A curious case of a spontaneous infective native pseudoaneurysm of the internal carotid artery

We present a case of a 77-year-old patient who presented with a stroke. She subsequently became unwell and was found to have a spontaneous infective native carotid artery pseudoaneurysm. The patient was managed conservatively as per her wishes. Despite the rarity of this clinical diagnosis, clinicians should be aware of the pathophysiology of this entity and the available literature on management.

Endovascular treatment of mycotic aneurysms: An update meta-analysis

INTRODUCTION

Intracranial mycotic or infectious aneurysms result from the infection of arterial walls, most caused by bacterial or fungal organisms. These infections can weaken the arterial wall, leading to the formation of an aneurysm, a localized dilation, or a bulge. The management can be conservative mainly based on antibiotics or invasive methods such as clipping or endovascular treatment.

PURPOSE

We performed a systematic review and meta-analysis of the current literature on endovascular treatment of mycotic aneurysms, analyzing the safety and efficacy associated with this procedure.

METHODS

We systematically searched on PUBMED, Cochrane Library, Embase, and Web of Science databases. Our search strategy was carefully crafted to conduct a thorough investigation of the topic, utilizing a comprehensive combination of relevant keywords. This meta-analysis included all studies that reported endovascular treatment of mycotic aneurysms. To minimize the risk of bias, studies with fewer than four patients, studies where the main outcome was not found, and studies with no clear differentiation between microsurgical and endovascular treatment were excluded.

RESULTS

In a comprehensive analysis of 134 patients, it was observed that all except one patient received antibiotics as part of their treatment. Among the patients, 56% (a total of 51 out of 90 patients) underwent cardiac surgery. Additionally, three patients required a craniotomy following endovascular treatment. 12 patients experienced morbidity related to the procedures performed, indicating complications arising from the interventions. Furthermore, four aneurysms experienced rebleeding while treatment. A pooled analysis of the endovascular treatment of the mycotic aneurysm revealed a good level of technical success, achieving a 100% success rate in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as illustrated in Fig. 2. Similarly, the aneurysm occlusion rate demonstrated a notable efficacy, with a success rate of 97% observed in 12 out of 14 studies (97-100%; CI 95%; I2 = 0%), as depicted in Fig. 3.

CONCLUSION

The results strongly support the efficacy of endovascular treatment in achieving technical success, complete aneurysm occlusion, and favorable neurological outcomes. Additionally, the notably low incidence of complications and procedure-related mortality reaffirms the safety and benefits associated with this intervention.

Fifteen-year, single-center experience with in situ reconstruction for infected native aortic aneurysms

OBJECTIVE

The purpose of the present study was to evaluate the survival and freedom from reinfection for patients with infected native aortic aneurysms (INAAs) treated with in situ revascularization (ISR), using either open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and to identify the predictors of outcome.

METHODS

Patients with INAAs who had undergone ISR from January 2005 to December 2020 were included in the present retrospective single-center study. The diagnosis of INAAs required a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging findings, and (4) intraoperative findings. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. The predictive factors for adverse outcomes were evaluated using the Mann-Whitney U test or the Fisher exact test and multivariate regression analysis.

RESULTS

A total of 65 patients (53 men [81.5%]; median age, 69.0 years; interquartile range, 61.5-75.0 years) were included, 31 (47.7%) were immunocompromised, 60 were symptomatic (92.3%), and 32 (49.2%) had presented with rupture, including 3 aortocaval fistulas (4.6%) and 12 aortoenteric fistulas (18.5%). The most common location was infrarenal (n = 39; 60.0%). Of the 65 patients, 55 (84.6%) had undergone primary OSR with ISR, 3 (4.6%) had required EVAR as a bridge to OSR, and 8 (12.3%) had undergone EVAR as definitive treatment. The approach was a midline laparotomy for 44 patients (67.7%), mostly followed by reconstruction and aortic-aortic bypass (n = 28; 40.6%) and the use of a silver and triclosan Dacron graft (n = 30; 43.5%). Causative organisms were identified in 55 patients (84.6%). The 30-day and in-hospital mortality rates were 6.2% (n = 4) and 10.8% (n = 7). The median follow-up was 33.5 months (interquartile range, 13.6-62.3 months). The estimated 1- and 5-year survival rates were 79.7% (95% confidence interval [CI], 67.6%-87.7%) and 67.4% (95% CI, 51.2%-79.3%). The corresponding freedom from reinfection rates were 92.5% (95% CI, 81.1%-97.1%) and 79.4% (95% CI, 59.1%-90.3%). On multivariate analysis, in-hospital mortality increased with uncontrolled sepsis (P < .0001), rapidly expanding aneurysms (P = .008), and fusiform aneurysms (P = .03). The incidence of reinfection increased with longer operating times (P = .009).

CONCLUSIONS

The selective use of ISR and OSR combined with targeted antimicrobial therapy functioned reasonably well in the treatment of INAAs, although larger, prospective, multicenter studies with appropriately powered comparative cohorts are necessary to confirm our findings and to determine the best vascular substitute and precise role of EVAR as a bridge to OSR or definitive treatment.

The Association of Spondylitis and Aortic Aneurysm Disease

OBJECTIVES

The aim of this study is to assess any relation between spondylitis and aortic aneurysmal disease by reviewing the current literature.

METHODS

A systematic search was undertaken using MEDLINE, EMBASE and CENTRAL databases till May 2019, for articles reporting on patients suffering from spondylitis and aortic aneurysm.

RESULTS

The most involved aortic segment was infrarenal aorta (56.9%). The lumbar vertebrae were more frequently affected (79.7%). Commonest symptoms were back pain (79.1%), fever (33.7%) and lower limb pain (29.1%). 55.8% of cases were diagnosed using computed tomography. The pathology was attributed to infectious causes in 25.1% of cases. 53.4% of patients were treated only for the aneurysm, 27.9% for both pathologies, while two patients solely for the vertebral disease. Endovascular aneurysm repair was chosen in 12.8% of cases. The 30-day mortality was 8.1% (7/86); mostly from vascular complications.

CONCLUSIONS

A synchronous spondylitis and aortic aneurysm may share common etiopathology, when an infectious or inflammatory cause is presented. The lumbar vertebrae are more frequently affected. Low quality data do not allow safe conclusion to suggest the best treatment option.

Hybrid operation for infectious thoracic and abdominal aortic aneurysms complicated with Bacillus Calmette-Guérin therapy for bladder cancer: A case report

RATIONAL

Bacillus Calmette-Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication.

PATIENT CONCERNS

A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months.

DIAGNOSIS

Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms.

INTERVENTIONS

Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed.

OUTCOMES

BCG "Tokyo-172" strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation.

LESSONS

A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.

18F-fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of native valve infective endocarditis: A prospective study

BACKGROUND

¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE).

AIMS

Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake).

METHODS

Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected.

RESULTS

Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P<0.001), without a change in specificity. Diffuse splenic uptake was observed in 39 (52.0%) patients, including 37 (58.7%) with a final diagnosis of NVE (specificity 83.3%).

CONCLUSIONS

¹⁸F-FDG PET/CT has poor sensitivity but high specificity in the diagnosis of NVE. The usefulness of ¹⁸F-FDG PET/CT is high for embolic detection. Diffuse splenic uptake represents a possible new diagnostic criterion for NVE.

An unusual ischaemic presentation of thrombosed intracranial mycotic aneurysm with subsequent subarachnoid haemorrhage

We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.

Mycotic aneurysm secondary to melioidosis in China: A series of eight cases and a review of literature

Burkholderia pseudomallei is the causative agent of melioidosis, endemic in Southeast Asia and Northern Australia, and increasingly recognized in southern China, especially in Hainan Province. Mycotic aneurysm caused by B. pseudomallei is a rare but potentially severe illness with a high mortality rate. The clinical features of the mycotic aneurysm secondary to melioidosis have not been illustrated in China. Over a seven-year period (2013 to 2019), 159 patients with bacteremic melioidosis were retrospectively analyzed in Hainan province, China, of whom eight patients were confirmed to have mycotic aneurysm through the combination of imaging examination, pathologic examination and aneurysm tissue culture. We summarized these eight patients’ clinical characteristics, demographical features, treatments and outcomes. The susceptibilities to five commonly-used antibiotics for these eight B. pseudomallei isolates were also determined by E-test strips. Furthermore, the mycotic aneurysm cases secondary to melioidosis retrieved from the literature were also reviewed. Of the eight cases, six had abdominal mycotic aneurysms, one had a left iliac aneurysm, and the other one had an infectious mesenteric aneurysm. They were aged from 48 to 69 years old, and had the underlying risk factors of diabetes mellitus (2 patients), long-term smoking (4 patients), hypertension (6 patients), and soil and water contact history (6 patients), respectively. The positive arterial aneurysm imaging was observed in all patients via computed tomography (CT) or angiography. Eight B. pseudomallei isolates collected from both blood and mycotic aneurysm tissues remained 100% susceptible to imipenem and ceftazidime. After surgery combined with antibiotic administration, six patients survived, with a mortality rate of 25%. In melioidosis endemic areas, the mycotic aneurysm secondary to melioidosis might be underdiagnosed, and increased awareness of predisposing risk factors and clinical features of the mycotic aneurysm is required. Following a positive B. pseudomallei blood culture, the diagnosis of mycotic aneurysm should be under consideration in those with abdominal pain and/or hypertension. Imaging by CT or angiography is indispensable for its timely diagnosis and management.

Burkholderia pseudomallei has the potential to cause mycotic aneurysm, an infrequently-occurred complication of melioidosis, with a high mortality rate despite appropriate antibiotic therapy and vascular surgery. The comprehensive clinical features of mycotic aneurysm due to B. pseudomallaei have not been documented in the People’s Republic of China and might be underrecognized. Therefore, we described eight patients with mycotic aneurysm from 159 bacteremic melioidosis patients in Hainan, China, over a seven-year period (between 2013 to 2019). We summarized their clinical characteristics, demographical features, treatments and outcomes. To our knowledge, this is the first comprehensive report of mycotic aneurysm secondary to melioidosis in China. In summary, in melioidosis endemic areas, or for those returning from endemic areas, increased awareness of the risk factors is required for early diagnosis and management of mycotic aneurysm secondary to melioidosis.

In situ revascularization with rifampicin-soaked silver polyester graft for aortic infection: Results of a retrospective monocentric series of 18 cases

OBJECTIVE

To evaluate the short and long-term results of in situ prosthetic graft treatment using rifampicin-soaked silver polyester graft in patients with aortic infection.

MATERIAL AND METHOD

All the patients surgically managed in our center for an aortic infection were retrospectively analyzed. The primary endpoint was the intra-hospital mortality, secondary outcomes were limb salvage, persistent or recurrent infection, prosthetic graft patency, and long-term survival.

RESULTS

From January 2004 to December 2015, 18 consecutive patients (12 men and 6 women) were operated on for aortic infection. Six mycotic aneurysms and 12 prosthetic infections, including 8 para-entero-prosthetic fistulas, were treated. In 5 cases, surgery was performed in emergency. During the early postoperative period, we performed one major amputation and two aortic infections were persistent. Intra-hospital mortality was 27.7%. The median follow-up among the 13 surviving patients was 26 months. During follow-up, none of the 13 patients presented reinfection or bypass thrombosis.

CONCLUSION

This series shows that in situ revascularization with rifampicin-soaked silver polyester graft for aortic infection have results in agreement with the literature in terms of intra-hospital mortality with a low reinfection rate.

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience

BACKGROUND

Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients.

METHODS

A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality.

RESULTS

During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%.

CONCLUSIONS

The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.

Unusual infective prosthetic valve endocarditis due to Pseudomonas monteilii and Acinetobacter nosocomialis with a fatal result

We report a case of Pseudomonas monteilii and Acinetobacter nosocomialis endocarditis with a fatal outcome in a patient with a recent history of prosthetic aortic valve replacement. Transesophageal echocardiography and computed tomography confirmed the presence of vegetation on the prosthetic valve and aortic pseudoaneurism with an aortic root abscess. Valve cultures yielded P.monteilii and A.nosocomialis. The patient underwent surgery and received antibiotics, but his condition deteriorated and he died 44days after surgery. To our knowledge, this is the first case of P.monteilii and A.nosocomialis endocarditis reported in the literature. These organisms have been described as environmental contaminants; however, they must be considered potential pathogens, particularly in patients with prosthetic valves.

Endovascular Reconstruction of the Hepatic Arterial System for the Management of Mycotic Pseudoaneurysm in a Liver Transplant Patient

BACKGROUND

Hepatic artery pseudoaneurysm is a rare but very morbid complication after liver transplant. Treatment options include ligation or endovascular embolization, followed by revascularization. We describe a new endovascular approach by stent exclusion in a high-risk patient.

RESULTS

A 62-year-old male who received a second liver transplant after failed allograft presented with hemobilia and was diagnosed with a hepatic artery pseudoaneurysm in the setting of infection. Given his hostile abdomen, an endovascular approach was sought. We excluded the mycotic pseudoaneurysm with multiple covered stent grafts extending from the common hepatic artery to the right and left hepatic arteries. He was discharged with long-term antibiotics. On his 6-month follow-up visit, his stent was patent and hepatic function was stable.

CONCLUSIONS

Endovascular stent-graft placement for management of hepatic artery pseudoaneurysm after liver transplant should be considered as a lower morbidity alternative to surgical repair, even in the setting of infection.

When Less Invasive Causes Major Sequelae: A Dramatic Evolution of an Infected Common Femoral Artery Patch

Endarterectomy of the common and profunda femoris is currently performed for treatment of atherosclerotic lesions involving femoral bifurcation. Misperception of surgical risk in terms of morbidity and mortality has induced the trend to extend the indication for treatment to patients with mild symptoms at presentation, at the cost of unnecessary increased complication rate and mortality risk, which persists even after patient discharge. We report the case of a giant infected femoral pseudoaneurysm occurring in a 74-year-old patient, previously treated with femoral artery endarterectomy with prosthetic patch closure because of mild claudication. Surgically managed with en block resection and autologous vein reconstruction, his postoperatory course was further complicated by fatal sepsis. Complications for femoral artery endarterectomy, including infectious and fatal events, need a close follow-up of these patients to promptly diagnose and treat any event which may occur, preventing its evolution to more challenging and potentially life-threatening clinical scenario.

Mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection causing a diagnostic dilemma

Mycotic pseudoaneurysms usually arise from an infectious arteritis or mycotic aneurysms secondary to weakening and destruction of the arterial wall resulting in a contained rupture. We report a case of a mycotic pseudoaneurysm affecting the aortic isthmus of the thoracic aorta which is an extremely rare infection. To our knowledge no case report of mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection has thus far been described. The specific case we present is also unique in that it posed a diagnostic imaging dilemma where the initial imaging revealed a periaortic mass which could not be accurately characterized and only on subsequent imaging reveal itself to be a thrombosed mycotic pseudoaneurysm. We hope that our case report highlights to the medical community the high degree of suspicion one should have regarding pseudoaneurysms when dealing with a complex mass intimately related to a vascular structure.

[Infected Thoracic Aortic Aneurysm Secondary to the Purulent Pericarditis;Report of a Case]

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

Endovascular treatment of primary mycotic aortic aneurysms: a 7-year single-center experience

Objective This study was performed to assess the efficacy and outcome of endovascular aneurysm repair (EVAR) for treatment of primary mycotic aortic aneurysms (PMAAs). Methods Fourteen consecutive patients who presented with PMAA from April 2010 to July 2017 were retrospectively reviewed. Preoperative, intraoperative, and postoperative clinical data were recorded, and late infection-related complications and long-term survival were assessed. Results The aneurysms were located in the abdominal aorta in 10 patients and in the left common iliac artery in 4 patients. Positive microbial cultures were found in 12 patients, including Salmonella species in 11 and Streptococcus in 1. The remaining two patients had negative culture results. Ten patients received preoperative antibiotics before elective EVAR for 7 ± 9 days after admission. Four patients who underwent emergent EVAR due to ruptured aneurysms were given their first dose of antibiotics before EVAR. Three patients underwent surgical drainage, and six underwent percutaneous drainage within 30 days after EVAR. No death occurred within 30 days of the initial procedure. The mean follow-up was 34.8 (range, 3-84 months). One patient underwent re-intervention to resolve obstruction of the iliac/femoral artery 5 months postoperatively. Relapse of infection occurred in six patients (42.8%) during follow-up; infection-related death occurred in three of these patients. The other patients recovered with either conversion to open radical surgery or medical therapy. The actuarial 7-year survival after EVAR was 75.7%. Conclusions EVAR and aggressive antibiotic therapy might be suitable for PMAAs. Favorable results may be typical for infection caused by Salmonella.

[Mycotic aorta aneurysm treated with an autologous venous graft]

Systemic side effects, including sepsis, due to bacille Calmette-Guérin treatment for carcinoma in situ in the bladder, are observed in 15% of the patients. In rare cases, patients have developed systemic infections and mycotic aneurysms. In this case report, a 72-year-old man developed a mycotic aortic aneurysm, and the appropriate tuberculostatic drugs had no effect on his systemic infection. He was successfully treated surgically, replacing the affected aortic segment with an autologous venous graft, resulting in complete remission. A follow-up PET-CT three months later showed no sign of ongoing aortic infection.

[Tuberculous mycotic aneurism of the aorta: a case report of haemoptysis.]

Mycotic aneurysm secondary to tuberculous infection (TB) of the aorta is a rare and life-threatening disease. We report a case report of a 78-year-old woman with a tuberculous mycotic aortic aneurysm (TBAA). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.

Sustained local delivery of high-concentration vancomycin from a hybrid biodegradable, antibiotic-eluting, nanofiber-loaded endovascular prosthesis for treatment of mycotic aortic aneurysms

BACKGROUND

Endovascular repair for mycotic aortic aneurysm (MAA) is a less invasive alternative to open surgery, although the placement of a stent graft in an infected environment remains controversial. In this study, we developed hybrid biodegradable, vancomycin-eluting, nanofiber-loaded endovascular prostheses and evaluated antibiotic release from the endovascular prostheses both in vitro and in vivo.

METHODS

Poly(D,L)-lactide-co-glycolide and vancomycin were dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol. This solution was electrospun into nanofibrous tubes, which were mounted onto commercial vascular stents and endovascular aortic stent grafts. In vitro antibiotic release from the nanofibers was characterized using an elution method and high-performance liquid chromatography. Antibiotic release from the hybrid stent graft was analyzed in a three-dimensional-printed model of a circulating MAA. The in vivo drug release characteristics were examined by implanting the antibiotic-eluting stents in the abdominal aorta of New Zealand white rabbits (n = 15).

RESULTS

The in vitro study demonstrated that the biodegradable nanofibers and the nanofiber-loaded stent graft provided sustained release of high concentrations of vancomycin for up to 30 days. The in vivo study showed that the nanofiber-loaded stent exhibited excellent biocompatibility and released high concentrations of vancomycin into the local aortic wall for 8 weeks.

CONCLUSIONS

The proposed biodegradable vancomycin-eluting nanofibers significantly contribute to the achievement of local and sustainable delivery of antibiotics to the aneurysm sac and the aortic wall, and these nanofibers may have therapeutic applications for MAAs.

Rare Presentation of a Syphilitic Aneurysm of the Infrarenal Aorta with Contained Rupture

We report, to our knowledge, the first case of a rare syphilitic infrarenal aortouniiliac aneurysm with contained rupture that presented with midepigastric abdominal pain. Review of the patient's medical history revealed untreated syphilis and poorly treated congestive heart failure. Given his comorbidities, the patient was treated with an emergent endovascular aneurysm repair. His 30-day postoperative recovery period was uneventful, and follow-up imaging revealed complete resolution of the aneurysms. Syphilitic infrarenal aortic aneurysm is currently considered a rare entity in this era of antibiotics. The present article provides a brief case report and short review of literature pertaining to syphilitic aortic aneurysms.

Healthy Adolescent with a Mycotic Aortic Aneurysm from Community-Acquired Methicillin-Resistant Staphylococcus aureus

Mycotic aneurysm after bacteremia is a rare diagnosis in children and adolescents. We report the case of a previously healthy adolescent who presented with chest pain and fever and who developed a mycotic aneurysm of the aorta after contracting community-acquired, methicillin-resistant Staphylococcus aureus. Early recognition of widening of the patient's superior mediastinum, noted during a comparison of the patient's initial and follow-up chest radiographs, prompted computed tomographic angiography of the chest and led to a timely diagnosis, rapid surgical intervention, and a good clinical outcome. To our knowledge, this is the first reported case of mycotic aortic aneurysm from community-acquired methicillin-resistant S. aureus in a healthy adolescent who had no predisposing cardiac or aortic anomalies.

Fatal rupture of a mycotic aneurysm of the right coronary artery post pneumococcal sepsis

Aneurysms of the coronary arteries are rare and mycotic coronary aneurysms are even rarer. We report a unique, yet unfortunately autopsy-proven fatal case of a ruptured atherosclerotic mycotic aneurysm of the right coronary artery with streptococcus pneumoniae in a non-immunocompromised patient resulting in cor tamponade and death.

Red blood cell transfusion-transmitted acute hepatitis E in an immunocompetent subject in Europe: a case report

BACKGROUND

Acute hepatitis E in industrialized countries is usually related to intake or manipulation of undercooked or raw meat. Cases of transfusion-transmitted hepatitis E have rarely been documented in immunosuppressed patients, mainly after receiving frozen plasma.

STUDY DESIGN AND METHODS

A 61-year-old man was admitted to hospital for jaundice. His personal history included disseminated bacillus Calmette-Guerin infection treated with antituberculous drugs. He had received red blood cell (RBC) transfusion 2 months previously, during admission for mycotic aneurysm surgery. Since liver function tests worsened despite stopping antituberculous drugs, other causes of acute hepatitis were explored.

RESULTS

Acute hepatitis E was diagnosed by the presence of both immunoglobulin M and hepatitis E virus (HEV) RNA. Traceback procedure for the 8 RBC units was carried out, and one of the eight archive plasma samples tested positive for HEV RNA, with an estimated viral load of 75,000 IU/mL. Phylogenetic analysis revealed the same HEV strain Genotype 3 in one of the transfused RBC products and in the patient's serum sample.

CONCLUSION

Transfusion of RBCs with detectable HEV RNA is a risk factor for acute hepatitis E in immunocompetent patients in Europe.

Management of a Mycotic Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery

A mycotic aneurysm that also involves the visceral arteries is a life-threatening condition. Surgical management typically consists of débridement and in situ repair with a Dacron graft and reimplantation of the involved visceral branches. We report a rare case of a mycotic saccular thoracoabdominal aortic aneurysm involving the celiac artery, with Streptococcus pneumoniae as the responsible organism. Successful repair of the aneurysm and concomitant revascularization of the celiac artery were achieved.

Pericardial fat flap: surgical technique for infection control after graft replacement

Surgical treatment of mycotic aneurysm of the thoracic aorta is challenging because contamination from surrounding tissues may occur even after complete debridement with a prosthetic graft replacement of the aneurysm. This study describes the simple but very useful technique of using a pericardial fat flap to protect the prosthetic graft from reinfection.

Mycotic Aneurysm of the Abdominal Aorta due to Group B Streptococcus (GBS) Infection: A Case Report and Review of the Literature

We present a case report of an extremely rare infected abdominal aortic aneurysm (AAA) caused by group B streptococcus (GBS). A 66 years old, afebrile male patient with hypertension and history of chronic smoking presented with mild abdominal pain and discomfort. Physical examination revealed a pulsatile mass of 5 cm in diameter located at the periumbilical region. A computed tomography (CT) scan of the whole abdomen exhibited an outpouching lesion with intramural hematoma located at the infrarenal abdominal aorta, sized 5.1x3.7 cm in diameter, suggesting an abdominal aortic aneurysm. A transthoracic echocardiography demonstrated normal endocardium without vegetation. Surgical abdominal aortic aneurysm repair (aneurysmorrhaphy) was successfully done and intravenous amoxicillin/clavulanic acid was given. Tissue culture obtained from the aneurysm sac and para-aortic lymph nodes revealed group B streptococcus infection. Intravenous amoxicillin/clavulanic acid was continued for 14 days, and was transitioned to oral amoxicillin 3 grams/day. Currently, the patient has been followed-up for 20 months with neither recurrent infection nor post-operative complication. This is the first case report of infected abdominal aortic aneurysm due to GBS in Thailand.

Left Anterior Descending Coronary Artery and Multiple Peripheral Mycotic Aneurysms Due to Mycobacterium Bovis Following Intravesical Bacillus Calmette-Guerin Therapy: A Case Report

The use of live attenuated intravesicular Bacillus Calmette-Guerin (BCG) therapy is a generally accepted safe and effective method for the treatment of superficial transitional cell carcinoma (TCC) of the bladder. Although rare, < 5% of patient's treated with intravesicular BCG therapy may develop potentially serious complications, including localized infections to the genitourinary tract, mycotic aneurysms and osteomyelitis. We present here a case of a 63-year-old male who developed left coronary and multiple peripheral M. Bovis mycotic aneurysms as a late complication of intravesicular BCG therapy for superficial bladder cancer. The patient initially presented with acute onset pain and swelling in the left knee > 2 years following initial therapy, and initial workup revealed a ruptured saccular aneurysm of the left popliteal artery as well as incidental bilateral common femoral artery aneurysms. Following endovascular treatment and additional workup, the patient was discovered to have additional aneurysms in the right popliteal artery and left anterior descending artery (LAD). Surgical pathology and bacterial cultures obtained from the excised femoral aneurysms and surgical groin wounds were positive for Mycobacterium Bovis, and the patient was initiated on a nine-month antimycobacterial course of isoniazid, rifampin and ethambutol. Including the present case, there has been a total of 32 reported cases of mycotic aneurysms as a complication from intravesicular BCG therapy, which we will review here. The majority of reported cases involve the abdominal aorta; however, this represents the first known reported case of a coronary aneurysm.

Salmonella Aortic Aneurysm: Suggestions for Diagnosis and Therapy Based on Personal Experience

Infectious aneurysm is a rare event, especially after the introduction of antibiotic therapy. However, its early detection is very important for timely treatment with antibiotics and surgical intervention. This pathology may generally be due to mycotic endocarditis or septic embolization, prevailing in the preantibiotic era, and to aortitis, whose incidence is actually increasing, mainly in subjects with preexisting large-vessel atherosclerosis and intimal defects. This clinical entity is usually defined as microbial arteritis and recognizes Salmonella spp as the microorganism most frequently isolated from blood or vascular tissue cultures. The authors present the case of a 56-year-old man with a history of hypertension that some weeks before admission manifested as hyperpyrexia and episodic lumbar pain, associated with hepatosplenomegaly and with a pulsing mass in the periumbilical region. Abdominal computed tomography (CT) scan documented a voluminous infrarenal aortic aneurysm with a markedly reduced and irregular vessel wall. The patient underwent surgical excision of the aneurysm, during which marked periaortic inflammation phenomena, complete absence of the posterior aortic wall for a length of 5-6 cm, and the exposure of the correspondent vertebral bodies were observed. Histopathologic examination of the aneurysmal tissue showed atheromatous and thrombotic aspects and confirmed strong signs of inflammation. This case may suggest that the occurrence of microbial aortitis, especially from Salmonella spp, should be taken into account in the presence of a septic status associated with back, abdominal, or thoracic pain.

Infective Endocarditis of the Aortic Valve with Anterior Mitral Valve Leaflet Aneurysm

Mitral valve leaflet aneurysm is a rare and potentially devastating complication of aortic valve endocarditis. We report the case of a 48-year-old man who had endocarditis of the native aortic valve and a concomitant aneurysm of the anterior mitral valve leaflet. Severe mitral regurgitation occurred after the aneurysm perforated. The patient showed no signs of heart failure and completed a 6-week regimen of antibiotic therapy before undergoing successful aortic and mitral valve replacement. In addition to the patient's case, we review the relevant medical literature.

Stent-graft for Recurrent Melioidosis Mycotic Aortic Aneurysm

Melioidosis is a tropical disease caused by Burkholderia pseudomallei and is prevalent in South East Asia and Northern Australia. It can infect any organ system and is potentially deadly. Melioidosis causing a mycotic aneurysm of the aorta is rare. We present a patient with a melioidosis mycotic aneurysm of the descending aorta presenting with fever and right pleural effusion, managed successfully with initial Dacron graft repair with staged omental reinforcement, and subsequent endovascular stent grafting of a late anastomotic leak.

Endoprosthetic Treatment of a Mycotic Superficial Femoral Artery Aneurysm

Purpose:

To describe the successful stent-graft exclusion of a mycotic aneurysm of the superficial femoral artery.

Case Report:

A 78-year-old man presented with Salmonella arteritis and the formation of a mycotic false aneurysm of the superficial femoral artery. Antibiotics were administered; the aneurysm was excluded using 2 Hemobahn stent-grafts, and the surrounding hematoma was drained. One year postoperatively, there are no clinical or biochemical signs of infection. Ultrasound examination does not show any fluid around the patent stent-graft.

Conclusions:

Stent-graft placement might be an alternative to traditional surgery in selected cases of mycotic aneurysm.

Nontraumatic Aneurysms Affecting Crural Arteries: Case Report and Review of the Literature

Aneurysms involving the infrapopliteal arteries are rare, with most cases being attributed to a previous traumatic event. Mycotic aneurysms in this location are even more uncommon. Owing to their infrequency, these aneurysms represent a difficult diagnostic challenge. We present a case of a symptomatic anterior tibial artery aneurysm in a 59-year-old male with a medical history significant only for an episode of bacterial endocarditis, subsequently requiring an aortic valve replacement. Surgical repair was performed with a popliteal to anterior tibial bypass with a reversed saphenous vein graft. The patient's recovery was uneventful. We also reviewed the literature on this type of aneurysm to assess the incidence, etiology, options for treatment, and outcomes.

Nocardia asteroides–Infected Aneurysm of the Aorta: Case Report and Review of the Literature

Infected aneurysms of the aorta were first described as a result of septic emboli or contiguous spread from bacterial endocarditis and are usually caused by Staphylococcus or Salmonella species. We report a case of Nocardia-associated infected aneurysm of the native suprarenal aorta in an immunocompromised host. Surgical management consisted of placement of an interposition cryopreserved aortic homograft. Nocardia asteroides was identified on a microbiology specimen of the aorta and both microbiology and pathology specimens of the splenic tissue. To the best of our knowledge, this represents the first carefully documented, unique case of a Nocardia-infected aneurysm treated with homograft interposition. In addition, pathologic and microbiologic data are included from the postmortem examination 10 months later.

Cerebral Aneurysm from Cardiobacterium hominis Endocarditis

A 43-year-old male with a history of bioprosthetic aortic valve replacement and tricuspid valve annuloplasty presented with vertigo and was found to have an acute infarct in the left superior cerebellum, as well as a left-middle cerebral artery mycotic aneurysm. Blood cultures grew Cardiobacterium hominis and bioprosthetic aortic valve vegetation was found on transthoracic echocardiogram.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

Mycotic Abdominal Aortic Aneurysm Secondary to Septic Embolism of a Thoracic Aorta Graft Infection

Mycotic aneurysms account for 1% of abdominal aortic aneurysms. There are very few cases published that describe the formation of mycotic aneurysms after septic embolism due to graft infection. We present the first case to our knowledge to be described in the literature of a mycotic aneurysm caused by septic embolism derived from a thoracic aorta graft infection, treated with conventional surgery leading to a successful outcome and evolution.

Mycotic Aneurysm Caused by Bacteroides fragilis in an Elderly Immunosuppressed Patient

An 82-year-old Japanese man, who presented with a fever and abdominal pain, was admitted to our hospital. According to enhanced computed tomography images, the probable diagnosis was abdominal aortic mycotic aneurysm. Eight sets of blood cultures obtained from the patient were negative. Despite administering treatment with vancomycin and ceftriaxone, the aneurysm progressively enlarged. He underwent open debridement surgery and in situ replacement because of an aneurysmal rupture. Bacteroides fragilis was isolated from the tissue culture of the aortic wall. Metronidazole was administered and discontinued without any infection relapse. When faced with similar cases, rare pathogens should thus be considered as possible causes of mycotic aneurysms.

Vascular complications and surgical interventions after world's largest Q fever outbreak

OBJECTIVE

Since chronic Q fever often develops insidiously, and symptoms are not always recognized at an early stage, complications are often present at the time of diagnosis. We describe complications associated with vascular chronic Q fever as found in the largest cohort of chronic Q fever patients so far.

METHODS

Patients with proven or probable chronic Q fever with a focus of infection in an aortic aneurysm or vascular graft were included in this study, using the Dutch national chronic Q fever database.

RESULTS

A total of 122 patients were diagnosed with vascular chronic Q fever between April 2008 and June 2012. The infection affected a vascular graft in 62 patients (50.8%) and an aneurysm in 53 patients (43.7%). Seven patients (5.7%) had a different vascular focus. Thirty-six patients (29.5%) presented with acute complications, and 35 of these patients (97.2%) underwent surgery. Following diagnosis and start of antibiotic treatment, 26 patients (21.3%) presented with a variety of complications requiring surgical treatment during a mean follow-up of 14.1 ± 9.1 months. The overall mortality rate was 23.7%. Among these patients, mortality was associated with chronic Q fever in 18 patients (62.1%).

CONCLUSIONS

The management of vascular infections with C. burnetii tends to be complicated. Diagnosis is often difficult due to asymptomatic presentation. Patients undergo challenging surgical corrections and long-term antibiotic treatment. Complication rates and mortality are high in this patient cohort.

The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography

Transesophageal echocardiography continues to have a central role in the diagnosis of infective endocarditis and its sequelae. Recent technological advances offer the option of 3-dimensional imaging in the evaluation of patients with infective endocarditis. We present an illustrative case and review the literature regarding the potential advantages and limitations of 3-dimensional transesophageal echocardiography in the diagnosis of complicated infective endocarditis. A 51-year-old man, an intravenous drug user who had undergone bioprosthetic aortic valve replacement 5 months earlier, presented with prosthetic valve endocarditis. Preoperative transesophageal echocardiography with 3D rendition revealed a large abscess involving the mitral aortic intervalvular fibrosa, together with a mycotic aneurysm that had ruptured into the left atrium, resulting in a left ventricle-to-left atrium fistula. Three-dimensional transesophageal echocardiography enabled superior preoperative anatomic delineation and surgical planning. We conclude that 3-dimensional transesophageal echocardiography can be a useful adjunct to traditional 2-dimensional transesophageal echocardiography as a tool in the diagnosis of infective endocarditis.