Deciphering Unexpected Vascular Locations of Scedosporium spp. and Lomentospora prolificans Fungal Infections, France.

Scedosporium spp. and Lomentospora prolificans are emerging non-Aspergillus filamentous fungi. The Scedosporiosis/lomentosporiosis Observational Study we previously conducted reported frequent fungal vascular involvement, including aortitis and peripheral arteritis. For this article, we reviewed 7 cases of Scedosporium spp. and L. prolificans arteritis from the Scedosporiosis/lomentosporiosis Observational Study and 13 cases from published literature. Underlying immunosuppression was reported in 70% (14/20) of case-patients, mainly those who had solid organ transplants (10/14). Osteoarticular localization of infection was observed in 50% (10/20) of cases; infections were frequently (7/10) contiguous with vascular infection sites. Scedosporium spp./Lomentospora prolificans infections were diagnosed in 9 of 20 patients ≈3 months after completing treatment for nonvascular scedosporiosis/lomentosporiosis. Aneurysms were found in 8/11 aortitis and 6/10 peripheral arteritis cases. Invasive fungal disease--related deaths were high (12/18 [67%]). The vascular tropism of Scedosporium spp. and L. prolificans indicates vascular imaging, such as computed tomography angiography, is needed to manage infections, especially for osteoarticular locations.

Embolic Events in Infective Endocarditis: A Comprehensive Review.

Infective endocarditis (IE) is a life-threating entity with three main complications: heart failure (HF), uncontrolled infection (UI) and embolic events (EEs). HF and UI are the main indications of cardiac surgery and have been studied thoroughly. On the other hand, much more uncertainty surrounds EEs, which have an abrupt and somewhat unpredictable behaviour. EEs in the setting of IE have unique characteristics that must be explored, such as the potential of hemorrhagic transformation of stroke. Accurately predicting which patients will suffer EEs seems to be pivotal to achieve an optimal management of the disease, but this complex process is still not completely understood. The indication of cardiac surgery in order to prevent EEs in the absence of HF or UI is in question as scientific evidence is controversial and mainly of a retrospective nature. This revision addresses these topics and try to summarize the evidence and recommendations about them.

Physician Made Bovine Pericardial Tube Grafts in Aortic Infection: A European Multicentre Study.

OBJECTIVE: This study examines outcome and durability of physician made bovine pericardial tube grafts in aortic infections in all anatomical locations. METHODS: This was a retrospective and prospective international multicentre study. Peri-operative and long term outcomes of patients undergoing in situ aortic reconstruction for native or graft infections with physician made bovine pericardial tube grafts between January 2008 and December 2020 in four European tertiary referral centres were analysed. The primary endpoint was recurrent aortic infection. Secondary endpoints were persistent infection, aortic re-operation for infection, graft related complications, and death. RESULTS: One hundred and sixty eight patients (77% male, mean age 67 ± 11 years) were identified: 38 (23%) with native and 130 (77%) with aortic graft infection. The thirty day mortality rate was 15% (n = 26) overall, 11% (n = 4), and 17% (n = 22) for native and aortic graft infections, respectively (p = .45). Median follow up was 26 months (interquartile range [IQR] 10, 51). Estimated survival at one, two, three, and five years was 64%, 60%, 57%, and 50%, and significantly better for native (81%, 77%, 77%, and 69%) than for graft infections (58%, 55%, 51%, and 44%; p = .011). Nine patients (5.3%) had persistent infection and 10 patients (6%) had aortic re-infection after a median of 10 months (IQR 5, 22), resulting in an estimated freedom from re-infection at one, two, three, and five years of 94%, 92%, 90%, and 86%. Estimated freedom from graft complications at one, two, three, and five years was 91%, 89%, 87%, and 87%. CONCLUSION: This multicentre study demonstrates low re-infection rates when using physician made bovine pericardial tube grafts, comparable to those of other biological grafts. The rate of graft complications, mainly anastomotic aneurysms and stenoses, was low, while graft degeneration was absent. Physician made bovine pericardial tube grafts are an excellent tool for in situ reconstruction in the setting of native aortic infection or aortic graft infection.

Microsurgical management of a ruptured intracranial mycotic aneurysm in infancy.

INTRODUCTION: During infancy, infectious aneurysms are uncommon and potentially fatal lesions with an imminent risk of intracranial hemorrhage development. CASE PRESENTATION: A 1-month-old infant presented with loss of consciousness and clonic movements of the right superior limb after a work-up for Hirschsprung's disease. His physical exam revealed stupor, miosis, anterior fontanelle swelling, and hyperreflexia of the right superior limb. Blood cultures were positive for Candida albicans. In addition, brain imaging revealed an intraparenchymal hematoma in the left temporal lobe and a saccular aneurysm at the M3 segment of the left middle cerebral artery. Upon careful discussion with the patient's family, he underwent evacuation of the hematoma and aneurysm repair. His postoperative clinical course was uneventful. At the 5-month follow-up, a brain MRI showed encephalomalacia in the area of prior hemorrhage. Furthermore, he had preserved motor function and adequate psychomotor development on subsequent pediatric evaluations. CONCLUSION: Microsurgical management of ruptured mycotic aneurysms demands a systematic work-up and nuanced appraisal of clinical and aneurysmal factors. Operating in a confined space and considering the fragile nature of aneurysms are of utmost relevance for effectively treating these lesions.

Six-year progression of medically treated infective aortitis.

OBJECTIVE: To report a medically treated case of infective aortitis with mycotic aneurysms that went on to have many years of surveillance imaging. This has not yet been documented as current recommendations for infective aortitis strongly suggest operative intervention combined with aggressive antibiotics, with very high reported mortality for non-operative management. Thus, the natural progression of sac growth during the acute infective period and in the long-term has had an opportunity to be explored. METHODS: A 77-year-old patient presented with infective aortitis confirmed on computed tomography angiography and refused operative intervention despite being explained the associated risks and benefits. She was treated aggressively with antibiotics and monitored in the community, successfully clearing the infection. RESULTS: She received a total of 6 weeks of ceftriaxone intravenously and 1 year of oral ciprofloxacin. She rapidly developed mycotic aneurysmal disease both infrarenal and suprarenal which stabilised within 1 year after diagnosis and did not progress further. CONCLUSIONS: Infective aortitis with mycotic aneurysms is usually treated surgically due to the significant risk of rupture in the acute period. This case suggests that if the acute infective period is passed, the aneurysmal disease stabilises and does not progress.

Rupture of Mycotic Abdominal Aortic Aneurysm as a Result of Incompletely Treated Multiple Peripheral Mycotic Aneurysms.

Background: A mycotic aortic aneurysm is a rare type of aortic aneurysm that can have disastrous outcomes. Most mycotic aneurysms originate from infectious sources, such as trauma, vegetation in the heart, and adjacent infectious sources. If a mycotic aneurysm is diagnosed, it should be treated simultaneously with the primary source of the infection. Case Summary: Treatment was performed for a mycotic aneurysm of the brachial artery that occurred suddenly during treatment for a fever for which the primary source of infection had not been confirmed. The workup revealed that a mycotic aneurysm of the brachial artery was the cause of the fever, followed by aneurysms in the abdomen and lower extremities and even vegetation in the heart that was not initially present. The patient declined to undergo treatment for personal reasons. After 5 months, it was revealed that the abdominal aortic aneurysm, which was initially considered normal aorta, was ruptured; however, the aneurysm was successfully treated. Conclusions: A peripheral mycotic aneurysm may be associated with multiple aneurysms. Appropriate diagnosis and complete treatments are necessary to prevent fatal consequences.

Management of a right coronary artery mycotic coronary aneurysm with percutaneous intervention with covered stents.

Coronary artery aneurysmal dilation is a rare finding with poorly understood mechanism of action that is found in small population of patients undergoing coronary angiography. Mycotic coronary aneurysm is an even rarer cause of coronary aneurysmal dilatation that develops as a potentially fatal complication of bacteremia. We present a case of mycotic right coronary artery aneurysm in a nonsurgical candidate with complex medical comorbidities treated with percutaneous coronary intervention via covered stents.

Endovascular Stent Graft Repair for Mycotic Aorto-Iliac Aneurysm Due to Brucella.

PURPOSE: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms. MATERIALS AND METHODS: The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed. RESULTS: Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak. CONCLUSION: EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms. CLINICAL IMPACT: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Danish Nationwide Study on Surgical Treatment of Infective Native Abdominal Aortic Aneurysms.

OBJECTIVE: This study aimed to describe surgical trends, survival, and infection related complications (IRC) in a Danish cohort of patients with infective native aortic aneurysms (INAAs). METHODS: A retrospective nationwide cohort study including all patients in Denmark who were surgically treated for abdominal INAA between 2000 and 2020 was conducted. Patients were identified through the Danish vascular registry, Karbase, which is a database registering all patients treated with vascular surgery in Denmark. Subsequent data on clinical presentation, treatment, all cause mortality, and complications were obtained from the electronic patient charts. RESULTS: Seventy-five patients were included in the study, of whom 60 (80%) were male, with a median age of 69 (IQR 64, 75) years. Open surgical repair (OSR) was performed in 54 (72%) patients and endovascular aortic repair (EVAR) in 21 (28%). Median follow up was 52 (IQR 32, 103) months. Open repair was consistently the most frequent treatment modality throughout the study period, but EVAR became more frequent over time. The 30 day survival of the total cohort was 97% (94 - 100%). Kaplan-Meier survival estimates for the cohort were 92% (95% CI 85 - 98%), 80% (95% CI 71 - 91%), 63% (95% CI 52 - 78%), and 48% (95% CI 35 - 66%) at one, three, five and 10 years, respectively. Patients treated by EVAR had comparable long term survival to patients treated by OSR, with a hazard ratio of 0.35 (95% CI 0.10 - 1.22), but was associated with better short term survival up to five years. The most common cause of death was sepsis. Five (9%) OSR patients had IRC compared with one (5%) EVAR patient. CONCLUSION: In this nationwide study of patients treated for abdominal INAA, an increasing number of patients were surgically treated during the study period. Patients treated by EVAR demonstrated long term survival comparable to OSR. The incidence of post-operative IRC was low. These results should be interpreted with caution and prospective registries are needed.

Referral Centre Experience with Infected Abdominal Aortic Endograft Explantation.

OBJECTIVE: The increasing use of endovascular aneurysm repair (EVAR) appears to be associated with the burden of vascular endograft infections. Complete stent graft explantation is recommended but leads to significant mortality. This study aimed to assess the technical challenges, complications, and mortality rate following infected endograft explantation. METHODS: Patients who underwent abdominal aortic endograft explantation for infection at the Bordeaux University Hospital from July 2008 to December 2020 were included retrospectively in this single centre observational study. The diagnosis was established based on the MAGIC criteria. The primary endpoint was 30 day mortality. Secondary endpoints were 90 day and in hospital mortality, survival, and re-infection. RESULTS: Thirty-four patients were included, median age 69 years (interquartile range [IQR] 65, 76), with four (12%) treated as an emergency. The median time from EVAR to explantation was 17.5 months (4.5 - 36.3). In situ reconstruction was carried out with prosthetic grafts in 24 patients (71%, including 23 antimicrobial grafts combining silver and triclosan), and biological grafts in 10 (five femoral veins, four arterial allografts, three bovine patches, one biosynthetic graft). Seventeen aorto-enteric fistulae (AEnF) were addressed with direct repair of the intestinal tract (n = 10/17; 59%) or resection and anastomosis (n = 7/17; 41%). The culture was polymicrobial in 12 patients (35%) and remained sterile in four (12%). The 30 day and in hospital mortality rates were 21% (n = 7) and 27% (n = 9). Twenty-five patients (73%) presented with early post-operative complications, requiring 16 revision procedures (47%). Over a median follow up of 16.2 months (IQR 8.3, 33.6), the mortality rate was 35% (n = 12; 11 aortic related; 32%), with two re-infections (6%), both after biological reconstruction (one for an AEnF). CONCLUSION: Early morbidity and mortality remain high after complete infected endograft explantation, even in a high volume centre. Comparison with other treatment modalities in large multicentre cohorts might be of interest.

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

OBJECTIVE: There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. METHODS: The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. RESULTS: All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. CONCLUSION: This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Adding Fuel to the Fire: Infective Endocarditis and the Challenge of Cerebrovascular Complications.

PURPOSE OF REVIEW: Infective endocarditis is a deadly disease and made more deadly by neurologic complications. We review the cerebrovascular complications of infective endocarditis and focus our discussion on medical and surgical management. RECENT FINDINGS: While management of stroke in the setting of infective endocarditis differs from standard stroke treatment, mechanical thrombectomy has proven safe and successful. Optimal timing of cardiac surgery in the setting of stroke remains an area of debate, but additional observational studies continue to add more detail to the discussion. Cerebrovascular complications in the setting of infective endocarditis remain a high stakes clinical challenge. Timing of cardiac surgery in IE complicated by stroke exemplifies these dilemmas. While more studies have suggested that earlier cardiac surgery is likely safe for those with small ischemic infarcts, there remains a need for more data defining optimal timing of surgery in all forms of cerebrovascular involvement.

Staphylococcus aureus sepsis and hemoptysis as messengers of a rather impractically located mycotic aneurysm.

BACKGROUND: Mycotic aortic aneurysms (MAA) arise due to infection of a pre-existent aneurysm or aneurysmal degeneration of an infected vascular wall. MAA of the thoracic aorta are relatively rare. Treatment is mainly guided by clinical experience as there are no large randomized trials available. CASE PRESENTATION: A 79-year-old patient was hospitalized with staphylococcus aureus sepsis and MAA originating from the ostium of the left common carotid artery (CCA). Initial treatment consisted of high-dose antibiotics and blood pressure control. After 48 hours, a CT-angiography revealed rapid growth of the MAA with imminent rupture. Various treatment options were considered: a covered stent in the left CCA, a carotid-subclavian bypass with ligation of the left CCA ostium or arch replacement, or an extra-anatomical transposition of the supra-aortic vessels combined with a thoracic endoprosthesis. The last option was selected and, combined with six weeks of antibiotics, proved successful in controlling the impending rupture and treating the MAA. CONCLUSIONS: Endovascular techniques are used if open surgery is refused, when surgical risks are prohibitively high (as definitive or palliative treatment), or as an emergency temporary treatment until definitive surgical treatment is feasible. Our high-risk patient underwent endovascular treatment for MAA as a definitive treatment. Endovascular treatment is increasingly becoming the treatment of choice due to the high morbidity and mortality of open surgical repair. Although the main concern using endovascular treatment is absence of debridement, recent studies show that combining endovascular treatment and long-term antibiotic therapy represents a potentially durable treatment and viable alternative to open surgical repair.

Treatment of superior mesenteric artery mycotic aneurysm by synthetic vascular graft: A case report.

Superior mesenteric artery (SMA) aneurysm is a rare disease, especially if it is mycotic (infective) in origin. It is difficult to detect the problem during its initial natural course and usually presents in late phase due to its complications such as rupture, dissection, haemorrhage, and mesenteric ischaemia. Initially, the patient present with non-specific symptoms like vague colicky abdominal pain, nausea, vomiting, discomfort, malaise, and low-grade fever but prompt workup and intervention can lead to definitive diagnosis and uneventful outcome. This report describes the case of a 60-year-old male patient who presented with non-specific abdominal symptoms and, on workup, was diagnosed with superior mesenteric artery mycotic aneurysm. It was successfully treated surgically by resection of aneurysm and reconstruction of superior mesenteric artery by inter-positional Polytetrafluoroethylene (PTFE) synthetic vascular graft.

Acute subdural hematoma caused by rupture of a mycotic aneurysm due to meningitis associated with infectious endocarditis: comparison of autopsy findings with postmortem computed tomography.

Forensic pathologists often encounter cases of acute subdural hematoma (SDH) due to trauma, whereas those attributable to endogenous causes are rare. Here, we report a case of the latter type in a 42-year-old man who was found dead at home after several months of fever and malaise. Postmortem computed tomography (PMCT) and autopsy were undertaken to clarify the cause of death. PMCT images revealed a fatal SDH and a localized hyper-density area in the right parietal lobe; macroscopic and microscopic examinations revealed SDH due to rupture of a mycotic aneurysm (MA) associated with meningitis. The PMCT images also indicated thickening and calcification of the mitral valve, while autopsy demonstrated infective endocarditis (IE). In addition, PMCT demonstrated a low-density area in the spleen, which was shown to be a splenic abscess at autopsy. PMCT also demonstrated tooth cavities. Based on the findings of autopsy, the cause of death was considered to be SDH due to rupture of the MA resulting from meningitis with IE and splenic abscess. Although PMCT was unable to clarify the significance of any individual feature, a retrospective review of the PMCT images might have suggested IE, bacteremia, or ruptured MA leading to SDH. This case suggests that, instead of interpreting individual features demonstrated on PMCT images, integrated interpretation of overall PMCT findings might provide clues for identifying causes of death, despite the fact that PMCT lacks diagnostic accuracy for infectious diseases such as IE and meningitis.

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.

Mycotic/Infective Native Aortic Aneurysms: Results After Preferential Use of Open Surgery and Arterial Allografts.

OBJECTIVE: Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards. METHODS: A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses. RESULTS: Seventy patients (60 men [86%], median age 68 years [range 59 - 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan-Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 - 93.0) and 71.7% (95% CI 59.2 - 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 - 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0-66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 - 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 - 33.9), 4 (OR 14.9, 95% CI 1.7 - 129.3), and CKD (OR 32.0, 95% CI 1.2 - 821.5) were related to 90 day mortality. CONCLUSION: Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn.

Femoral artery aneurysm with large hematoma from Pasteurella: case report and literature review.

BACKGROUND: Pasteurella multocida is a well-known gram-negative facultative anaerobe well known for its ability to cause soft tissue infections following animal bite or scratch. Here we present a case with mycotic aneurysm of the superficial femoral artery due to P. multocida infection. CASE PRESENTATION: A 62 year old male patient presented with worsening right leg pain and swelling. On examination, he was found to have profound swelling and erythema of the right medial thigh and tenderness to palpation. Computerized tomography showed findings suggestive of right femoral pseudoaneurysm with a large right medial thigh hematoma. Blood cultures grew P. multocida. Patient underwent emergent open resection of the mycotic aneurysm and vascular bypass surgery. Intraoperatively, the site was noted to be grossly infected with multiple pockets of pus which were drained and pus cultures grew P. multocida. The diagnosis of P. multocida bacteremia with right femoral mycotic aneurysm and thigh abscess was made. Patient received 6 weeks of intravenous ceftriaxone and recovered. CONCLUSION: Our case is the first report on infection of peripheral vessel with Pasteurella and highlights the importance of prompt surgical intervention and effective antibiotic treatment.

Mycotic Aneurysm of Internal Carotid Artery Secondary to Livestock-associated Methicillin-resistant Staphylococcus Aureus Clonal Complex CC398.

The aim of this article is to present a case of mycotic aneurysm of internal carotid artery secondary to livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) treated with resection and common-to-internal carotid artery bypass with autologous vein graft in a male pig farmer. A 69-year-old man, pig farmer, with recent dental extraction was admitted with a right cervical pulsatile mass, dysphonia, pain, leukocytosis and elevated C-reactive protein (CRP). Ultrasonography (US) and computed tomography angiography (CTA) showed a 3.9 × 4.5 cm mycotic aneurysm of right internal carotid artery with hypermetabolic uptake in positron emission tomography (PET) scan. Resection of the mycotic aneurysm and a common-to-internal carotid artery bypass with major saphenous vein graft were performed. LA-MRSA clonal complex (CC) 398 was detected in intraoperative samples and antibiotic therapy was changed according to antibiogram. Patient was discharged at the seventh postoperative day and received antibiotic therapy for 6 weeks. US 12 months later showed patency of the bypass without collections. Mycotic aneurysms of internal carotid artery are very infrequent. MRSA isolation is rare, and to the best of our knowledge this is the first case caused by multi-drug resistant LA-MRSA CC398. The treatment includes mycotic aneurysm resection and reconstruction with venous graft bypass plus intensive antibiotic therapy.

Mycobacterium Bovis Causing Mycotic Aneurysm Secondary to Intravesical Treatment with Bacillus Calmette-Guérin: A Case Report.

BACKGROUND: Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis that is used in the treatment of non-muscle invasive bladder cancer (NMIBC). Vascular complications, including mycotic aneurysms, after BCG therapy are exceedingly rare. In this patient population, the diagnosis of mycotic aneurysms can be delayed or missed due to their non-specific clinical and radiologic presentation. Literature review reveals management of mycotic aneurysms attributable to BCG therapy is widely varied.2,5-8,12,15 CASE REPORT: We report a patient who presented with mycotic aneurysm formation secondary to BCG treatment for bladder cancer that was repaired with in-line reconstruction utilizing cryoartery and buttressed with omental flap. We suggest this as an alternative treatment to in-line prosthetic graft or extra-anatomic reconstruction.