Extra-Anatomic Management of Homograft Reinfection after Thoracic Aortic Rupture

Endovascular wall-grafting for mycotic common iliac pseudo-aneurysm: Systemic mycoses

Mycotic pseudoaneurysms of the iliac arteries are extremely rare and are caused by infection of the artery wall. It is difficult to diagnose early due to its silent manifestation. We present a case of a 64-year-old man with an isolated left common iliac artery pseudoaneurysm caused by Candida albicans who presented with thrombophlebitis, abdominal pain, nausea and vomiting associated with fever, which was successfully treated with interposition grafting and antibiotic therapy. We present this case to highlight that aneurysms and other vascular lesions can affect different arteries in the body and may therefore only be discovered during routine investigations of non-specific symptoms.

[Extra-anatomical bypass grafting of the thoracic aorta in a female patient with an infected pseudoaneurysm]

Presented herein is the remote (more than 15-year follow up) result of successful surgical treatment of aortic coarctation complicated by septic aortitis and a false aneurysm of the anastomosis between the graft and the aortic arch. In 2002, after correction of aortic coarctation the woman was admitted to our Clinic with an incompetent proximal anastomosis and an infected aortic pseudoaneurysm. Taking into consideration the general and local septic process, repeat reconstruction of the thoracic aorta was impossible due to the risk for generalization of the infectious process and fatal complications. Therefore, the woman was subjected to extra-anatomical bypass grafting of the thoracic aorta with a synthetic graft from the ascending aorta to the infrarenal portion of the abdominal aorta in order to isolate the infection focus to be followed by removal thereof. The postoperative period turned out uneventful, with no complications. After 15 years, the woman was examined again, with her condition being stable. The findings of contrast-enhanced magnetic resonance imaging demonstrated complete patency of the extra-anatomical bypass graft. The carotid-subclavian anastomosis functioned well, without narrowed portions. No infectious complications after the carried out operations were observed. Using extra-anatomical bypass grafting with exclusion from circulation and removal of the infected portion of the aorta along with the graft is one of reliable variants of treatment for such a severe complication as an infected false aneurysm.

Management options for aorto-oesophageal fistula: case histories and review of the literature

OBJECTIVE

An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica.

METHODS

Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity.

CONCLUSIONS

Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

The treatment of infectious aneurysms in the thoracic aorta; our experience in treating five consecutive patients

The surgical strategy for infected thoracic aortic aneurysms (ITAA) remains controversial. Effective antibiotic therapy is mandatory and surgical intervention is indicated only to prevent an aneurysmal rupture. In-situ reconstruction through an aseptic route is ideal; however, urgent surgery is often required in the uncontrolled infectious phase. Five patients were recently treated surgically for ITAA. They were all males with a mean age of 61.2 (range: 58-66) years. Two patients were operated on urgently in the active infectious phase due to impending aneurysmal rupture. A total arch reconstruction with an extra-anatomical bypass between the ascending aorta and both femoral arteries in one and an extended aortic arch resection with an in-situ graft reconstruction were performed in the other. The other three patients underwent in-situ graft reconstructions in the controlled infectious phase. Four patients had multiple aneurysms, including nine saccular or nodular aneurysms. Short-interval computed tomography (CT) re-examinations revealed a rapid enlargement of the aneurysms and confirmed the diagnosis. All patients successfully survived and are doing well without any evidence of a recurrent aortic infection. The surgical strategy for ITAA should be determined on a case-by-case basis under a careful follow-up with short-interval CT re-examinations.