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.

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.

Systematic Review and Meta-Analysis of Outcomes Following Endovascular and Open Repair for Infective Native Aortic Aneurysms.

OBJECTIVE: The aim of our systematic review and meta-analysis was to demonstrate the clinical outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infective native aortic aneurysms (INAAs). METHODS: MEDLINE, Embase, and Cochrane Databases were searched for articles reporting OSR and/or EVAR repair of INAA. The methodological quality of included studies was assessed by the Newcastle-Ottawa scale and Moga-Score. Random-effects models were used to calculate the pooled measures. RESULTS: A total of 34 studies were included, with 22 studies reporting OSR alone, 6 studies reporting EVAR alone and 6 comparative studies for INAAs. The pooled estimates of infection-related complications (IRCs) were 8.2% (95% CI 4.9%-12.2%) in OSR cohort and 23.2% (95% CI 16.1%-31.0%) in EVAR cohort. EVAR was associated with a significantly increased risk of IRCs compared with OSR during follow-up (OR 1.9, 95% CI 1.0-3.7). As for survival outcomes, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality in OSR cohort were 11.7% (95% CI 7.7%-16.1%), 21.6% (95%CI 16.3%-27.4%) and 28.3% (95% CI 20.5%-36.7%; I2=50.47%), respectively. For EVAR cohort, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality were 4.9% (95% CI 1.1%-10.4%), 9.4% (95% CI 2.7%-18.7%) and 22.2% (95% CI 12.4%-33.7%), respectively. EVAR was associated with a significantly decreased of 30-day mortality (OR 0.2, 95% CI 0.1-0.6). However, no difference was found between EVAR and OSR in 3-month (OR 0.2, 95% CI 0-1.1), 1-year all-cause mortality (OR 0.4, 95% CI 0.1-1.1) or aneurysm-related mortality (OR 1.4, 95% CI 0.5-3.9). Moreover, no difference of incidence of reintervention was observed (OR 2.6, 95% CI 0.9-7.7; I2=53.7%) between two groups. CONCLUSIONS: EVAR could provide better short-term survival than OSR in patients with INAAs. However, patients undergoing EVAR suffered from higher risks of IRCs. EVAR could be considered as an alternative for low-risk patients with well-controlled infections or patients considered high-risk for open reconstruction.

Impact of PET/CT among patients with suspected mycotic aortic aneurysms.

PURPOSE: To determine the impact of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) on clinical management in patients with suspected mycotic aortic aneurysms (MAA). MATERIALS AND METHODS: For this observational cohort study 101 PET/CT were acquired in 50 patients, thereof 50 for the initial diagnosis/baseline scan, 51 for follow-up. Impact on patient management was defined in three categories: PET/CT results were "confirmed" (by clinical follow-up), "suspected" (conclusive, not confirmed), or "misleading" (proven wrong by follow-up). For clinical follow-up patient data were recorded at the time of imaging, and at the latest recorded clinical visit. It included patient demographics, clinical information, laboratory data, results of microbiology and other diagnostic procedures, information about treatment, and patient's general health condition. RESULTS: In four patients (8%) no clinical follow-up was feasible, the other 46 patients were clinically followed for a median of 898 days (IQR 320-4105). The combined evaluation of all 101 PET/CT demonstrated an impact on patient management in 78,5% of cases (48,5% confirmed, 30% suspected). Results of 21,5% of the PET/CT examinations were misleading. Respective values at baseline and at follow-up were: impact on patient management in 82% and 74,5% (70% and 27.5% confirmed, and 12% and 47% suspected), misleading cases in 18% and 25.5%. CONCLUSION: In MAA, PET/CT has a high impact on patient management, which is more pronounced with baseline than with follow-up examinations. However, PET/CT results may be misleading in a smaller proportion of cases.

First case of an invasive Bacteroides dorei infection detected in a patient with a mycotic aortic aneurysm-raising a rebellion of major indigenous bacteria in humans: a case report and review.

BACKGROUND: Bacteroides dorei is an anaerobic gram-negative bacterium first described in 2006. Because of the high similarity in mass spectra between B. dorei and Bacteroides vulgatus, discriminating between these species is arduous in clinical practice. In recent decades, 16S rRNA gene sequencing has been a complementary method for distinguishing taxonomically close bacteria, including B. dorei and B. vulgatus, at the genus and species levels. Consequently, B. dorei has been shown to contribute to some diseases, including type 1 autoimmune diabetes mellitus and atherosclerotic diseases. However, there are no reports on invasive infectious diseases caused by B. dorei. This report describes the first case of direct invasion and colonisation of human tissue by B. dorei, thus providing a warning regarding the previously proposed application of B. dorei as a live biotherapeutic for atherosclerotic diseases. CASE PRESENTATION: A 78-year-old Japanese man complained of intermittent chest/back pain and was diagnosed with a mycotic thoracic aortic aneurysm by enhanced computed tomography on admission. Despite strict blood pressure control and empirical antibiotic therapy, the patient's condition worsened. To prevent aneurysmal rupture and eliminate infectious foci, the patient underwent surgical treatment. The resected specimen was subjected to tissue culture and 16S rRNA gene sequencing analysis to identify pathogenic bacteria. A few days after the surgery, culture and sequencing results revealed that the pathogen was B. dorei/B. vulgatus and B. dorei, respectively. The patient was successfully treated with appropriate antibacterial therapy and after improvement, was transferred to another hospital for rehabilitation on postoperative day 34. There was no recurrence of infection or aneurysm after the patient transfer. CONCLUSIONS: This report describes the first case of invasive infectious disease caused by B. dorei, casting a shadow over its utilisation as a probiotic for atherosclerotic diseases.

Culture-Negative Mycotic Aortic Aneurysms Probably Have a Less Severe Clinical Nature Than Culture-Positive Counterparts.

BACKGROUND: Mycotic aortic aneurysm constitutes a potentially devastating disease that necessitates prompt suspicion and diagnosis. There is no exact consensus for treatment, but removal of infected tissues and prolonged use of antimicrobials based on the identified causative microorganisms seem widely acceptable and have been similarly practiced worldwide. However, some patients still show no identified microorganisms. In this study, we sought to determine whether there are any clinical significance or differences of note in culture-negative mycotic aortic aneurysms. METHODS: Between October 2003 and August 2018, 71 patients were identified as treated for mycotic aortic aneurysms at a single tertiary institution. Review of medical records and imaging studies were completed to collect the following information: demographics, previous medical/surgical history regarding potential infection sources, laboratory and radiologic findings, clinical presentations, treatment method, and morbidity and mortality rates. For analysis, patients were categorized into two groups: the blood and/or tissue culture-positive (CP) group and the blood and/or tissue culture-negative (CN) group. The latter was further divided as CN with identified microorganism by molecular biologic methods [CN(+)] and CN with no identified microorganism [CN(-)]. RESULTS: More patients in the CP group were symptomatic than were in the CN(+) group (100% vs. 80%; P = 0.034). However, identification of causative microorganisms did not result in a difference in symptom status upon comparing the [CP + CN(+)] and [CN(-)] groups. Inflammatory markers were the most elevated in the CP group and least elevated in the CN(-) group. The aneurysm growth rate seemed slower in the CN(-) group than in the CN(+) and CP groups (1.3 vs. 3.4 vs. 9 mm/month respectively). Aneurysm rupture at initial presentation was more prevalent in the CP group (33.3%). 18F-Fluorodeoxyglucose-positron emission tomography showed increased uptake regardless of whether or not the microorganisms were identified. Early mortality and disease-specific mortality rates during the follow-up period were higher in the CP group but without statistical significance. CONCLUSIONS: Compared with the CP group, the CN groups appeared clinically less severe, and also exhibited a relatively less devastating course as exhibited by the slower aneurysm expansion rate and smaller number of ruptured aneurysms at the initial presentation.

PET/CT in therapy control of infective native aortic aneurysms.

Infective native aortic aneurysms (INAA) are aneurysms arising from infection of the aortic wall. Treatment is demanding with 5-year survival rates between 53 and 55%. The aim of our study was to evaluate the usefulness of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the long-term monitoring of patients with proven INAA. Fifty-three PET/CT were performed in 15 patients with INAA in this single-center retrospective cohort study and retrospective analysis of prospectively collected Vascular Graft Cohort Study (VASGRA) data. Median metabolic activity (as measured by maximum standardized uptake value, SUVmax) of the aneurysms at the initial PET/CT was high (6.8 (IQR 5.7-21.8)), and lower at the last PET/CT prior to the end of antimicrobial therapy (3.9 (IQR 2.7-6.8); n = 11) as well as in the first PET/CT after the end of the treatment (3.9 (IQR 3.0-4.4);n = 6). Compared to the course of C-reactive protein alone, PET/CT provided different (> 20% difference in trend) or altering (opposed trend) information on the course of disease in at least 14 comparisons (56%) in 11 patients (73%). The one-year and five-year freedom from all-cause lethality was 92% (95% confidence interval 57%-99%). As compared to the course of C-reactive protein, PET/CT provides different and occasionally altering information in therapy control of INAA.

The value of 18F-FDG-PET-CT in the management of infective native aortic aneurysms.

OBJECTIVE: The objective of this systematic literature review was to explore the value of positron emission tomography combined with low-dose computed tomography (18F-FDG-PET-CT) in the diagnostics of infective native aortic aneurysm (INAA). METHODS: A systematic literature review was performed using the search terms mycotic- and infected aortic aneurysms in Medline and Sciencedirect databases, published between 1 January 2000 and 1 January 2020. Using the PRISMA statement, articles were scrutinized according to a predefined protocol including: timing of 18F-FDG-PET-CT examination, the maximum standardized uptake value (SUVmax), additional findings on examination, and findings on repeated scanning of 18F-FDG-PET-CT. RESULTS: Four studies were included in the analysis, comprising a total of 11 patients. Two studies were single case reports, and two were small case series, all were graded to be of low quality with high risk of bias. All patients were examined with a preoperative 18F-FDG-PET-CT, and 10 (91%) had increased 18F-FDG uptakes. The median SUVmax value was 6.53, range 4.46-9.23. The mean duration of antibiotic therapy prior to 18F-FDG-PET-CT was not known. Two patients were examined with repeated 18F-FDG-PET-CT examinations after treatment, where a decrease in SUVmax values could be demonstrated after successful treatment. CONCLUSION: The literature on 18F-FDF-PET/CT for diagnosing infective native aortic aneurysms is scarce. However, there might be a role for 18F-FDF-PET/CT in the management of the disease, in particular for patients with clinical suspicion of INAA without convincing findings on CT. SUVmax values ranging from 4.5 to 6.5 could be guiding and suggestive of metabolic activity in agreement of INAA. However, further conclusions on its usefulness, robustness and specific SUVmax values are premature, and a definitive cut-off value is probably not attainable.

Infected aortic aneurysm caused by Helicobacter cinaedi: case series and systematic review of the literature.

BACKGROUND: Helicobacter cinaedi is rarely identified as a cause of infected aneurysms; however, the number of reported cases has been increasing over several decades, especially in Japan. We report three cases of aortic aneurysm infected by H. cinaedi that were successfully treated using meropenem plus surgical stent graft replacement or intravascular stenting. Furthermore, we performed a systematic review of the literature regarding aortic aneurysm infected by H. cinaedi. CASE PRESENTATION: We present three rare cases of infected aneurysm caused by H. cinaedi in adults. Blood and tissue cultures and 16S rRNA gene sequencing were used for diagnosis. Two patients underwent urgent surgical stent graft replacement, and the other patient underwent intravascular stenting. All three cases were treated successfully with intravenous meropenem for 4 to 6 weeks. CONCLUSIONS: These cases suggest that although aneurysms infected by H. cinaedi are rare, clinicians should be aware of H. cinaedi as a potential causative pathogen, even in immunocompetent patients. Prolonged incubation periods for blood cultures are necessary for the accurate detection of H. cinaedi.

Association of Infections and Use of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection.

Importance: Prior observational studies have suggested that fluoroquinolone use may be associated with more than 2-fold increased risk of aortic aneurysm or aortic dissection (AA/AD). These studies, however, did not fully consider the role of coexisting infections and the risk of fluoroquinolones relative to other antibiotics. Objective: To estimate the risk of AA/AD associated with infections and to assess the comparative risk of AA/AD associated with fluoroquinolones vs other antibiotics with similar indication profiles among patients with the same types of infections. Designs, Settings, and Participants: This nested case-control study identified 21 651 176 adult patients from a nationwide population-based health insurance claims database from January 1, 2009, to November 30, 2015. Each incident case of AA/AD was matched with 10 control individuals by age, sex, and follow-up duration in the database using risk-set sampling. Analysis of the data was conducted from April 2019 to March 2020. Exposures: Infections and antibiotic use within a 60-day risk window before the occurrence of AA/AD. Main Outcomes and Measures: Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% CIs comparing infections for which fluoroquinolones are commonly used with no infection within a 60-day risk window before outcome occurrence, adjusting for baseline confounders and concomitant antibiotic use. The adjusted ORs comparing fluoroquinolones with antibiotics with similar indication profiles within patients with indicated infections were also estimated. Results: A total of 28 948 cases and 289 480 matched controls were included (71.37% male; mean [SD] age, 67.41 [15.03] years). Among these, the adjusted OR of AA/AD for any indicated infections was 1.73 (95% CI, 1.66-1.81). Septicemia (OR, 3.16; 95% CI, 2.63-3.78) and intra-abdominal infection (OR, 2.99; 95% CI, 2.45-3.65) had the highest increased risk. Fluoroquinolones were not associated with an increased AA/AD risk when compared with combined amoxicillin-clavulanate or combined ampicillin-sulbactam (OR, 1.01; 95% CI, 0.82-1.24) or with extended-spectrum cephalosporins (OR, 0.88; 95% CI, 0.70-1.11) among patients with indicated infections. The null findings for fluoroquinolone use remained robust in different subgroup and sensitivity analyses. Conclusions and Relevance: These results highlight the importance of accounting for coexisting infections while examining the safety of antibiotics using real-world data; the findings suggest that concerns about AA/AD risk should not deter fluoroquinolone use for patients with indicated infections.

Recommendations on Securing Microbiological Specimens to Guide the Multidisciplinary Management of Infective Native Aortic Aneurysms.

BACKGROUND: The absence of recommendations for the systematic collection of microbiological specimens to help determine the management of infective native aortic aneurysms (INAAs) may lead to diagnostic difficulty and suboptimal antibiotic treatment. In this review, we attempt to establish recommendations in the field by identifying current strategies for the diagnosis and management of INAA and comparing them with those for infective endocarditis (IE). METHODS: A systematic literature review of Medline and ScienceDirect databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)methodology to identify guidelines for the management of INAA. These guidelines were scrutinized for recommendations concerning the procurement of microbiological specimens according to a defined protocol and involvement of specialists in infectious diseases and compared with current practice for IE. RESULTS: Three guidelines were found to have sections dedicated to INAA. Of these, none provided any recommendations concerning the procurement of microbiological specimens for diagnostic and therapeutic purposes. The guidelines from the American Heart Association recommend that patients with INAA should be managed by a team of specialists (including representation from the fields of infectious diseases and/or microbiology). Current guidelines for the investigation and management of IE provide detailed recommendations concerning the procurement of microbiological specimens for diagnostic and therapeutic purposes, as well as the involvement of specialists in infectious medicine in multidisciplinary management. CONCLUSION: This article emphasizes the absence of recommendations for the optimal diagnosis and management of patients with INAAs. While specific research is required to create evidence-based recommendations, application of strategies to identify microorganisms and multidisciplinary team management derived from the management of IE may be both safe and appropriate for the clinical management of this highly complex and heterogeneous group.

In situ revascularization with rifampicin-soaked silver polyester graft for aortic infection: Results of a retrospective monocentric series of 18 cases.

OBJECTIVE: To evaluate the short and long-term results of in situ prosthetic graft treatment using rifampicin-soaked silver polyester graft in patients with aortic infection. MATERIAL AND METHOD: All the patients surgically managed in our center for an aortic infection were retrospectively analyzed. The primary endpoint was the intra-hospital mortality, secondary outcomes were limb salvage, persistent or recurrent infection, prosthetic graft patency, and long-term survival. RESULTS: From January 2004 to December 2015, 18 consecutive patients (12 men and 6 women) were operated on for aortic infection. Six mycotic aneurysms and 12 prosthetic infections, including 8 para-entero-prosthetic fistulas, were treated. In 5 cases, surgery was performed in emergency. During the early postoperative period, we performed one major amputation and two aortic infections were persistent. Intra-hospital mortality was 27.7%. The median follow-up among the 13 surviving patients was 26 months. During follow-up, none of the 13 patients presented reinfection or bypass thrombosis. CONCLUSION: This series shows that in situ revascularization with rifampicin-soaked silver polyester graft for aortic infection have results in agreement with the literature in terms of intra-hospital mortality with a low reinfection rate.

Saprochaete capitata aortitis in an immunocomopetent patient after myocardial revascularization.

Saprochaete species infection is a rare fungal disease reported so far only in immunocompromised patients. We describe the first case of aortitis caused by Saprochaete capitata, presenting as ascending aorta aneurysm, with secondary endophthalmitis in an immunocompetent patient. Infection by Saprochaete capitata is potentially fatal, with a mortality ranging from 50% to 90% of cases. In the present case aortic aneurysm caused by Saprochaete capitata aortitis was successfully treated by the combination of accurate diagnosis with surgical and specific antifungal therapy.

Chimney Endovascular Repair of Primary Mycotic Aneurysms Involving the Paravisceral Aorta.

BACKGROUND: Primary mycotic aneurysm of the aorta (MAA) is a rare and potentially life-threatening disease. Endovascular aneurysm repair (EVAR) of MAAs involving the paravisceral aorta has been rarely reported. The purpose of this study is to report our experience with chimney EVAR (CHEVAR) in patients with MAAs involving the paravisceral aorta. METHODS: We performed a retrospective review of all patients treated with EVAR at our institution during the years 2009-2019. Of those, we identified the patients who were treated with CHEVAR for MAAs. Diagnosis of MAAs was based on clinical presentation, abnormal laboratory results, and a computed tomography scan suggestive of a MAA. The data collected included patient demographics, clinical presentation, the antibiotic regimen before and after the surgery, preoperative imaging, surgical details, and perioperative and long-term morbidity and mortality. RESULTS: During the study period, we performed 54 cases of CHEVARs for aortic aneurysms. Of those, 8 (15%) were performed for mycotic aneurysms involving the visceral segment. Six (75%) were men, and the mean age was 68 years (range: 59-76). All patients were symptomatic at the time of diagnosis, presenting with either back or abdominal pain. A total of 16 visceral vessels (celiac trunk, 2; superior mesenteric artery, 7; right renal artery, 4; and left renal artery, 3) were revascularized with parallel grafts (PGs). Six patients required 2 PGs, 1 patient required 3 PGs, and 1 patient had a single PG inserted. Fifteen (94%) PGs were upward-pointing chimney stent grafts, and 1 was placed in a downward-pointing "periscope" configuration. Eight visceral arteries in 6 patients were sacrificed, either by preoperative occlusion or intentional coverage with the endograft during the procedure. The vessels sacrificed included 4 celiac trunks and 4 renal arteries (3 main branches and 1 accessory renal artery). Technical success was achieved in all patients. One patient expired in the perioperative period. One patient developed an infection-related complication. One patient experienced worsening of his renal function and eventually required dialysis. Of the 4 patients who underwent intentional sacrifice of a kidney, all experienced a moderate decrease in renal function from the baseline ( mean preoperative and postoperative serum creatinine 0.76 mg/dL and 1.2 mg/dL, respectively, increase of 43%). The mean follow-up was 8 months (range: 3-28 months). During this period, 2 patients expired, 1 from an aneurysm-related cause. No stent occlusion of the PGs occurred and no reintervention due to endoleaks was required. No patient required explanation of the stent grafts or conversion to an open repair. CONCLUSIONS: CHEVAR is a feasible and safe treatment modality for MAAs involving the visceral segment. Occasionally, intentional occlusion of the selected visceral arteries may be required to minimize the risk of gutter endoleaks in this urgent setting. Further follow-up is needed to accurately assess the durability of this repair.

Syphilitic aortitis: still a current common cause of aneurysm of the tubular portion of ascending aorta.

Aortic syphilis today is infrequently diagnosed clinically. Described herein are findings in 5 women who had resection of a fusiform aneurysm of the tubular portion of ascending aorta, and examination of the wall of the aneurysm disclosed classic features of aortic syphilis. The 5 patients were among 36 who had ascending aortic operations at Baylor University Medical Center in Dallas in 2018 and early 2019. Syphilitic aneurysm in each spared the sinus portion and involved diffusely the tubular portion of ascending aorta, beginning at the sinotubular junction. The aneurysmal wall was thicker than normal because of thickening of both intima and adventitia. The latter contained foci of lymphocytes and plasmacytes and thickened and narrowed vasa vasora. The media was disrupted by fibrous scars, which weakened the integrity of the aorta. Aortitis of the tubular portion of ascending aorta in syphilis is a diffuse process, but often is mistakenly called "atherosclerosis" which, when present in this portion of aorta, can be extensive but is focal. Aortic syphilis is important to diagnose so that patients can receive antibiotic therapy to delay, prevent, or treat neurosyphilis, a common accompaniment of aortic syphilis.

Open surgery and endovascular repair for mycotic aortic aneurysms: Benefits beyond survival.

OBJECTIVE: Endovascular techniques have been increasingly used to treat mycotic aortic aneurysms. However, apart from survival, the potential benefits of open surgery and endovascular repair for mycotic aortic aneurysms are poorly understood. The aim of this study was to evaluate the short- and mid-term outcomes after open surgery versus endovascular repair for mycotic aortic aneurysms. METHODS: All patients treated for mycotic aortic aneurysms at Peking University People's Hospital between 2001 and 2017 were identified. Survival was analyzed using Kaplan-Meier analysis and log-rank tests. The reoperation rate was analyzed using a competing-risk analysis. RESULTS: Forty-three patients were identified. The mean follow-up time was 41 months (median, 29; range, 1-135 months). The 30-day mortality in the open surgery group was 8.7% (2/23) versus 5% (1/20) in the endovascular repair group (P = .999). The overall survival for open surgery and endovascular repair was 78% versus 75%, respectively, at 1 year, and 69% versus 41% (P = .210), respectively, at 5 years. But during the follow-up, the open surgery group demonstrated multiple benefits, including a shorter length of hospital stay (26.80 ± 14.1 days vs 42.73 ± 21.22 days, P = .026), fewer readmissions (mean 0.61 vs 1.30, P = .037), and lower infection-related reoperations (P = .018) than endovascular repair at 3 years. Subgroup analysis revealed better survival for open surgery in patients with a periaortic mass less than 20 mm (P = .03). CONCLUSIONS: There were no significant differences between endovascular repair and open surgery in survival. However, in the mid-term, the potential benefits of open surgery are favorable compared with endovascular repair, including lower infection-related reoperation rates and reduced medical burden.

Clostridium septicum-infected aortic aneurysm or graft is a deadly diagnosis.

BACKGROUND: Clostridium septicum is an anaerobic, motile, spore-forming, toxin-producing gram-positive bacillus that can lead to rapidly progressive gas gangrene due to the release of alpha toxin. Aortic aneurysm secondary to C. septicum infection is a rare condition with 60 cases reported in the literature; however, we have recently treated several patients with the condition in our large tertiary care and aortic center. METHODS: Blood and tissue culture results collected between January 2005 and January 2018 and maintained in the microbiology laboratory database at the Cleveland Clinic were reviewed to identify those with C. septicum reported. Each was reviewed to determine radiographic or histopathologic correlation with aortic disease. RESULTS: Seven cases of C. septicum aortitis were reviewed. Underlying malignant disease was found in four cases and a history of remote malignant disease in one case. The most common location for infection was the infrarenal abdominal aorta. Vascular surgery had previously been performed in three of the cases. Five of the seven patients underwent operative repair. All patients were treated with ß-lactam antibiotics. The two patients who did not undergo an operation died, which is consistent with the 100% mortality described in the literature. Of the five patients who underwent an operation, there was only one documented survivor and one was lost to follow-up. CONCLUSIONS: In the largest reported case series, only a small percentage of patients with C. septicum-infected aortic aneurysms survived >1 year. In the patients described, those who did not receive an operation had 100% mortality. Earlier recognition and prompt operation with appropriate antimicrobial therapy are needed to improve the outcome of patients diagnosed with this rare infection.

Methicillin-resistant Staphylococcus aureus portends a poor prognosis after endovascular repair of mycotic aortic aneurysms and aortic graft infections.

OBJECTIVE: Mycotic aortic aneurysms and aortic graft infections (aortic infections [AIs]) are rare but highly morbid conditions. Open surgical repair is the "gold standard" treatment, but endovascular repair (EVR) is increasingly being used in the management of AI because of the lower operative morbidity. Multiple organisms are associated with AI, and bacteriology may be an important indication of mortality. We describe the bacteriology and associated outcomes of a group of patients treated with an EVR-first approach for AI. METHODS: All patients who underwent EVR for native aortic or aortic graft infections between 2005 and 2016 were retrospectively reviewed. Primary end points were 30-day mortality and overall mortality. The primary exposure variable was bacteria species. Logistic regression analysis was used to determine association with mortality. Kaplan-Meier survival analysis was used to estimate survival. RESULTS: A total of 2038 EVRs were performed in 1989 unique and consecutive patients. Of those, 27 patients had undergone EVR for AI. Thirteen presented ruptured (48%). Eighteen (67%) were hemodynamically unstable. Ten had a gastrointestinal bleed (37%), whereas others presented with abdominal pain (33%), fever (22%), chest or back pain (18.5%), and hemothorax (3.7%). Twenty patients had a positive blood culture (74%), with the most common organism being methicillin-resistant Staphylococcus aureus (MRSA) isolated in 37% (10). Other organisms were Escherichia coli (3), Staphylococcus epidermidis (2), Streptococcus (2), Enterococcus faecalis (1), vancomycin-resistant Enterococcus (1), and Klebsiella (1). Thirteen patients had 4 to 6 weeks of postoperative antibiotic therapy, six of whom died after therapy. Fourteen were prescribed lifelong therapy; 10 died while receiving antibiotics. On univariate analysis for mortality, smoking history (P = .061) and aerodigestive bleeding on presentation (P = .109) approached significance, whereas MRSA infection (P = .001) was strongly associated with increased mortality. On multivariate analysis, MRSA remained a strong, independent predictor of mortality (adjusted odds ratio, 93.2; 95% confidence interval, 1.9-4643; P = .023). Overall 30-day mortality was 11%, all MRSA positive. At mean follow-up of 17.4 ± 28 months, overall mortality was 59%. Overall survival at 1 year, 3 years, and 5 years was 49%, 31%, and 23%. Kaplan-Meier survival analysis demonstrated that MRSA-positive patients had a significantly lower survival compared with other pathogens (1-year, 20% vs 71%; 5-year, 0% vs 44%; P = .0009). CONCLUSIONS: In our series of AI, the most commonly isolated organism was MRSA. MRSA is highly virulent and is associated with increased mortality compared with all other organisms, regardless of treatment. Given our results, EVR for MRSA-positive AI was not a durable treatment option.