Endovascular stent-graft repair of a tuberculous mycotic aortic aneurysm

Endovascular treatment of a tuberculous aneurysm of the pararenal abdominal aorta leading to an aortoduodenal fistula

This case report describes the presentation of a 79-year-old woman with no significant past medical history diagnosed with a saccular aneurysm with an aortoduodenal fistula. An emergency endovascular aneurysm repair was performed. Although the postoperative course was uneventful, 10 months after endovascular aneurysm repair, the patient died of miliary tuberculosis from mycotic aneurysms. Mycotic aneurysms are uncommon, and mycotic aneurysms caused by Mycobacterium tuberculosis are even rarer. Therefore, we believe our study makes a significant contribution to the literature given the rarity of the condition and suggests the importance of maintaining a high index of suspicion for tuberculosis as a possible cause of aortoduodenal fistula in primary mycotic aneurysm.

Tuberculosis and the Heart

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.

Miliary tuberculosis in a patient with tuberculous mycotic aneurysm of the abdominal aorta: Case report and review of the literature

The combination of miliary tuberculosis and tuberculous mycotic aneurysm has been described in the literature. We present the case of an 84-year-old man who was diagnosed with a mycotic aneurysm of the abdominal aorta and an adjacent soft tissue mass, after a 3- month history of fever. The patient underwent endovascular restoration of the aneurysm and was treated with broad-spectrum antibiotics. One and a half months later the fever relapsed and the chest CT scan revealed findings consistent with miliary tuberculosis and opacities of both upper lobes not present before, while the abdominal CT scan revealed an increase in the size of the para-aortic mass. Tuberculosis was documented by positive culture for M. tuberculosis of bronchial washing and by the CT-guided para-aortic mass biopsy. The patient received anti-TB treatment for 9 months leading to a spectacular improvement of his clinical condition and imaging findings. A review of the literature since 2008 revealed 28 more cases of tuberculous mycotic aneurysm. The treatment and outcome of all cases are described. Mycotic aneurysm of tuberculous etiology remains a reality and has a relatively good prognosis. Although miliary tuberculosis affects mortality even elderly patients may benefit from "aggressive" management and treatment.

Single-center experience in the endovascular management of isolated iliac artery aneurysm

BACKGROUND

Isolated iliac artery aneurysms (IAA) are relatively uncommon and represent 2-7% of all intra-abdominal aneurysms. Surgery is the gold standard treatment for IAA. However, endovascular stent-graft placement is gaining acceptance as an alternative to surgery especially in patients with high surgical risk.

PURPOSE

To evaluate the effectiveness and safety of endovascular management of isolated IAA having various anatomic and pathologic bases.

MATERIAL AND METHODS

Between 2008 and 2011, 31 patients who underwent endovascular treatment for isolated IAA were retrospectively analyzed. The mean aneurysm size was 43 mm (range, 30-71 mm). The age ranged from 37 to 87 years (mean, 70.0 years). Isolated IAAs were treated in one of three different ways: (i) infrarenal aortic stent-graft placement with limb extension; (ii) stent-graft placement for isolated iliac artery coverage; and (iii) embolization with a coil and a vascular plug combined with femoral-femoral bypass grafting. All patients were assessed by contrast-enhanced computed tomography (CT). The mean follow-up period was 25.1 months (range, 1-60 months).

RESULTS

Common iliac artery involvement was seen in 28 patients. Ten (35.7%) of those patients also had an internal IAA. Three patients had an isolated internal IAA. Infrarenal stent-graft placement was performed in 25 patients. Stent-graft placement for coverage of the only iliac artery was performed in five patients. One patient, who had a mycotic aneurysm of the right common iliac artery underwent coil embolization of the ipsilateral common iliac artery with concurrent femoral-femoral bypass graft. Five of the 31 patients (16.1%) with stent grafts had type II endoleaks at the time of the last imaging study, one of those patients underwent percutaneous embolization with glue. None of the patients showed major procedure-related complications.

CONCLUSION

Percutaneous management of IAA is effective and safe with various techniques depending on the anatomical and pathologic features of the isolated IAA.

Stent graft exclusion of a ruptured mycotic popliteal pseudoaneurysm complicating sternoclavicular joint infection

A mycotic pseudoaneurysm of the popliteal artery is usually a consequence of septic embolization and often a result of bacterial endocarditis. Conventional treatment is surgical and avoids the placement of foreign material in infected sites. Here we report our treatment of a 59-year-old man who presented with a rupture of a mycotic pseudoaneurysm of the popliteal artery due to septic embolism from sternoclavicular infectious arthritis. Radiological investigations are included. This is the first documented case of septic arthritis complicated by a rupture of a mycotic popliteal false aneurysm and treated using an endovascular procedure. Combining endovascular stent grafts with evacuation of the joint abscess and antibiotic therapy can offer a safe alternative for frail and unstable patients.