Infected aortic aneurysm

Glenda F. Medina

Department of Cardiothoracic and Vascular Surgery McGovern Medical School The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute

MSN, RN, ACNP-BC

Infected (Mycotic) aneurysm Aneurysmal degeneration of the arterial wall

secondary to infection. A serious clinical condition that is associated

with significant morbidity and mortality

Case Study CC: Abdominal Pain, Nausea HPI: 68 yo female with PMHX of Hep C and HTN who presented to urgent care clinic for abdominal pain and nausea for 1 month. Abdominal US demonstrated small abdominal aortic aneurysm and was discharged. Her PCP referred to GI services, and EGD was performed with findings of gastritis. The patient was further planned for colonoscopy. However, abdominal pain increased and she presented to ED with the following findings: VS: HR 100 BPM, BP 169/92, RR 11, O2 SAT 98% RA, TEMP 97.2 F LABS: K 2.8, CR 0.9, BUN 6, ALT 55, AST 124, LIPASE 133, LACTIC ACIC 1.3, WBC 12.4, HBG 11.0, UA Negative CT A/P w contrast: 4.1cm saccular abdominal aneurysmal without evidence rapture or dissection. Correlate clinically for aortitis

Case CT image

Case Study 10 days after initial presentation to ED patient returned to facility with complains of persistent severe abdominal, nausea, tarry stools and loss of appetite VS: HR 121 BPM, BP 196/103, RR 20, O2 SAT 98% RA, TEMP 97.0 F LABS: K 2.9, CR 0.73, BUN 7, ALT 51, AST 133, LACTIC ACID 1.4, WBC 18.7, HGB 12.1, UA Negative, INR 1.37 CTA C/A/P: contained rupture of a juxtarenal abdominal aortic aneurysm, poor perfusion to right kidney

Case CT image

Case CT image

Case Study CVS evaluation : mycotic thoracoabdominal aortic aneurysm Recommendation: emergent repair HD#1 Emergency repair of thoracoabdominal aortic aneurysm using 26 mm Dacron tube graft and bypass to left renal artery with 10 mm Dacron graft with delayed closure for second look HD#3 Exploration of left chest and retroperitoneum with omental mobilization and covering of woven Dacron graft with formal closure of chest and abdomen Surgical tissue culture : Streptococcus pneumoniae BC Negative x 2 ABX: Ceftriaxone 2gm IV Q24 HRS, x 2 months Discharged to LTAC

Etiology Direct bacterial inoculation Bacteremic seeding Contiguous/antecedent infection Endocarditis/septic emboli Impaired immunity

Microbiology Only 50-75% of cases are noted with positive

blood cultures Most common bacteria found:

Staphylococcus spp and Salmonella spp Fungal infections are rare and seen mostly on

immunosuppressed population

Clinical Manifestations

Acute Phase Chest/abdomen/back

pain Fever Malaise Weight loss N/V

Late Phase Pulsatile or enlarging mass GI Bleeding HF Acute or chronic

mesenteric ischemia Dysphagia/hoarseness Hemoptysis

Imaging CTA MRI/MRA TEE PET CT US

Medical Management Antibiotic therapy

Blood and fungal cultures prior to any antibiotic infusion

Vancomycin, Ceftriaxone, Zosyn ID consult 6 weeks of IV ABX Possible need for life long suppressive oral

antibiotic therapy

Surgical Management

Open Surgical repair Pt with low or tolerable

comorbidities Cryopreserved homograft Prosthetic grafts Antibiotic beads Omentum flap

Endovascular repair Pt with high comorbidities Pt with high mortality rates Location of aneurysm Increased risk of

persistent/recurrent infections

Take home points

History and physical exam Blood test can be normal Diagnostic imaging CTA Saccular aneurysm

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Pennell RC, Hollier LH, Lie JT, et al. Inflammatory abdominal aortic aneurysms: a thirty-year review. J Vasc Surg 1985; 2:859

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Murakami M, et al. Fluorine-18-fluorodeoxyglucose positron emission tomography-computed tomography for diagnosis of infected aortic aneurysms. Ann Vasc Surg 2014; 28:575

Sorelius K, Wanheinen A, Furebring M, et al. Nationwide Study of the treatment of Mycotic Aortic Abdominal Aortic Aneurysm Comparing Open and Endovascular repair. Circulation 2016; 134:1822

Cina CS, Arena GO, Fiture AO, et al. Raptured mycotic thoracoabdominal aortic aneurysm; a report of three cases and a systematic review. J Vasc Surg 2001; 33:861

Sorelius K, Summa P, et al. On the diagnosis of Mycotic Aortic Aneurysms. Clinic Medicine Insights Volume 12:1-8

Jia, X, Dong Y, et al. Open and endovascular repair of primary mycotic aortic aneurysms: a 10 year single center study. J Endovascular Theraphy 2013;20(3):305-310

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