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Concomitant paravisceral and thoracic mycotic aortic aneurysms in a cirrhotic patient

Open AccessPublished:June 30, 2021DOI:https://doi.org/10.1016/j.jvscit.2021.06.013

      Abstract

      In the present case report, we have described concomitant, rapidly expanding, abdominal and thoracic mycotic aortic pseudoaneurysms in a patient who had originally presented for right arm superficial thrombophlebitis and a right-hand abscess in the presence of methicillin sensitive Staphylococcus aureus bacteremia. Within 12 days, the patient had developed a rapidly expanding paravisceral mycotic abdominal aortic pseudoaneurysm that required open surgical repair. After the initial operation, she developed a thoracic mycotic aortic aneurysm that ultimately required open surgical repair. Her postoperative course after the initial operation was complicated by decompensated hepatitis C cirrhosis that required convalescence before repair of the thoracic aneurysm. Follow-up data were available for ≤10 months after the initial operation.

      Keywords

      Mycotic aortic aneurysms (MAAs) comprise 0.6% to 4.5% of aortic aneurysms, with concomitant thoracic MAAs (TMAAs) and abdominal MAAs (MAAAs) comprising only 1.5% of these cases.
      • Sörelius K.
      • Wanhainen A.
      • Furebring M.
      • Björk M.
      • Gillgren P.
      • Mani K.
      • et al.
      Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair.
      The complexity of MAAs presents a challenge for surgeons and represents a highly mortal condition.
      • Oderich G.S.
      • Bower T.C.
      • Cherry C.J.
      • Panneton J.M.
      • Sullivan T.M.
      • Noel A.A.
      • et al.
      Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center.
      • Wilson W.R.
      • Bower T.C.
      • Creager M.A.
      • Amin-Hanjani S.
      • O’Gara P.T.
      • Lockhart P.T.
      • et al.
      Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association.
      • Bernal L.R.
      • Requejo L.R.
      • Ribes A.R.
      • Miralles M.R.
      Mycotic aortic aneurysms.
      Surgical intervention is critical, but no consensus has been reached regarding the preferred operative therapy owing to the diverse pathology.
      • Wilson W.R.
      • Bower T.C.
      • Creager M.A.
      • Amin-Hanjani S.
      • O’Gara P.T.
      • Lockhart P.T.
      • et al.
      Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association.
      The ultimate intervention depends on the clinical scenario and anatomic location of the MAA. Open in situ reconstruction (OISR) with native aorta resection and/or periaortic debridement has become the accepted surgical approach for TMAAs and MAAAs.
      • Oderich G.S.
      • Bower T.C.
      • Cherry C.J.
      • Panneton J.M.
      • Sullivan T.M.
      • Noel A.A.
      • et al.
      Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center.
      ,
      • Wilson W.R.
      • Bower T.C.
      • Creager M.A.
      • Amin-Hanjani S.
      • O’Gara P.T.
      • Lockhart P.T.
      • et al.
      Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association.
      ,
      • Lee C.H.
      • Hsieh H.C.
      • Ko P.J.
      • Li H.J.
      • Kao T.C.
      • Yu S.Y.
      • et al.
      In situ versus extra-anatomic reconstruction for primary infected infrarenal infected abdominal aortic aneurysms.
      Additionally, endovascular repair has recently emerged as a promising therapy.
      • Sörelius K.
      • Wanhainen A.
      • Furebring M.
      • Björk M.
      • Gillgren P.
      • Mani K.
      • et al.
      Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair.
      ,
      • Sörelius K.
      • Budtz-Lilly J.
      • Mani K.
      • Wanhainen A.
      Systematic review of the management of mycotic aortic aneurysms.
      ,
      • Sörelius K.
      • Wanhainen A.
      • Wahlgren C.-M.
      • Langenskiöld M.
      • Roos H.
      • Resch T.
      • et al.
      Nationwide study on treatment of mycotic thoracic aortic aneurysms.
      We present the case of a patient with a rapidly progressing paravisceral MAAA and concomitant TMAA in the presence of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and Child's class B cirrhosis requiring separate open repairs. The patient's mother provided written informed consent for the report of her daughter's case details and imaging studies.

      Case report

      A 57-year-old woman was transferred to our institution because of concerns for a right hand abscess and cephalic vein suppurative thrombophlebitis. The pertinent initial laboratory test results, history details, and imaging results are presented in the Table. The blood cultures were confirmed positive for MSSA. Broad-spectrum antibiotics were initiated and ultimately tailored to cefazolin. Despite debridement of the hand abscess and aggressive antibiotic therapy, her blood cultures remained positive with no identifiable nidus. On hospital day 12, the patient developed severe abdominal pain. The computed tomography angiogram (CTA) revealed a periaortic abscess extending into the left psoas muscle with a rapidly expanding paravisceral mycotic thoracoabdominal aneurysm with a contained rupture (Fig 1, A). The patient was taken to the operating room urgently for open repair owing to concern for an impending free rupture.
      TablePatient demographics, comorbidities, and operative variables
      VariableDetails
      Admission data and patient demographics
       Age57 years
       GenderFemale
       Medical historyHepatitis C cirrhosis (Childs class B); hypertension; depression; mediastinitis secondary to previous PICC line infection 2 years earlier
       Pertinent admission laboratory test resultsWBC count, 22 × 109/L; LA, 3.2 mmol/L; Cr, 2.1 mg/dL; blood cultures positive for MSSA
       Social history20 Pack-year smoking history; occasional alcohol use; history of intravenous drug abuse
       Surgical historyPartial sternotomy and left clavicular head resection secondary to PICC line infection (2017); resection or replacement of infected right knee arthroplasty (2016)
       Admission imaging studiesCT scan at OSH showing nonocclusive thrombus of right cephalic vein and fluid collection in dorsum of right hand concerning for abscess; CTA showing hepatic cirrhosis with portal vein hypertension, fluid collection surrounding left subclavian vein and aortic arch, severe luminal narrowing of distal abdominal aorta secondary to significant atherosclerotic disease with no apparent ectatic change; TEE with no concern found for vegetative endocarditis as a source for bacteremia; normal EF
      First stage (abdominal)
       Hospital day performed12
       Preoperative MELD score16
       Preoperative APRI0.3
       Patient positionRight lateral decubitus
       Procedural detailsRetroperitoneal exposure of thoracoabdominal aorta with extensive debridement of aortic tissue; aortic replacement with rifampin-soaked Dacron graft; right renal artery bypass with Dacron; reimplantation of left renal artery; proximal anastomosis just inferior to celiac trunk; ABTHERA application with washout and closure on POD 1
       Operative time266 Minutes
       Supraceliac clamp time23 Minutes
       EBL4.3 mL
       Intraoperative transfusions5 U of RBCs, 2 U of FFP, 1 U of PLT, 4 L of Isolyte
       Postoperative APRI0.5
       Postoperative MELD score23
       Preoperative echocardiographyEF >55%; no vegetations
      Second stage (thoracic component)
       Time from first stage62 Days (hospital day 74)
       Preoperative MELD score13
       Preoperative APRI0.3
       Procedural detailsTotal aortic arch replacement and debridement with rifampin-soaked Dacron arch graft; cardiopulmonary bypass required
       Operative time240 minutes
       EBL535 mL
       Intraoperative transfusions3 U of pRBCs, 2 U of FFP, 2 U of PLT
       CPB time102 Minutes
       Aortic cross-clamp time45 Minutes
      Postoperative details
       Overall length of stay83 Days (POD 70 from index procedure)
       Echocardiography40%-45% EF during follow-up
       Initial dischargeDischarged to inpatient rehabilitation
       Readmission 1Postdischarge day 16: readmitted for sternal wound infection requiring sternectomy, pectoral flap coverage, and NPWT
       Second dischargeDischarged home with home healthcare and physical therapy
       Readmission 28 Months after initial discharge, she was readmitted for atrial fibrillation requiring ablation and initiation of anticoagulation
       Follow-up duration10 months
       Final postoperative imagingCTA of chest, abdomen, and pelvis at 8 months demonstrated stable appearance of aortic repair
      Miscellaneous details
       ConsultationsCardiothoracic surgery, wound care, infectious disease, hepatology, plastic surgery, pain management, palliative care
       AspirinYes
       StatinYes
       AnticoagulationApixaban (Eliquis; after atrial fibrillation diagnosis)
      Considerations for other approaches
       Palliative approachDiscussed goals of care with the patient, who wished to pursue aggressive management and continued to optimize her health, working with all consultants and physical therapy
       BEVAR/FEVARBecause of the virulence of the organism identified and the patient deemed not prohibitively at high risk for open repair by a team of experts, we elected not to pursue fenestrated repair for fear of failure of the graft owing to infection-related complications
      APRI, Alanine aminotransferase/platelet ratio index; BEVAR, branched endovascular aneurysm repair; CPB, cardiopulmonary bypass; CT, computed tomography; CTA, computed tomography angiography; EBL, estimated blood loss; EF, ejection fraction; FEVAR, fenestrated endovascular aneurysm repair; FFP, fresh frozen plasma; LA, lactic acid; MELD, model for end-stage liver disease; MSSA, methicillin-sensitive Staphylococcus aureus; NPWT, negative pressure wound therapy; OSH, outside hospital; PICC, peripherally inserted central catheter; PLT, platelets; POD, postoperative day; pRBCs, packed red blood cells; RBCs, red blood cells; TEE, transesophageal echocardiography; WBC, white blood cell.
      Figure thumbnail gr1
      Fig 1Radiographic images of abdominal mycotic aortic aneurysm (MAA). A, Three-dimensional reconstruction demonstrating a paravisceral abdominal MAA (MAAA; arrows) with a pseudoaneurysm just above the left renal artery. B, Postoperative three-dimensional reconstruction allowing for visualization of proximal and distal anastomoses and visualization of the left renal artery reimplantation and bypass graft from the right renal artery.
      Retroperitoneal exposure revealed necrotic tissue surrounding a contained rupture of the aortic wall with significant periaortic inflammation. The aorta was clamped at the supraceliac position and bilateral common iliac arteries. The necrotic tissue and native aorta were excised in their entirety, and a rifampin-soaked Dacron tube graft was sutured into place with left renal artery reimplantation and right renal artery bypass. Additional debridement, irrigation, circumferential omental flap coverage, and closure were performed the next day.
      The broad-spectrum antibiotics were maintained and, ultimately, transitioned to rifampin and nafcillin. The postoperative complications included persistent hypertension, decompensated cirrhosis, large volume ascites, hepatorenal syndrome, hypokalemia, and malnutrition. A postoperative CTA revealed a developing mycotic aneurysm of the transverse aortic arch that expanded from 1.6 to 3.2 cm during the course of 8 weeks. The patient required nutritional and medical optimization before repair of the thoracic aneurysm (Fig 2, A). Because of concern for impending rupture of the TMAA, the patient underwent total aortic arch replacement with a rifampin-soaked arch graft (Fig 2, A). The intraoperative tissue cultures were positive for MSSA. The postoperative complications and follow-up data are also presented in the Table. Late follow-up data revealed negative blood cultures and a stable appearance of the aortic repairs on a CTA (Figs 1 and 2, B). However, she died at 10 months postoperatively of an unknown cause.
      Figure thumbnail gr2
      Fig 2Pre- and postoperative imaging studies of thoracic mycotic aortic aneurysm (TMAA). A, Three-dimensional reconstruction demonstrating rapidly expanding TMAA before repair. B, Three-dimensional reconstruction after repair and total arch replacement.

      Discussion

      MAAs are rare in clinical practice and in the literature. The surgical treatment of patients with multifocal MAAs is important to highlight, because these patients can require additional operations with resulting increased mortality. Most MAAAs will affect the infrarenal aorta (51%) but have shown a greater propensity to affect the paravisceral aorta (13%-20%) or suprarenal segment (15%) compared with degenerative atherosclerotic aneurysms.
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      • Copeland H.
      • Murphy D.
      • Hess Jr., P.J.
      • Pillai S.T.
      • et al.
      Repair of thoracic and thoracoabdominal mycotic aneurysms and infected aortic grafts using allograft.
      Delays in operative intervention for patients with MAAs have been associated with poor outcomes and increased aneurysm-related mortality.
      • Huang Y.K.
      • Ko P.J.
      • Chen C.L.
      • Tsai F.C.
      • Wu C.H.
      • Lin P.J.
      • et al.
      Therapeutic opinion on endovascular repair for mycotic aortic aneurysm.
      ,
      • Lee W.K.
      • Mossop P.J.
      • Little A.F.
      • Fitt G.J.
      • Vrazas J.I.
      • Hoang J.K.
      • et al.
      Infected (mycotic) aneurysms: spectrum of imaging appearances and management.
      Some investigators have delayed operative or endovascular intervention to observe for a response to antibiotic therapy in the absence of concerning signs or symptoms.
      • Aoki C.
      • Fukuda W.
      • Kondo N.
      • Minakawa M.
      • Taniguchi S.
      • Daitoku K.
      • et al.
      Surgical management of mycotic aortic aneurysms.
      ,
      • Huang Y.K.
      • Ko P.J.
      • Chen C.L.
      • Tsai F.C.
      • Wu C.H.
      • Lin P.J.
      • et al.
      Therapeutic opinion on endovascular repair for mycotic aortic aneurysm.
      Our case demonstrated both approaches in that urgent intervention was performed in the wake of contained rupture in stage 1 with delay before the second stage for medical and antimicrobial optimization. Imaging findings indicating the presence of rapid expansion, a contained rupture, or pseudoaneurysm formation should prompt more urgent intervention.
      • Aoki C.
      • Fukuda W.
      • Kondo N.
      • Minakawa M.
      • Taniguchi S.
      • Daitoku K.
      • et al.
      Surgical management of mycotic aortic aneurysms.
      ,
      • Lee W.K.
      • Mossop P.J.
      • Little A.F.
      • Fitt G.J.
      • Vrazas J.I.
      • Hoang J.K.
      • et al.
      Infected (mycotic) aneurysms: spectrum of imaging appearances and management.

      Conclusions

      The details from the present case have highlighted the challenges of MAAs in the setting of synchronous infections in multiple anatomic locations. A high index of suspicion and an early diagnosis is imperative for these patients, with prompt surgical management, including aggressive debridement of the infected aorta and surrounding tissues, wound cultures, and organism-directed antibiotic therapy. Patient comorbidities and the possibility of concomitant MAAs should be factored into the operative decision-making.

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