Endovascular treatment of aorta-iliac arterial pseudoaneurysm caused by Brucella.

We aimed to analyze the feasibility of endovascular treatment for brucellosis-related aorta-iliac artery pseudoaneurysm. We did a statistical analysis that among the 11 cases, the thoracic aorta was involved in 3 cases, the abdominal aorta was involved in 6 cases, and the iliac artery was involved in 2 cases. Five patients had a history of contact with cattle and sheep, 3 had a history of drinking raw milk, 10 patients had a fever before the operation, and 11 patients had positive serum agglutination test. Blood culture was positive in 2 patients. All patients were given anti-brucellosis treatment immediately after diagnosis. One died of aortic rupture 5 days after emergency endovascular gastrointestinal bleeding. Endovascular-covered stent implantation and active anti-brucellosis therapy were used to treat 10 patients. The follow-up period was 8 years without aortic complications or death for all patients. We think early diagnosis and a combination of anti-brucellosis drugs and endovascular therapy may be the first choice for treating the pseudoaneurysm caused by Brucella.

Aspergillus spp. renal arteritis after kidney transplantation: A reappraisal.

BACKGROUND: Aspergillus spp. is an uncommon and life-threatening cause of transplantrenal artery pseudoaneurysm after kidney transplantation. CASE: We report the case of a 62-year-old woman who underwent kidney transplantation 10 months before and presented a 7-cm asymptomatic transplant renal artery pseudoaneurysm. Transplanted kidney and pseudoaneurysm were surgically removed in emergency. Renal graft, urine, and pseudoaneurysm cultures grew Aspergillus flavus. She recovered after 12 months of antifungal therapy. LITERATURE REVIEW: To date 14 cases of Aspergillus spp. renal arteritis after kidney transplantation have been published, including 50% Aspergillus flavus arteritis. Vast majority were diagnosed within 90 days after transplantation (73%). Despite allograft nephrectomy and antifungal therapy, mortality rate was high (33%).

Results of Obturator Foramen Bypass in Patients with Groin Infection and Arterial Involvement.

BACKGROUND: Arterial bypass tunneling via the obturator foramen (OFB) can be performed to circumvent groin infections during lower extremity revascularization. The objective of this study is to report safety and efficacy outcomes of OFB in the setting of infected femoral pseudoaneurysms and infected prosthetic femoral bypass grafts. METHODS: A multihospital, single-entity healthcare system retrospective review was conducted for all patients who underwent OFB between January 2014 through June 2020. Any patient >18 years of age who underwent OFB in the setting of groin infection with a minimum of 30 days follow-up was included in the trial. Demographic, operative, and clinical characteristics of patients were gathered during chart review. Statistical analysis was performed using Microsoft Excel and R studio. RESULTS: Seventeen patients underwent OFB during the defined time-period. Demographic data are presented in the first table (Demographic Characteristics). Mean American Society of Anesthesiologists score was 3.25. Mean estimated blood loss was 500 mL. Mean operative time was 307 min. Mean follow-up time was 8.5 months (range 0-35 months). In total, 41.2% patients underwent fluoroscopic-guided tunneling, and, when compared to blind tunneling, showed no difference in intraoperative complications or operative time (P value 0.3). In total, 52.9% of patients required ICU admission resulting in a mean number of 0.8 ICU days. The overall mean length of stay was 16.8 days. Two major amputations were reported during follow-up. Patient mortality within 30 days was 0%. Primary patency within 30 days was 100%. Intravenous drug use was not associated with an increased number of subsequent groin wound procedures (P value 0.3). Intravenous drug use was not associated with concomitant methicillin-resistant Staphylococcus aureus infection (P value 0.3). CONCLUSION: OFB is a safe and effective surgical option in patients who are unable to undergo anatomic tunneling during lower extremity bypass. OFB is associated with favorable rates of primary patency and amputation-free survival at midterm follow-up.

Primary Aortoduodenal Fistula: A Case Report and Current Literature Review.

Primary aortoduodenal fistula is a rare, life-threatening pathology that is difficult to diagnose and manage. We present the case of a 64-year-old male with a primary aortoduodenal fistula. Our patient initially underwent an endovascular aneurysm repair at an outside institution before being transferred to our tertiary care center, where he ultimately had definitive management with an extra-anatomic bypass, aortic ligation, duodenal resection with primary anastomosis, and gastrojejunostomy tube placement. His surgical cultures grew Candida albicans, and he was discharged with a 6-week course of intravenous antibiotics with subsequent antibiotic suppression for 1 year. He died 14 months postoperatively from tongue squamous cell carcinoma. We also review the current literature regarding epidemiology, pathology, diagnostics, management, and case reports from 2015 to present. Overall, timely diagnosis and treatment is imperative for reducing mortality from primary aortoduodenal fistula, and although formal consensus is lacking regarding most clinical aspects, an increasing number of case reports has helped describe options for management.

Factors associated with local invasion in infective endocarditis: a nested case-control study.

OBJECTIVE: A substantial proportion of infective endocarditis (IE) cases are complicated by local invasion. The purpose of this study was to identify patient and disease characteristics associated with local invasion in surgically treated IE patients. METHODS: This was a nested case-control study. All episodes of IE for patients admitted to Cleveland Clinic from 1 January 2013 to 30 June 2016 were identified from the Cleveland Clinic IE Registry. Patients ≥18 years of age who underwent surgery for IE were included. Among these, cases were those with local invasion, controls were those without. Local invasion, defined as periannular extension, paravalvular abscess, intracardiac fistula or pseudoaneurysm, was ascertained from the surgical operative note. Associations of selected factors with local invasion were examined in a multivariable logistic regression model. RESULTS: Among 511 patients who met inclusion criteria, 215 had local invasion. Mean age was 56 years; 369 were male. Overall 345 (68%) had aortic valve, 228 (45%) mitral valve, and 66 (13%) tricuspid or pulmonic valve involvement. Aortic valve involvement (OR 6.23, 95% CI 3.55-11.44), bioprosthetic valve (OR 3.88, 95% CI 2.36-6.44), significant paravalvular leak (OR 3.80, 95% CI 1.60-9.89), new atrioventricular nodal block (OR 3.77, 95% CI 1.87-7.90), infection with streptococci other than viridans group streptococci (OR 7.54, 95% CI 2.42-24.87) and presence of central nervous system emboli (OR 1.85, 95% CI 1.13-3.04) were associated with local invasion. DISCUSSION: Intracardiac and microorganism factors, but not comorbid conditions, are associated with local invasion in IE.

Graft Infection after Prosthetic Bypass Surgery for Infectious Femoral Artery Pseudoaneurysm in Intravenous Drug Users: Manifestation, Management, and Prognosis.

BACKGROUND: The aim of this study is to assess the incidence, clinical manifestations, management, and prognosis of graft infection after bypass surgery with prosthetic conduit for infectious femoral artery pseudoaneurysms (IFAPs) in patients with a history of intravenous drug use (IVDU). METHODS: A single-center retrospective chart review of IVDU presenting with graft infections after previously being treated with extra-anatomic prosthetic conduit bypass surgery for IFAPs between 2009 and 2019 was performed. Relevant clinical data and patient demographics were collected and analyzed. All patients underwent procedures consisting of graft removal with analysis of operative details and complications. RESULTS: Of all 122 patients who underwent IFAP resection with extra-anatomic prosthetic bypass, the incidence of graft infection was 38.5% (47 patients, 48 grafts) with an average age of 35.7 ± 7.3 years. The average interval between bypass surgery and infectious symptoms was 9.2 ± 2.5 months and average time from bypass to graft removal was 13.6 ± 3.4 months. The most common presentation was repeated or unhealable chronic ulcers with sinus formation or purulence either within the bypass area or along the graft conduit route (43, 89.6%). Occlusion of the infected bypass graft occurred in nearly all cases (46, 95.8%). Severe hemorrhage occurred in only 1 case (2.1%). After graft removal, the stumps were ligated in the majority of patients (33, 68.8%) with 15 patients (31.2%) not amenable to ligation due to a difficult dissection. The average time of operation was 35.4 ± 8.7 min with an average blood loss of 35.8 ± 6.7 mL. There were no significant complications such as infection reoccurrence, severe limb ischemia, amputation, or death observed postoperatively. CONCLUSIONS: Patients who receive bypass surgery with prosthetic conduit for IFAPs carry a high incidence of graft infection and subsequent occlusion. However, the presenting symptoms are generally mild, and the incidence of fatal complications is rare. This study suggests that a safe treatment option consists of direct graft removal without reconstruction. Additionally, the procedure proved to be relatively convenient and straightforward, which provides further support toward the strategy of treating IFAPs in IVDUs with pseudoaneurysm resection and prosthetic conduit bypass surgery.

Contemporary management and outcomes of complex vascular surgical groin wound infections.

OBJECTIVE: Vascular surgical groin wound infection (VS-GWI) has multiple causes and frequently is manifested as a limb- or life-threatening problem, resulting in significant morbidity and mortality. For patients undergoing operative extirpation, in situ repair, extra-anatomic bypass, or ligation can be used; however, limited data exist describing comparative results of the different operative choices or conduit subtypes. Therefore, we sought to describe our experience with management of VS-GWI and to detail outcomes of the different strategies. METHODS: Patients (2003-2017) undergoing surgical treatment of VS-GWI (Szilagyi grade III) secondary to primary infectious arteritis or infected pseudoaneurysm after percutaneous intervention as well as previous prosthetic graft placement were reviewed. The primary end point was major adverse limb events (MALEs; major amputation, graft occlusion, or unplanned reintervention). Secondary end points included 30-day mortality, wound healing, amputation-free survival (AFS), and all-cause mortality. Cox proportional hazards modeling was used to determine relative risk of end points; Kaplan-Meier methodology was employed to estimate freedom from outcomes. RESULTS: There were 149 patients (age, 65 ± 11 years; body mass index, 27 ± 6 kg/m2; 70% male; 32% diabetes) identified, of whom 120 (81%) had unilateral and 29 (19%) had bilateral VS-GWI. Indications included infected prosthetic bypass (88% [n = 131]; infrainguinal, 107; suprainguinal, 24) and primary infectious femoral artery complications (12% [n = 18]). A majority underwent single-stage operations (87% [n = 129]). In situ reconstruction occurred in 87% (n = 129); 9% (n = 13) underwent ligation, and 6% (n = 7) received extra-anatomic revascularization. Autogenous conduit was used most commonly (68% [n = 101/149]; 88% single stage), of which 81% (n = 80) were femoral vein. The remaining patients received cadaveric (15% [n = 23]; 87% single stage) or prosthetic (8% [n=12]; 67% single stage) grafts. Adjunctive myocutaneous flap was used in 37% (n = 54). Length of stay was 19 ± 15 days and 30-day mortality was 7% (n = 10), with no difference between conduit repair types. All femoral wounds healed (mean follow-up, 17 ± 11 months); however, 33% (n = 49) underwent reoperation (unplanned graft reintervention, 33%; graft occlusion, 16%; wound débridement, 15%; major amputation, 11%). Reinfection occurred in 17% (n = 27), with no difference between groups. MALE rate was 22% (n = 33; most were arterial reinterventions, 19%), with no difference in single-stage vs multistage, in situ vs extra-anatomic, or autogenous vs nonautogenous conduit strategies Predictors of MALE included younger age (hazard ratio [HR], 1.6 per decade; 95% confidence interval [CI], 1.1-2.5; P = .02) and lower body mass index (<25 kg/m2; HR, 1.6 per BMI category; 95% CI, 1.1-2.5; P = .02). Overall, 1- and 3-year freedom from MALE, AFS, and survival were as follows: MALE, 74% ± 5% and 63% ± 6%; AFS, 68% ± 4% and 58% ± 5%; survival, 78% ± 3% and 70% ± 4%. Autogenous conduit use was associated with better survival (HR, 0.5; 95% CI, 0.3-0.8; 1-year: 83% ± 4% vs nonautogenous, 78% ± 4%; 3-year: 68% ± 8% vs 53% ± 9%; log-rank, P = .006). CONCLUSIONS: An individualized approach to operative strategy and conduit choice leads to comparable outcomes in this challenging group of patients. VS-GWI can be safely managed with in situ, autogenous reconstruction in a majority of patients with acceptable mortality, excellent wound healing rates, and improved overall survival. However, a significant proportion of patients experience reinfection and MALEs, the preponderance of which are arterial reintervention, mandating need for close follow-up and graft surveillance.

Percutaneous device closure of a large complex aortic root pseudoaneurysm.

Pseudoaneurysm of the aorta is a rare and high-risk complication of native aortic valve endocarditis and can develop following cardiac surgery for aortic valve and root disease. If left untreated, there is a significant risk of aortic wall rupture and fatality. Given the high risk of mortality associated with traditional open surgical repair of aortic pseudoaneurysms, endovascular approach is a potentially favourable alternative. We describe a unique case of a young woman with a large and complex paraprosthetic pseudoaneurysm with multiple communicating fistulae which was successfully percutaneously treated with two occluder devices. In this technically challenging case, a minor but unique procedural complication is also illustrated.

A Bail Out Solution for an Urgent Situation: Endovascular Exclusion and Embolization of an Infected Femoral Pseudoaneurysm.

PURPOSE: The aim of this study is to show the utility of the combination of thrombin and endograft to solve an urgent situation related to femoral infections. CASE: We present the case of a 91-year-old female patient who underwent a femoral endarterectomy and superficial femoral artery angioplasty and developed a surgical site infection. She was readmitted to the hospital because of bleeding and was operated to suture the femoral patch and to do a plasty of sartorius muscle. Six days after the last intervention a femoral pulsatile mass was noted, and the computed tomography showed a big femoral pseudoaneurysm. Taken again to the theater and via a contralateral puncture a viabahn covered endograft was deployed from the external iliac artery to the yet diseased but patent femoral superficial femoral artery and the pseudoaneurysm was punctured, emptied, and filled with thrombin. The patient was discharged 2 weeks after the last procedure and lived for 10 months (she died because of a nonvascular related cause) with a patent graft and with healed lesions. CONCLUSIONS: In this case the endovascular solution was a definitive solution in a very old patient with several comorbidities.

Extracranial carotid artery pseudoaneurysm due to Mycobacterium tuberculosis.

Mycobacterium tuberculosis is a very rare cause of extracranial carotid artery pseudoaneurysm. A 39-year-old man presented with a rapidly increasing neck mass and hoarseness of voice for 15 days. He was on antitubercular treatment for pulmonary tuberculosis. Computed tomography angiography showed a large pseudoaneurysm of the right common carotid artery. Emergency surgery was performed to excise the pseudoaneurysm sac and repair the artery with a Dacron graft. Postoperative angiography showed normal flow in the carotids and cerebral circulation. Histology of the excised tissue was consistent with a tubercular etiology of the pseudoaneurysm.

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.

Infectious pseudo-aneurysm of the left ventricle: a case report and a review of the literature.

BACKGROUND: In the workup of a pediatric patient with pericarditis we found evidence of a pseudo-aneurysm of the left ventricle, which is a rare complication of purulent pericarditis. CASE PRESENTATION: We present a case of a six-year-old girl who was diagnosed with pericarditis and a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart. She was successfully treated with antibiotics and cardio-thoracic surgery. We found 23 published cases (21 with follow-up) of infectious pseudo-aneurysm of the heart, of which 19 underwent surgery, 5 had fatal outcome, and 2 who refused surgery survived. The majority of cases were associated with Staphylococcus aureus. The exact mechanisms of this rare complication remain unknown. CONCLUSIONS: A pseudo-aneurysm of the left ventricle is a rare and not well understood complication of a purulent pericarditis most commonly caused by Staphylococcus aureus infection. Because of risk of rupture, surgical intervention is advised.

Autogenous Femoral Vein for Secondary Repair of Subclavian Arteries: A Salvage Solution for Complex Clinical Scenarios.

BACKGROUND: Endovascular stent and prosthetic graft placement are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair due to the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency, and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here we present 3 successful cases of its use as a salvage technique following iatrogenic complications of prior surgical repair. METHODS: From 2015 to 2019, 3 patients underwent harvest of the femoral vein for use in SCA repair, with 2 carotid-axillary bypasses and 1 carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored via clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex or computed tomography (CT) scan. RESULTS: All these patients had a good outcome following their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed via CT scan or arterial duplex. The SCA repair also allowed for salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep vein thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. CONCLUSIONS: The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair via standard techniques is complicated by infection or thrombosis, and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.

A Mycotic Common Iliac Artery Pseudoaneurysm of Indeterminate Etiology.

We present the unusual case of a mycotic right common iliac artery pseudoaneurysm caused by the methicillin-susceptible Staphylococcus aureus (MSSA) of indeterminate etiology in a healthy 57-year-old man with no risk factors for infection, trauma, or malignancy. The patient initially presented with worsening subacute right lower quadrant pain and was found to have a pseudoaneurysm of the right common iliac artery. Given concern for rupture on a computed tomography angiogram (CTA), he underwent exclusion of the pseudoaneurysm with a covered stent. At the time of presentation, he had no signs or symptoms of infection. However, the patient developed fever, chills, and worsening right lower quadrant pain 13 days after the index operation and was found to have a leukocytosis, blood cultures positive for MSSA, and progressive soft-tissue changes involving the right common iliac artery on CTA consistent with infection. He was definitively treated with stent explantation, aggressive debridement and replacement with an in situ cryopreserved bypass, and short-term suppressive antibiotic therapy.