Outcomes Following Use of Bovine Pericardium (Xenoprosthetic) Grafts for Reconstruction of Mycotic Aortic Aneurysms and Infected Aortic Grafts: A Systematic Review and Meta-Analysis.

BACKGROUND: Infected aortic grafts and mycotic aneurysms represent one of the most complex challenges faced by vascular surgeons. Treatment has progressed from extra-anatomical bypass to in situ reconstruction. Additionally, bovine pericardium reconstruction (BPR) has increased, due to accessibility and reduced lower limb morbidity. There remains, however, limited evidence for its use. The aim is to pool all known data to understand outcomes following BPR of mycotic aneurysms or infected vascular grafts. METHODS: A systematic review was conducted in November 2021 with subsequent computerized meta-analysis of the pooled results and a final search in March 2022. Three databases, Excerpta Medica dataBASE (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and National Institutes of Health PubMed (PubMed), were searched for the search term "(bovine OR xenoprosthetic) AND (aneurysm)", according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: From 9 studies, there were 133 patients: 67% graft infections and 33% mycotic aneurysms. Fifty-seven percent of reconstructions were in the abdominal aorta and 33% were in the thoracic aorta. One hundred fifty-eight pathogens were identified, including Staphylococcus aureus (23%), Candida albicans (13%), and Escherichia coli (13%). In 12%, no microorganisms were identified. Thirty-day mortality was 19.14% (CI 10.83-28.71), late mortality was 19.08% (confidence interval [CI] 7.76-32.83), and overall mortality was 40.20% (CI 29.82-50.97). One patient died intraoperatively. There were a total of 151 in-hospital complications after 30 days postoperation. Common complications were acute renal failure (17%), pneumonia (14%), delirium (12%), respiratory insufficiency (11%) and renal insufficiency (7%). Lower limb ischemia was low, occurring in 5.66% (CI 0.54-13.82) of patients. Loss of graft patency leading to reintervention occurred in 1.20% (CI 0.00-7.71) of the grafts. Reinfection rate was 0.00% (CI 0.00-1.21). CONCLUSIONS: This meta-analysis highlights low reinfection and high graft patency using BPR with medium-length follow-up; however, there remain limited long-term and comparative data regarding options for aortic reconstruction. As expected in this complex cohort, the complication rate and 30-day mortality remain high.

Coxiella Burnetii Endocarditis In A Patient With Mycotic Cerebral Aneurysms.

Q fever is an ubiquitous zoonosis caused by Coxiella burnetii, an intracellular bacterium that can produce acute or chronic infections in humans. These forms are characterized by different evolution, serological profile and treatment that must be very long to achieve a cure in chronic forms. However, the serological profile for diagnosis and the real value of serology for predicting outcome are controversial, and management dilemmas for many patients with Q fever infection are continuously emerging. In this case report, we present a 20-year-old man from Nicaragua who worked as a farmer with a culture-negative infective endocarditis who presented with a mycotic aneurysm. The present report reviews the clinical presentation and diagnosis of Q fever IE.

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.

Surgical Outcomes of Infective Native Aortoiliac Aneurysms in a Chilean Academic Center.

BACKGROUND: Infective native aortic aneurysms (INAAs), formerly called mycotic aneurysms, remain an uncommon disease with significant heterogeneity among cases; hence, there is lack of solid evidence to opt for the best treatment strategy. The present study aims to describe a 20-year experience at a single institution treating this uncommon condition. METHODS: Retrospective study of all patients treated for INAA at a single academic hospital in Santiago, Chile, between 2002 and 2022. Clinical characteristics are described, as well as operative outcomes per type of treatment. Nonparametric Mann-Whitney U-test or Kruskal-Wallis tests were performed when appropriate, and results were reported as median and ranges. Survival at given timeframes was determined by a Kaplan-Meier curve, with analysis performed through a Cox regression model. RESULTS: During the study period, 1,798 patients underwent aortic procedures at our center, of which 35 (1.9%) were treated for INAA. Of them, 25 (71.4%) were male. One patient had 2 INAAs. Median age was 69.5 years (range: 34-89 years). Of the 36 INAAs, the most frequent location was the abdominal and thoracic aorta in 20 (55.5%) and 11 (30.5%) cases, respectively, followed by the iliac arteries in 4 (11.1%) cases. One (2.7%) patient presented a thoracoabdominal INAA. Overall, endovascular treatment associated with long-term antibiotics was used in 20 (57.1%) patients: 4 of them underwent hybrid treatment. Fifteen (42.8%) patients underwent direct aortic debridement followed by in situ or extra anatomic revascularization. There was a significant difference in age between both treatment strategies (a median of 76.5 years for endovascular versus a median of 57 years for open, P = 0.011). The median hospital stay was 15 days (range: 2-70 days). The early complications rate (<30 postoperative days) was 20% (n = 7). Early mortality rate (inhospital or before postoperative 30 days) was 14.2% (n = 5). Median follow-up was 33 months (range: 6-216 months). The overall survival rates at 1, 3, and 5 years were 69.9% (standard error [SE] 8.0), 61.7% (SE 9.8), and 50.9% (SE 11.8), respectively. Five-year survival rate of patients undergoing endovascular treatment compared with open approach was 45.9% (SE 15.1) versus 80.0% (SE 17.8), respectively (P = 0.431). There were no significant differences in survival between open and endovascular treatment, hazard ratio 3.58 (confidence interval 95%: 0.185-1.968, SE ± 0.45 P = 0.454). CONCLUSIONS: Patients treated by endovascular approach were older than patients treated by open approach. Even though, the open group had a higher 5-year survival rate than the endovascular group, not statically significance differences were found between treatments.

BCGitis with aortoiliac aneurysm involvement: Report of two cases and review of the literature.

BCGitis is a rare complication after intravesical administration of Bacillus Calmette-Guérin for high-grade superficial bladder cancer and carcinoma in situ. May cause vascular involvement. We present 2 cases and a review of the literature of the case reports pubished on the 10 years prior to April of 2022, when this proyect was finished, which described a case of aortoiliac mycotic aneurysm after receiving this treatment. Of the 51 cases included (49 revised and 2 original), 100% were men, 82% were older than 65 years. The median latency period was 15 months (IQR 18). The most frequent location was the abdominal aorta, rupture occurred in 45,1% of patients. The most frequent symptom was abdominal or lumbar pain (61%), followed by general syndrome (49%). In 39,2% cases, it was associated with retroperitoneal abscesess. Attributable mortality was 13,6%. BCGitis should be included in the differential diagnosis in patients who have received BCG therapy and present vascular involvement, even years after being treated.

Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review.

BACKGROUND: To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA). METHODS: A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location. RESULTS: Forty-eight articles were included, encompassing a total of 1,358 patients (75.8% male; mean age 66.9 years; 1,372 aneurysms) treated by open (49.8%) or endovascular (50.2%) repair. Salmonella spp., and Staphylococcus spp. were the most prevalent pathogens in Asian and European countries respectively. An increasing number of descending thoracic MAAs were managed by endovascular repair (27.9% vs. 12.8%). Early mortality rates for supra- and infra-renal MAAs managed by endovascular repair were lower than OSR (suprarenal 5.4% vs. 43.2%; infrarenal 1.8% vs. 16.7%). Overall, endovascular repair demonstrated lower intraoperative (1.0% vs. 1.8%) and early mortality (6.5% vs. 15.9) rates than OSR. However, endovascular repair was associated with higher late sepsis rate (5.7% vs. 0.9%) and reintervention rate (17.6% vs. 7.3%). Pooled survival rates at 1- and 5-year were similar between the 2 groups. CONCLUSIONS: Current literature suggest that endovascular repair is an effective and safe alternative to OSR for descending thoracic, suprarenal, and infrarenal MAAs. However, endovascular repair is associated with higher risk of infection-related complications and reintervention during follow-up.

[Thoracic Endovascular Aortic Repair for Mycotic Thoracic Aortic Aneurysm After BCG Intravesical Therapy].

Bacille Calmette-Guérin( BCG) intravesical therapy is an effective and safe treatment for bladder cancer; however, mycotic aneurysms have been reported as a rare complication. Case 1:A 64-year-old man with a history of BCG intravesical therapy underwent emergent thoracic endovascular aortic repair (TEVAR) for a ruptured thoracic aortic aneurysm (TAA). He was diagnosed with BCG infection by hemosputum specimen culture five months later;then, antituberculous therapy was initiated. However, his follow-up computed tomography scan revealed stent-graft infection and new aneurysm formation. Therefore, we performed a repeated TEVAR with abdominal 4-vessel debranching. There was no recurrence of infection for six years while continuing postoperative antituberculous therapy. Case 2:A 72-year-old man who had undergone BCG intravesical therapy underwent TEVAR for a rapidly enlarging mycotic TAA. He received anti-tuberculous therapy for one year with no recurrent infection for one year. TEVAR may be an effective alternative to the open surgical procedure;however, multidisciplinary treatment including anti-tuberculous therapy and careful long-term follow up are required.

Surviving the nonsurvivable combination of a mycotic aneurysm progressing into a concomitant aorto-bronchial- and aorto-esophageal fistula, a case report.

BACKGROUND: Aortic mycotic aneurysms are a rare but life-threatening condition and may be associated with aorto-bronchial- and aorto-esophageal fistulas. Although both very rare, they carry a high mortality and require (urgent) surgical intervention. Surviving all three conditions concomitantly is extraordinary. We describe a patient who underwent staged repair of such combined defects.

Case of non-typhoidal Salmonella spp mycotic popliteal artery aneurysm with concurrent deep vein thrombosis.

Mycotic aneurysms are a well-recognised complication of non-typhoidal Salmonella bacteraemia; the risk is increased in patients with atherosclerotic disease. The infrarenal abdominal aorta is the most common site of infection; lower extremity aneurysms are uncommon.1Here we present the case of a patient with cardiovascular disease and recurrent non-typhoidal Salmonella bacteraemia, who developed a left-sided popliteal artery mycotic aneurysm with secondary popliteal vein thrombosis. The aneurysm was diagnosed upon rupture, and managed with surgical excision and bypass graft. He went on to have a complete recovery.This case illustrates the importance of clinician awareness of popliteal artery endovascular infection as a rare but significant complication of non-typhoidal Salmonella bacteraemia, which should be considered in cases with cardiovascular risk factors, recurrent or persistent bacteraemia, and lower limb deep vein thrombosis.

Multiple liver abscesses secondary to Listeria monocytogenes complicated by hepatic artery mycotic aneurysm.

A woman in her 50s presented to the emergency department with 5 days of abdominal pain, nausea and vomiting. CT imaging of her liver demonstrated three enhancing, cystic lesions in her hepatic parenchyma and a large enhancing lesion in her porta hepatis concerning for a hepatic artery aneurysm. Radiographic-guided drainage was performed on two accessible liver abscesses, and cultures from this drainage grew Listeria monocytogenes Serial imaging of the aneurysm demonstrated that the aneurysm spontaneously thrombosed and did not require further intervention. She was subsequently discharged on intravenous ampicillin with a plan to continue until radiographic resolution of the abscesses.

An autopsy case of infective aortic aneurysm with Pasteurella multocida infection: clinicopathological appearance and a review of literatures.

Here, we showed our clinicopathological findings of infected aortic aneurysm (IAA) with Pasteurella multocida, which is a Gram-negative coccobacillus and is part of the normal oral flora of many animals. The patient was a 76-year-old male animal owner with a history of diabetes mellitus, alcoholic liver damage, and laryngeal cancer. He died 16 days after admission without undergoing operation because of poor general condition. Autopsy showed saccular outpouching with loss of the existing aortic wall and marked neutrophilic infiltration in the suprarenal abdominal aorta. Rupture was not evident. A polymerase chain reaction assay using DNA extracted from formalin-fixed paraffin-embedded specimen of the aneurysmal wall detected the Pasteurella multocida gene, therefore we conclude that the present case was IAA of native aorta with Pasteurella multocida infection. A review of the literature showed that IAA of native aorta with Pasteurella multocida infection is opportunistic and that liver disorder, alcohol addiction, diabetes mellitus, and animal bite may increase its risk. On the other hand, aortic endograft infection with Pasteurella multocida frequently occurred without an immunocompromised state. Pasteurella multocida may be a distinct causative microorganism in IAA, and/or sepsis when the participant is an animal owner.

Salmonella enteritidis abdominal aorta mycotic aneurysm presented with acute cholestatic jaundice: A case report and literature review.

Mycotic aneurysm is one of the extra-intestinal manifestations of Salmonella Enteritidis infection. The diagnosis of this condition is challenging owed to its variation in clinical presentations. We presented a case of a 54-year-old man with underlying diabetes mellitus and chronic smokers presented with acute right flank pain and fever associated with mild jaundice. The initial laboratory investigations suggested features of obstructive jaundice and urinary tract infection. The contrast enhancing computed tomography of the abdomen revealed the presence of saccular mycotic aneurysm located at the infrarenal abdominal aorta. The blood culture grew Salmonella Enteritidis which was susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, ciprofloxacin, ampicillin, and amoxicillin-clavulanic acid. Intravenous ceftriaxone was initiated, and he underwent open surgery and artery repair at day 8 of admission. He responded well to the treatment given and subsequently discharged home after completed three weeks of intravenous ceftriaxone.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report.

BACKGROUND: Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention. CASE PRESENTATION: A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient's right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications. CONCLUSIONS: Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Mycotic Aortic Aneurysm As A Rare Case Of Constipation And Weight Loss.

Mycotic aortic aneurysm is a rare entity, manifesting with nonspecific symptoms of abdominal pain, fever, general malaise. We present a case of an 83-years-old-man, with hematemesis, generalized abdominal pain, and a six-month history of constipation, anorexia, and involuntary weight loss. Upper endoscopy revealed an erosion with oozing hemorrhage and hemostasis was performed. Later he developed a hemorrhagic shock. Abdominal computed tomography disclosed a 3,7x2,5x- 2,5cm aneurysm of the abdominal aorta with an aortoduodenal fistula, inducing an inflammatory plastron that encompassed the descending colon and duodenum. The inflammatory plastron prompted partial duodenal and colonic obstruction and led to an atypical presentation of an aortic aneurysm. Mycotic aneurysms complicated with aorto-enteric fistulas are potentially life-threatening conditions. We highlight the rarity of this case, as the clinical manifestations were prolonged and atypical. The goal is to drive awareness to maintain a high clinical suspicion, as early detection is critical to avoid a tragic outcome.