Systematic literature review and meta-analysis of Clostridium septicum aortitis.

BACKGROUND: Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic wall can rapidly lead to aneurysm induction through bacterial seeding into atheromatous lesions with consecutive life-threatening rupture. We summarize all published data on this rare and lethal disease to evaluate therapeutic approaches and give valid treatment recommendations because there are no guidelines. METHODS: A systematic review of the literature was conducted screening EMBASE and MEDLINE databases following the PRISMA guidelines with search period from first description to August 25, 2021. RESULTS: There were 72 cases of C septicum aortitis reported in 64 publications. Endovascular aortic repair (EVAR) was performed in a minority of patients (n = 6) unfit for surgery but lacked long-term survivors. Antibiotic treatment was beneficial in a bridge to surgery concept, but up to now harbored a 6-month mortality rate of 100% (median overall survival, 0.5 months) when no additional aortic repair was performed. Open aortic repair was the only potential curative approach but was accompanied with a 90-day-mortality of 26.7% (4/15). CONCLUSIONS: Open aortic repair combined with perioperative antibiotic treatment should be offered to all patients as the only potentially curative approach. If applicable, resection of a coexisting colonic tumor should be performed after successful aortic repair. Alternatively, long-term antibiotic treatment can be offered to patients unfit for surgery in a palliative setting. Endovascular aortic repair has been performed on a minority of patients with a high risk for stent graft infection and should remain a salvage strategy when therapeutic pressure demands acute intervention in patients unfit for surgery.

Transcatheter aortic valve implantation for severe pure aortic regurgitation due to active aortitis.

Aortitis is an uncommon systemic inflammatory disease affecting the aorta and its main branches. Severe aortic regurgitation (AR) represents a fearsome complication of aortitis and is associated with an increased mortality rate. Surgical aortic valve replacement represents the only treatment choice for these patients. However, it is associated with a higher risk of medium to long-term complications such as prosthetic valve detachment. This is the first reported case where severe AR secondary to aortitis was managed with transcatheter aortic valve implantation (TAVI). TAVI was safe and effective in this clinical setting and may be considered a viable alternative to high-risk surgery in these complex patients.

[Aortitis Syndrome Requiring Redo Bentall Procedure with Coronary Artery Bypass Grafting due to Graft Detachment;Report of a Case].

A 53-year-old woman was referred to us for reoperation of aortic root. Twenty-three years ago, she was diagnosed with aortitis and suffered from annuloaortic ectasia, aortic regurgitation, severe stenosis of left carotid and subclavian arteries and occulusion of the main trunk of left coronary artery. The left coronary system was perfused by collateral arteries from right coronary artery. She had undergone original Bentall procedure( Cooley graft 26 mm+SJM valve 25 mm) with coronary artery bypass grafting (CABG)[saphenous vein graft (SVG)-left anterior descending artery (LAD)]. When she was 52 years old, she suffered from angina on efforts. Computed tomography and catheter angiocardiogram revealed pseudoaneurysm formation due to detachment of right coronary artery button and occulusion of SVG. We underwent redo aortic root replacement (Hemashield graft 26 mm+On-X valve 23 mm) with redo CABG (SVG-LAD). Eight mm graft was interposed between composite valve graft and right coronary button. Postoperative course was uneventful. She was discharged from the hospital on the 17th day, and is now doing well without any symptoms.

Concomitant Gerbode-like defect and anterior mitral leaflet perforation after aortic valve replacement for endocarditis.

We present a case of concomitant left ventricle (LV) to right atrial shunt (Gerbode-like defect) and anterior mitral leaflet perforation in a 32-year-old male after aortic valve replacement for infective endocarditis of bicuspid aortic valve. This case emphasises that intra-operative transesophageal echocardiography is a sine qua non for valvular surgical procedures.

Intramural aortic abscess mimicking chronic aortic dissection.

A 77-year-old patient was referred for progressive fatigue and dyspnea on exertion. Preoperative imaging evaluations including transthoracic echocardiography and computed tomography were suggestive of a chronic ascending aortic dissection with an intramural hematoma. Intraoperatively, the intramural structure was identified as an abscess cavity.

Aortic rupture due to pneumococcal infection in aortoiliac stents.

We report a rare case of pneumococcal aortitis secondary to endovascular bare-metal stent infection. The patient was a 70-year-old man presenting with back pain 1 year after aortoiliac implantation of bare-metal kissing stents. Final diagnosis was microbial aortitis due to Streptococcus pneumoniae involving the stents that resulted in a contained aortic rupture requiring urgent surgical treatment. Emergency extra-anatomic revascularization, excision of the infected tissues, and appropriate antibiotic therapy led to a favorable outcome. A high index of suspicion is required in such a situation because the mortality rate is very high in the absence of appropriate treatment.

A novel approach to the management of an inflammatory abdominal aortic aneurysm associated with crossed-fused renal ectopia.

BACKGROUND: Crossed-fused renal ectopia is a rare anomaly that poses a therapeutic challenge in the management of abdominal aortic aneurysms (AAAs). Such challenges include preservation of renal blood flow in the setting of multiple aberrant renal arteries and ureteral anomalies. Several surgical approaches to this dilemma, including the use of traditional surgical techniques, have been described in the literature. We describe a novel approach to the management of a 7-cm inflammatory AAA associated with crossed renal ectopia with fusion. METHODS: During routine surveillance computed tomography angiography (CTA) in a 63-year-old man, a rapidly enlarging AAA with new inflammatory changes was detected. The aneurysm had increased in size from 4.8 to 7 cm over a period of 6 months. At the time of presentation, he was found to be hemodynamically stable. Findings from the laboratory tests conducted at the time of admission were normal, with a baseline glomerular filtration rate of 91.2 mL/min and creatinine of 1. The CTA revealed significant thickening of the aortic wall, suggestive of aortic inflammation, the presence of crossed renal ectopia with fusion, and numerous anomalous renal arteries. We identified two right renal arteries arising from the proximal aneurysm sac and three left renal arteries arising from the common iliac arteries. Given the aortic inflammation, an open repair approach was considered high risk compared with an endovascular aneurysm repair (EVAR). However, given the uncharacteristic arterial anatomy, a staged surgical and endovascular management option was selected. We performed an aortic debranching and renal artery revascularization, followed by an EVAR. RESULTS: We preserved renal function and excluded the aneurysm. The patient was discharged on the postoperative day 6 without periprocedural complications. A CTA was performed at 1- and 6-month follow-up period. This revealed a type 2 endoleak, which was confirmed by MR angiography. However, the aneurysm diameter had decreased in size from 7 to 6.3 cm in 1 month, and from 6.3 to 5.5 cm in 6 months. No further intervention was performed. CONCLUSION: Inflammatory AAAs associated with crossed-fused renal ectopia can be successfully managed with aortic debranching and renal artery revascularization followed by an EVAR. This epitomizes the growing role for advanced endovascular therapies in conjunction with open surgical techniques.

Abdominal pain may dominate the scene of idiopathic aortitis.

A 59-year-old man suffering from abdominal pain and having high acute phase reactants was admitted to hospital. Aortitis was discovered incidentally with magnetic resonance that was performed for another prediagnosis. Steroid and azathioprine combination was unsuccessful for remission and preventing relapses. However, steroid and methotrexate combination was successful for clinical and laboratory remissions. Also, the iliac artery occlusion was improved with stent implementation. In general, isolated idiopathic aortitis is a very rare entity and hard to be diagnosed. In this case, we describe a patient with aortitis that has only abdominal pain and treated with steroid and methotrexate combination.

Syphilitic aortitis causing bilateral coronary ostial stenosis.

Coronary ostial stenosis in otherwise normal coronary vessels is a rare complication of syphilitic aortitis. A 47-year-old man with no coronary risk factors developed severe isolated ostial stenosis in the left main coronary artery and right coronary artery. He underwent coronary artery bypass grafting using the bilateral internal thoracic arteries and gastroepiploic artery and recovered uneventfully.

Pseudoaneurysm of the ascending aorta combined with aortic valve infective endocarditis following cardiac operations.

BACKGROUND AND OBJECTIVE: Aortic pseudoaneurysms are rare but life-threatening complications of aortic procedures. Operation on the femorofemoral bypass with hypothermic circulatory arrest has been the method of choice. Iatrogenic ascending aorta pseudoaneurysm combined with infective endocarditis of the aortic valve has never been reported. MATERIALS AND METHODS: We describe a case of a pseudoaneurysm of the ascending aorta at the site of an aortotomy site concomitant with infective endocarditis of the aortic valve. A contrast computed tomographic scan was the investigation technology of choice. RESULTS: The operation was performed on femorofemoral bypass without hypothermic circulatory arrest, which provided safe re-entry and an opportunity to replace the infected aortic valve with a mechanical prosthesis and to repair the aortic defect with a patch. CONCLUSIONS: The ascending aorta pseudoaneurysm can be safely operated on with femorofemoral bypass without hypothermic cardiac arrest.

Giant pararenal abdominal aortic aneurysm.

Inflammatory aortic aneurysms are unusual vascular lesions and most commonly involve the infrarenal segment of the abdominal aorta. These complex aneurysms represent a challenge to the vascular surgeon and become even more difficult as the extent of the aneurysm and size of the inflammatory mass increase. Although well described, few cases of giant inflammatory aneurysms are reported. In this case, we review the clinical presentation and surgical management of a patient with a giant pararenal abdominal aortic aneurysm and highlight an uncommon morphologic pattern of aortic disease and provide a review of relevant literature.

Aortic root bentall graft disarticulation following repair of type a aortic dissection.

A 47-year-old man presented with chest pain and was found to have an ascending aortic dissection. He underwent aortic arch resection and replacement with a hemishield tube graft with a valve conduit, better known as the Bentall technique. Five months later he presented with shortness of breath. A transesophageal echocardiogram revealed near-complete dehiscence of the mechanical valve conduit and a periaortic root abscess. He underwent removal of the conduit and placement of a homograft aortic root and valve. One month later he developed rigors. A transthoracic echocardiogram showed worsening systolic function and a periaortic hematoma or abscess. Serial transthoracic echocardiograms revealed increasing size in the periaortic echogenic free space and subsequent evidence of flow from the left ventricle into the periaortic space. He was determined not to be a surgical candidate and discharged to hospice in fair condition. He subsequently expired.

Tubercular aortitis presenting as primary aortoenteric fistula: Report of an uncommon case.

Tubercular aortitis presenting as primary aortoenteric fistula (AEF) is a rare entity. We present a 78-year-old male who presented with upper gastrointestinal bleed and also had abdominal pain and pulsating abdominal mass and on evaluation was found to have tubercular AEF which was successfully repaired with surgery and the patient recovered with antitubercular therapy along with the surgery. This case highlights the importance of high index of suspicion with early institution of surgical repair along with antitubercular therapy for tubercular AEF with good results.

Inflammatory aneurysm of arcus aorta with massive hemoptysis.

A 72-year-old woman was admitted to the intensive care unit with a diagnosis of acute coronary syndrome. An aneurysm in the aortic arch was detected in the radiologic investigations. The aortic arch was replaced with a Dacron graft with the patient under total circulatory arrest. A pathology evaluation revealed an inflammatory aneurysm. To date, a few cases of inflammatory aneurysms of the aortic arch have been reported. Unlike the previously reported cases, the aneurysm in our case unexpectedly presented with massive hemoptysis.

A rare presentation of cardiac hydatid cyst: stroke and acute aortic occlusion.

Cardiac involvement in hydatid disease is uncommon. We report a case of a surgically treated ruptured left ventricular hydatid cyst, which presented with acute stroke and was later complicated by distal aortic embolism due to perioperative dislodgement of the germinative membrane.

Refractory PMR with aortitis: life-saving treatment with anti-IL6 monoclonal antibody (tocilizumab) and surgical reconstruction of the ascending aorta.

Aortitis is uncommon but well described in patients with polymyalgia rheumatica (PMR). While glucocorticoid remains the mainstay therapy for large-vessel vasculitis, there have been cases where tocilizumab therapy led to clinical and serological improvement in patients with relapsing or refractory disease. We report a case of life-threatening PMR with aortitis in the absence of manifestations related to giant cell arteritis, which, having failed to respond to corticosteroid therapy, was successfully treated with tocilizumab and emergency reconstruction of the ascending aorta. This case adds to the literature supporting the potential value of interleukin-6 inhibition in rare rheumatological conditions such as inflammatory aortitis.

Kissing ulcer of the aortic wall in a patient with aortic valve endocarditis.

In patients with aortic valve endocarditis, lesion of the mitral valve leaflets caused by jet strike or vegetation touch (kissing) is a well-described complication. We present a case of infectious aortic ulcer caused by aortic valve vegetation kissing. A 72-year-old woman who underwent operation for Streptococcus viridans aortic valve endocarditis presented with a "kissing ulcer" in the aortic wall disclosed by intraoperative transesophageal echocardiography. The aortic valve was replaced by a bileaflet prosthesis, and the ulcer was closed with a small patch of autologous pericardium after thorough inspection. Transesophageal echocardiography performed before discharge showed a good surgical result without signs of infection recurrence. To the best of our knowledge, this is the first report of aortic wall involvement by the mechanism described.