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Review on Mycotic Aneurysm Joint Hospital Surgical Grand Round Li Hoi Man Princess Margaret Hospital 26/4/2014.

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Presentation on theme: "Review on Mycotic Aneurysm Joint Hospital Surgical Grand Round Li Hoi Man Princess Margaret Hospital 26/4/2014."— Presentation transcript:

1 Review on Mycotic Aneurysm Joint Hospital Surgical Grand Round Li Hoi Man Princess Margaret Hospital 26/4/2014

2 History Definition Pathogenesis Disease characteristics Diagnosis Treatment Content

3 1844: Rokitansky 1 described abscess in the walls of arteries 1851: Koch 2 reported the sudden death of a 22/M from a ruptured SMA aneurysm while treating I.E. 1885: Sir William Osler 3 proposed a causal relationship between infection of the aortic wall and subsequent aneurysm formation History of Mycotic Aneurysm

4 Initially signified an infected aneurysm found in association with bacterial endocarditis Nowadays denote an infected aneurysm of any type Mycotic aneurysm: both true and false aneurysms that are associated with infection of the arterial wall Definition

5 1.Oslerian mycotic aneurysms Embolization of infected cardiac vegetations 2.Haematogenous seeding Bacteremia microbial seeding of arteries arteritis aneurysm formation 3.Infected aneurysms Bacteremia lodge within the intramural thrombus and arteriosclerotic intima 4.Others Mechanical arterial injury with contamination Contiguous spread Pathogenesis

6

7 Era of bacterial endocarditis: 2 nd -4 th decades Now: elderly 6 th -8 th decades Male predominance (> 2/3) Higher prevalence in drug addicts and patients with AIDS Epidemiology

8 S/S from infection / bacteremia: S/S secondary to local arterial involvement / aneurysm formation: Localized tenderness, bruits, neurologic defects, pulsatile masses Thrombosis / thromboembolization Rupture pseudoaneurysm hypotensive shock, life-threatening haemorrhage Clinical presentation

9 Salmonella choleraesuis, S. typhimurium Staphylococcus aureus Streptococcus spp. Escherichia coli Immunocompromised: Campylobacter spp., Listeria spp., Mycobacterium tuberculosis Bacteriology

10 Depends on pathology type: Oslerian: abdominal aorta, femoral artery, SMA Haematogenous seeding: distal aorta, femoral, iliac and popliteal Mechanical injury: femoral, brachial Anatomic distribution

11 Blood: WCC, ESR Blood cultures: only ~ 60% Arterial Gram stains, cultures, PCR CT and / or MRI Angiography PET-CT Diagnosis

12 CT findings of infected aneurysms Saccular aneurysm Irregular aneurysmal lumen Absence of calcification Gas within aortic wall Peri-aneurysmal gas Peri-aneurysmal fluid Encasing or contiguous mass Associated para-aortic / psoas abscess Vertebral osteomyelitis Saccular aneurysms

13 CT findings of infected aneurysms Saccular aneurysm Irregular aneurysmal lumen Absence of calcification Gas within aortic wall Peri-aneurysmal gas Peri-aneurysmal fluid Encasing or contiguous mass Associated para-aortic / psoas abscess Vertebral osteomyelitis CTA: irregularity and abrupt truncation of distal SMA arteritis and thromboembolism Fat stranding around SMA arteritis Periaortic fat stranding

14 CT findings of infected aneurysms Saccular aneurysm Irregular aneurysmal lumen Absence of calcification Gas within aortic wall Peri-aneurysmal gas Peri-aneurysmal fluid Encasing or contiguous mass Associated para-aortic / psoas abscess Vertebral osteomyelitis Gas forming inflammation Hazy aortic wall and gas formation

15 CT findings of infected aneurysms Saccular aneurysm Irregular aneurysmal lumen Absence of calcification Gas within aortic wall Peri-aneurysmal gas Peri-aneurysmal fluid Encasing or contiguous mass Associated para-aortic / psoas abscess Vertebral osteomyelitis Hazy aortic wall, para-aortic fluid collection, bilateral pleural effusions, intimal calcification Periaortic edema and inflammatory soft tissue

16 CT findings of infected aneurysms Saccular aneurysm Irregular aneurysmal lumen Absence of calcification Gas within aortic wall Peri-aneurysmal gas Peri-aneurysmal fluid Encasing or contiguous mass Associated para-aortic / psoas abscess Vertebral osteomyelitis Prominent periaortic inflammation with destruction of the L3

17 Blood: WCC, ESR Blood cultures: only ~ 60% Arterial Gram stains, cultures, PCR CT and / or MRI Angiography PET-CT Diagnosis

18 Blood: WCC, ESR Blood cultures: only ~ 60% Arterial Gram stains, cultures, PCR CT and / or MRI Angiography PET-CT Diagnosis

19 Control of sepsis Arterial reconstruction Principles of Management

20 Antibiotic therapy Broad-spectrum, high dose, according to c/st Extend for at least 6 weeks post-op Lifelong if prosthetic reconstructions involved Surgical debridement Aggressive wide debridement Drains Control of sepsis

21 Open approach - extra-anatomic reconstruction In-situ reconstruction - EVAR Arterial reconstruction

22 Debridement of infected tissues Stump closure Conventional open surgery

23 Extra-anatomic reconstruction

24 Conventional approach Lower reoperation rate for graft infection High mortality rate 20,21 (23-39%) Complications: aortic stump blowout extra-anatomic bypass occlusion recurrent aortoenteric fistula recurrent graft infection 9 (up to 13%)

25 In-situ reconstruction: EVAR EVAR Rapid control of haemorrhage Reduced surgical morbidity and mortality Places a graft in direct proximity to the infection Does not afford the opportunity to debride infected tissue In combination with prolonged antibiotics and use of drainage offer resolution of arterial infection

26 Comparison between open vs EVAR Kan 12 reviewed on efficacy of EVAR in infected AAA, 41cases, EVAR (n=20) vs conventional surgery (n=21) -Early (30 days) post-op mortality similar -Late (2 year) mortality greater in conventional surgery (10% vs 25%) -Aneurysm-related event-free survival similar

27 References : 1.Rokitansky: Handbuch der pathologischen Anatomie, Ed 2, 1844, p55 2.Koch: Uber Aneurysma der Arteriae mesenterichae superioris, 1851, Erlangen 3.Osler: The Buslstonian lectures on malignant endocarditis 4.Crane: Primary multilocular mycotic aneurysm of the aorta. Arch Patho 24: 634, Ponfick: Uber embolische Aneurysmen, nebst Bemerkungen uber das acute Herzaneurysma. Virchows Arch 58: 528, Eppinger: Pathogenese der Aneurysmen einschliesslich des Aneurysma equiverminosum. Arch Klin Chir 35: 404, Revell: Primary mycotic aneurysms. Ann Intern Med 22:431, Hawkins: Primary mycotic aneurysms. Surgery 40:747, Ewart: Spontaneous abdominal aortic infections: essentials of diagnosis and management. Am Surg 49: 37, Berchtold: Endovascular treatment and complete regression of an infected AAA. J Endovasc Ther 9: 543, Koeppel: mycotic aneurysm of the abdominal aorta with retroperitoneal abscess: successful endosvascular repair. J Vasc Surg 40: 164, Kan: The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm institute case management with systemic literature comparison. Ann Vasc Surg 24(4): , Forbes: Endovascular repair of Salmonella-infected AAAs: a word of caution. J Vasc Surg 44(1): , Vallejo: The changing management of primary mycotic aortic aneurysms. J Vasc Surg Lee: In situ versus extra-anatomic reconstruction for primary infected infrarenal AAA. J vasc Surg 54(1): 64-70, Brown: Arterial reconstruction with cryopreserved human allografts in the setting of infection: a single-center experience with midterm FU. J Vasc Surg 49(3): , Gelabert: Primary Arterial infections and antibiotic prophylasix. Vascular and Endovascular Surgery – a comprehesive review Perler: Infected aneurysm. Vascular Surgery Principles and Practice Ed Semba: Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent grafts. J Vasc Interv Radiol 1998; 9: Leon: Diagnosis and Management of aortic mycotic aneurysms. Vasc and Endova Surg 44(1) 5-13, Stone: Comparison of open and endovascular repair of inflammatory aortic aneurysms. J Vasc Surg

28 ~ The End ~

29 M/65, GPH, walks unaided LLQ pain with radiation to back and subjective fever for 1/52 Temp 37.7 abd: 5cm expansile mass, tender CT: 5.2cm infra-renal AAA with impending rupture and para- aortic fat stranding Put on augmentin and flagyl Blood c/st, TB, widal test, Treponema: all –ve EVAR done FU CT showed no endoleak and aortic sac wall thickening showed interval improvement Lifelong levofloxacin 750mg daily Our cases

30 M/65 GPH Abd pain x 1/12 CT: 2.9cm infrarenal AAA with eccentric mural thrombus EVAR + fem-fem bypass on 5/2010 Blood C/st: salmonella sensitive to ciprofloxacin Subsequent CT: resolution of the inflammatory changes Antibiotic coverage discontinued 1 year later FU CT 2.5 years later: ? Relapse of infection with increased perigraft soft tissue swelling Treated with a 8-week course of rocephin 2gm daily then changed to azithromycin 500mg daily po afterwards Our cases


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