and the oral antibiotic therapy was continued for half a year. In addition, we injected the dissolved vancomycin into the aneurysm cavity in operation, which we thought could be curable for the infected aneurysm wall and surrounding tissues. There is no remarkable proof to date that this procedure of antibiotic fluid injection into the excluded cavity of MAAAs is effective in the control of infection after EVAR. However, as a result, the patient healed completely with his laboratory data of WBC and CRP within normal limits and the disappearance of MAAA on CT scan. Because of the considerable risk of recurrence of infection and late aneurysm-related events, lifelong follow-up is important for improving the outcome of EVAR for patients with MAAAs.[1],[2],[3],[4],[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luo CM, Chan CY, Chen YS, Wang SS, Chi NH, Wu IH. Long-term outcome of endovascular treatment for mycotic aortic aneurysm. Eur J Vasc Endovasc Surg 2017;54:464-71.  Back to cited text no. 1
    
2.
Dang Q, Statius van Eps RG, Wever JJ, Veger HT; Dutch Society of Vascular Surgery, the Steering Committee of the Dutch Surgical Aneurysm Audit, and the Dutch Institute for Clinical Auditing. Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair in The Netherlands. J Vasc Surg 2020;72:531-40.  Back to cited text no. 2
    
3.
Sörelius K, Wanhainen A, Furebring M, Björck M, Gillgren P, Mani K, et al. Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair. Circulation 2016;134:1822-32.  Back to cited text no. 3
    
4.
Setacci C, de Donato G, Setacci F. Endografts for the treatment of aortic infection. Semin Vasc Surg 2011;24:242-9.  Back to cited text no. 4
    
5.
Razavi MK, Razavi MD. Stent-graft treatment of mycotic aneurysms: A review of the current literature. J Vasc Interv Radiol 2008;19:S51-6.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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