Management of a Mycotic Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery

Abstract

A mycotic aortic aneurysm (AA) is a rare and dangerous condition that is associated with substantial morbidity and mortality rates. It is defined as an aortic aneurysm with one or more of the following clinical signs: fever, elevated white blood cell count, positive blood or aneurysmal wall cultures, or purulent operative findings. Of all aortic aneurysms, 0.8% to 3.4% are mycotic.1 Those mycotic AAs that involve visceral arteries can result in disastrous sequelae, such as gangrene of the intestine. Here we present an account of the successful treatment of a mycotic thoracoabdominal aortic aneurysm (TAAA) that was accompanied by celiac artery occlusion. Case ReportIn May 2015, a 60-year-old woman presented with a 2-month history of back pain, which was associated with postprandial nausea and unintended weight loss. Before her admission, her gastric symptoms had led her to undergo esophagogastroduodenoscopy and colonoscopy, the results of which were specific for gastritis, hemorrhoids, and anal fissure. She had a history of hypertension and fibromyalgia and was taking nitrofurantoin for a recent urinary tract infection.Computed tomographic (CT) scans revealed a saccular aneurysm of the thoracoabdominal aorta, together with occlusion of the celiac artery and reconstitution via multiple small collateral arteries (Figs. 1 and 2). Her laboratory values were notable for leukocytosis (white blood cell count, 17 ×10 3 /mL) and a platelet count of 778,000/ mm 3 . Her blood and urine cultures on admission were negative. We chose to perform an open Crawford extent III TAAA repair, with reimplantation of the celiac axis using a prefabricated single-branched graft. Cerebrospinal fluid was drained preoperatively to protect the spinal cord. With the patient under endotracheal general anesthesia, a left thoracoabdominal incision was made through the 8th intercostal space. The left lung was collapsed with a double-lumen endotracheal tube. We divided the diaphragm and exposed the aneurysm (Fig. 3A). After administering heparin, we cross-clamped the mid-descending thoracic aorta. The aneurysm was opened, and the intraluminal thrombus was evacuated. We widely débrided the opened aortic wall, the appearance of which was consistent with infection. After soaking an 18-mm Dacron graft in rifampin (our standard choice of antibiotic when treating mycotic aneurysms), we anastomosed the graft to the affected segment of the aorta in an end-to-end fashion, with the distal anastomosis performed just proximal to the origins of the superior mesenteric artery. After endarterectomy, we sutured (also end-to-end) an 8-mm prefabricated side branch to the celiac artery (Fig. 3B).

Management of a rapidly expanding celiac artery aneurysm with the chimney technique

“…Although a few case reports showed good outcomes with the endovascular approach associated with antibiotic therapy, lifelong antibiotherapy is advisable as well as close monitoring, strict analytic follow-up, and repeated imaging to detect additional aneurysm formation because of theoretical concerns for recurrent infection or progression. 13 …”

Aortic Infection with Visceral Artery Involvement in the Endovascular Era: Treatment Options

“…Intraoperative culture was positive for Streptococcus pneumoniae. After more than 17 months from repair, the patient was alive and free from infection [94].…”

“…For these reasons, over the years, many authors have reported a plethora of alternative, less invasive, hybrid, or endovascular approach. Here, several cases of infectious aneurysms involving visceral branches are reported, with particular attention to treatment strategies and relative results [80,81,[87][88][89][90][91][92][93][94].…”

“…Despite those encouraging results, recently Houston experience "rediscovered" the role of open surgery and direct visceral artery reconstruction for a mycotic aneurysm [94]. Coselli and his group described the case of a 60-yearold woman who presented with a 2-month history of back pain, associated with nausea and unintended weight loss.…”

Streptococcus constellatus Causing Mycotic Aneurysm in A Patient with Diffuse Large B-Cell Lymphoma

“…Several [4][5][6][7]. Medical treatment alone is not sufficient to treat infected aneurysm due to rapid progression of pseudoaneurysm; surgical treatment is warranted to avoid aortic fistula, aneurysm rupture and bleeding [8,9]. We report a first case of mycotic aneurysm without endocarditis due to Streptococcus constellatus in 58 years old male with diffuse large B cell lymphoma from East Sussex Healthcare Trust (ESHT), United Kingdom.…”