Direct replacement of mycotic thoracoabdominal aneurysms

Necrotizing Fasciitis Secondary to Mycotic Femoral Aneurysm: A Narrative Review of Diagnosis and Management Strategies

This comprehensive literature review aims to investigate the pathophysiology, clinical manifestations, diagnostic tools, and treatment options for necrotizing fasciitis secondary to mycotic femoral aneurysm, a rare and potentially lethal infectious disease, particularly focusing on any changes throughout the years for an update of the current literature. The pathophysiology of necrotizing fasciitis and mycotic femoral aneurysms is a complex and multifaceted process that typically involves bacterial infections as a common precursor to the onset of these conditions. This can potentially lead to the formation of an aneurysm. As the infection progresses, it can spread from the aneurysm to surrounding soft tissues, resulting in significant tissue damage, obstructed blood circulation, and ultimately culminating in cell death and necrosis. Clinical manifestations of these conditions are diverse and encompass a range of symptoms, such as fever, localized pain, inflammation, skin changes, and other indicators. It is worth noting that skin color can influence the presentation of these conditions, and in patients with diverse skin tones, certain symptoms may be less noticeable due to a lack of visible discoloration. Imaging, laboratory findings, and clinical presentation are important components of the diagnosis of mycotic aneurysms. CT scans are a reliable tool for identifying specific features of infected femoral aneurysms, and elevated inflammatory laboratory results can also suggest a mycotic aneurysm. In the case of necrotizing fasciitis, clinicians should maintain a high level of suspicion as this condition is rare but life-threatening. Clinicians will need to view the big picture when an infection may be caused by necrotizing fasciitis, considering CT imaging, blood work, and clinical presentation of the patient without delaying surgical intervention. By incorporating the diagnostic tools and treatment options outlined in this review, healthcare professionals can improve patient outcomes and reduce the burden of this rare and potentially lethal infectious disease.

Emphysematous aortic arch aneurysm infected with Salmonella: A case report

Infected aortic aneurysm is a relatively rare disease that is extremely difficult to manage, resulting in a poor prognosis. We rescued a patient with Salmonella-infected aortic arch aneurysm surrounded with a specific and massive emphysema, despite experiencing aortic rupture, including delayed esophageal perforation after surgery.

Inflammatory and infectious aortic diseases

Aortitis is aortic inflammation, which can be due to inflammatory or infectious diseases. Left undiagnosed, aortitis can lead to aneurysm formation and rupture, in addition to ischemic compromise of major organs. Infectious aortic diseases include mycotic aneurysm and graft infection; the most common inflammatory diseases are Takayasu's and giant cell arteritis. We review the epidemiology, etiology, presentation and diagnosis, and treatment of these entities.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

BACKGROUND

Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates.

CASE PRESENTATION

A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death.

CONCLUSIONS

In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Surgical Treatment of Infected Aortoiliac Aneurysm

Purpose:

Infected aneurysms of the abdominal aorta or iliac artery (IAAA) are rare but fatal and difficult to treat. The purpose of this study was to review the clinical presentations and outcomes of IAAA and to establish a treatment strategy for optimal treatment of IAAA.

Materials and Methods:

Electronic medical records of 13 patients treated for IAAA at Seoul National University Hospital between March 2004 and December 2012 were retrospectively reviewed.

Results:

Mean age was 64.2 (median 70, range 20–79) years. Aneurysms were located in the infrarenal aorta (n=7), iliac arteries (n=5), and suprarenal aorta (n=1). Seven patients underwent excision and in situ interposition graft, 3 underwent extra-anatomical bypass, and 1 underwent endovascular repair. One patient with endovascular repair in an outside hospital refused resection, and only debridement was done, which revealed tuberculosis infection. One staphylococcal infection was caused by iliac stenting. Mycobacterium was the most common pathogen, followed by Klebsiella, Salmonella, and Staphylococcus. There were 3 in-hospital mortalities and the causes were sepsis in 2 and aneurysm rupture in 1. The 3 extra-anatomic bypasses were all patent after 5-year follow-up.

Conclusion:

IAAA develops from various causes and various organisms. IAAA cases with gross pus were treated with extra-anatomic bypass, which was durable. In situ reconstruction is favorable for long term-safety and efficacy, but extensive debridement is essential.

Mycotic pseudoaneurysm of the brachiocephalic artery

A 73-year-old woman with a history of hypertension and hyperlipidemia presented with a sharp pain ranging from the right shoulder to the upper limb. She had suffered a sharp pain at rest accompanied by general fatigue and nausea for about ten months prior to admission. Her white blood cell count was 12,800/microl, and her serum C-reactive protein was 17.5 mg/dl. A chest computed tomography scan revealed an aneurysmal change of the origin of the brachiocephalic artery. Pseudoaneurysm due to infection and aortic dissection was considered as a preoperative diagnosis. A total arch replacement was performed under cardiopulmonary bypass, deep hypothermia, and selective cerebral perfusion. Postoperatively, a bacteriologic culture of the contents of the aneurysm revealed Staphylococcus aureus. Perioperative administration of antibiotics was effective and the postoperative course was uneventful.

Mycotic aneurysm of the descending thoracic aorta caused by Pseudomonas aeruginosa in a solid organ transplant recipient: case report and review

BACKGROUND

Pseudomonas aeruginosa is a rare cause of aortic mycotic aneurysms. Optimal treatment, including reconstructive graft material and appropriate length of antibiotic therapy, is being debated.

METHODS

We describe a 26-year-old kidney-pancreas recipient who developed an aneurysm of the descending thoracic aorta caused by P. aeruginosa.

RESULTS

After surgical debridement and cryopreserved allograft reconstruction, parenteral antibiotics were continued for 12 months, at which time the patient was converted to oral antibiotic therapy. Within 6 months, he redeveloped a thoracic aortic aneurysm, necessitating reoperation and lifelong parenteral antibiotic therapy.

CONCLUSION

Herein we review and discuss the relevant literature concerning surgical and antibiotic treatment of mycotic thoracic aneurysms.

Bilateral splenorenal bypass and axillofemoral graft for management of juxtarenal mycotic aneurysm

The principles of treatment of mycotic aortic aneurysms are not well established and the optimal method of revascularization--extra-anatomic bypass or in situ grafting--is still debated. Infection of the juxtarenal or suprarenal aorta poses an additional challenge in management because of the requirement for visceral revascularization. The case of a 73-year-old man is reported who developed several mycotic aneurysms of the juxtarenal, infrarenal aorta and right main iliac artery following a Candida infection. He was successfully treated with suprarenal aortic ligation, aneurysmal excision, splenorenal bilateral bypass and systemic antifungal therapy. The patient subsequently underwent extra-anatomic revascularization of the lower extremities with a left axillobifermoral bypass involving a polytetrafluoroethylene graft.

Double clostridial mycotic aneurysms of the aorta

Mycotic aortic aneurysm continues to present challenging and difficult management issues with a significant morbidity and mortality. The offending organism in the etiology of this aneurysm can be variable and unusual. The first report of two mycotic aortic aneurysms caused by Clostridium septicum in the same patient is described here. Presentation and management as well as conditions commonly associated with Clostridium septicum infection and a review of all clostridial mycotic aortic aneurysms in the English literature are discussed.

Selective preservation of infected prosthetic arterial grafts. Analysis of a 20-year experience with 120 extracavitary-infected grafts

OBJECTIVE

The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts.

METHODS

When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years).

RESULTS

This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases).

CONCLUSION

Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision.