1. Endovascular repair of mycotic aortic aneurysms
Wee Ming TAY, Zhiwen Joseph LO, Glenn Wei Leong TAN, Sriram NARAYANAN, Sadhana CHANDRASEKAR

2. Disclosure
Speaker name:
......Tay Wee Ming
I do not have any potential conflict of interest

3. Debridement followed by reconstruction
Open Surgery
Debridement followed by reconstruction
Complications with bypass – 20% aortic stump disruption, 30% amputation rate, 20% risk of re-infection
Complications with in-situ aortic replacement – 8% mortality, 100% 5 year-limb-salvage , 22% graft re-infection rates
Oderich et al; Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001; 34:900-8)
EVAR
Avoidance of large incision, blood loss, revascularization, aortic clamping.
Overall mortality 19%
60% in patients with primary mycotic aorto-enteric fistula
6% in patients without aorto-enteric fistula
Kritpracha et al; Endovascular therapy for infected aortic aneurysms. J Vasc Surg 2011 ; 54:

4. Can they be managed by endovascular repair?
September 4, 2018
Endovascular repair of mycotic aneurysms :
Can they be managed by endovascular repair?
AIM: Evaluate characteristics and outcomes of patients with mycotic aortic aneurysms who underwent EVAR/TEVAR
The EVRF system yields
satisfactory clinical and anatomical midterm outcomes with very low complication rates
However, contemporary studies of the radiofrequency-induced thermal therapy device (RFiTT®), show that in experienced hands, clinical equivalence to the Venefit™ procedure can be achieved. The evidence base for EVRF® and VeinCLEAR™ devices is currently weak and absent, respectively.
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5. September 4, 2018
Methodology:
Records of patients who underwent EVAR/TEVAR in the hospital were extracted from Aortic Aneurysm Database:
Total of 271 EVAR/TEVAR performed from May 2008 to December 2015
14 Patients identified
Diagnosis of mycotic aneurysm :
Fever, abdominal pain
CT aortogram findings
Positive blood cultures
VNUS Closurefast now Venefit?
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6. September 4, 2018
Formulated based on literature review
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7. Results Immunocompromised states :
September 4, 2018
Results
Immunocompromised states :
64% had a comorbidity – Steroids, DM, HIV
Similar to other studies (70%)
Formulated based on literature review
Oderich et al; Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001; 34:900-8)
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8. Results: Salmonella Enteriditis (67%) was the most prevalent organism
Well known cause worldwide, tends to adhere to vascular endothelium, especially if atherosclerotic
Known to have fast disease progression with early rupture
Sorelius et al; Endovascular treatment of mycotic aortic aneurysms: A European multicenter study

9. Discussion: Antibiotics :
Once diagnosis suspected, IV antibiotics should be started, reasonable to perform course of antibiotics prior to surgery (2-4 weeks)
If patient not impending rupture
Extend for 12 weeks after excision and clearance of blood cultures
Lopes et al. Infectious Thoracic Aortitis: A Literature Review. Clin.Cardio. 32,9, (2009)

10. Discussion: From our study:
Pre-op, most of our patients are placed on antibiotics with average of 19 days prior to surgery
Sufficient for control of infection and sepsis
All our patients are placed on life-long antibiotics
Patients had smaller/no aneruysm by 3-6 month followup scans

11. Salmonella bacteraemia
September 4, 2018
69/male
Salmonella bacteraemia
For asian population?
Similar clinical outcomes? (But no CEAP comparison)
Efficacy, safety similar; technical aspects advantageous in EVRF
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12. EVAR performed
No endoleak
Good renal perfusion

13. Repeat CT Aortogram:
2 months later
No leak
Resolution of stranding and inflammation

14. Results

15. Discussion: Our EVARs 2 cases of endoleak
First: Type 3B endoleak in abdominal aorta graft – repeat EVAR and subsequent re-lining
Second: Type 1B/3 endoleak 1 year after initial EVAR. Complicated by aorto-esophageal fistula.
Low Aneurysm-related mortality (1/14)

16. Patient #B
MG (on prednisolone), old CVA
Admitted for abdominal pain & Fever
Blood cultures – Salmonella Enteritidis
Saccular outpouching
1.8 X 1.2 cm

18. 8 months later Re-admitted for dysphagia
CT Aortogram: Type 3 / 1b endoleak compressing on distal oesophagus
Repeat CT Aortogram 2/12 post procedure: No leak

19. 2 Grafts deployed Distal border (fix Type 1b)
Proximal border (fix Type 3)
Good flow to celiacs, SMA, renal arteries
Patients subsequently discharged well

20. Re-admitted 1/12 later
Back pain, fever
CT aortogram:
Increase in aneurysm
Gas locules
Type 1b leak

21. Endovascular repair done :
Celiac artery & SMA stented
Good seal post angiogram check
OGD done
Likely aortoenteric fistula

22. September 4, 2018
Progress
Initially in discussion with upper GI colleagues regarding stent of the esophagus
Complicated by perforated gastric ulcer
Underwent laparotomy and omental patch repair of ulcer
Sepsis, bacteraemia
Passed away a week later
For asian population?
Similar clinical outcomes? (But no CEAP comparison)
Efficacy, safety similar; technical aspects advantageous in EVRF
Copyright UPM-Kymmene Group 26

23. September 4, 2018
Conclusion
Endovascular stent grafting feasible in management of mycotic aneurysm
Fistulous aorto-enteric mycotic aneurysms poor prognosis
Sepsis must be controlled by antibiotics post-surgery
Satisfactory outcomes in this series
For asian population?
Similar clinical outcomes? (But no CEAP comparison)
Efficacy, safety similar; technical aspects advantageous in EVRF
Copyright UPM-Kymmene Group

24. Questions