Systematic Review of the Management of Mycotic Aortic Aneurysms

Abstract

This paper is the first systematic literature review on the rare and therapeutically demanding disease of mycotic aortic aneurysm (MAA). The article assesses surgical practice, antibiotic therapy, outcome regarding survival and risk of infection related complications, along with risk factors associated with favourable and adverse outcomes. This study offers not only an overview of the management of MAAs, and demonstrates the limited scientific support for its current management, but also reveals how this could efficiently be addressed. Standardised reporting is needed to increase comparability of studies. Endovascular aortic repair appears to be associated with superior short term survival without late disadvantages, compared with open surgical repair.Objectives: The aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes. Methods: A systematic literature review was performed using the search terms mycotic and infected aortic aneurysms in the MEDLINE and ScienceDirect databases, published between January 2000 and September 2018. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinised regarding surgical technique, aortic segment involved, pre-and post-operative antibiotic regimens, survival and infection related complications (IRCs), and factors associated with adverse or favourable outcomes. Results: Twenty-eight studies, with a total of 963 patients, were included. All publications were observational, retrospective studies. Patient and study heterogeneity, along with missing data, precluded meta-analyses. Overall treatment consisted of open surgical repair (OSR; n ¼ 556 [58%]), endovascular aortic repair (EVAR; n ¼ 373 [39%]), and medical treatment alone (n ¼ 34 [3%]). OSR was the dominant surgical technique prior to 2010, shifting to EVAR thereafter. For MAAs located in the abdominal aorta, EVAR was associated with better short term survival than OSR. Antibiotic treatment for more than six months post-operatively was associated with better survival, but there was no consensus on the length of treatment. MAAs were complicated by IRCs in 21%, irrespective of surgical technique, of which 46%e70% were fatal. The most consistently reported factors associated with adverse outcomes were increasing age, rupture, suprarenal abdominal aneurysm location, and non-Salmonella positive culture. Conclusions: With few exceptions, the literature mainly consists of small, retrospective single centre studies. Standardised reporting is needed to increase comparability of studies. EVAR appears to be associated with superior short term survival without late disadvantages, compared with OSR. This suggests that EVAR can be an acceptable alternative to OSR. However, MAA treatment should always be tailor made and planned individually, and general recommendations are in vain. IRCs pose a significant threat to patients after MAA repair and require further investigation.

Diagnostic Accuracy of PET/CT and Contrast Enhanced CT in Patients With Suspected Infected Aortic Aneurysms

“…The management of infected aortic aneurysms is very demanding, and these aneurysms are highly lethal. 3,4 Early diagnosis is the cornerstone of effective treatment, 5 based on physical findings, laboratory (including blood cultures), and imaging. Imaging is particularly important, since clinical findings are often non-specific.…”

Inflammation and TGF-β Signaling Differ between Abdominal Aneurysms and Occlusive Disease

“…For example, Karkhanis et al showed that about 16% of AAA patients studied showed major thoracic findings [69]. Vice versa, many TAA patients have aneurysms at multiple sites, including the abdominal part [70,71]. Therefore, similar mechanisms might be at work in both AAA and TAA patient groups.…”

Aortitis – An Interdisciplinary Challenge

“…The optimal duration of antibiotic treatment depends on several factors, such as the immune status. Overall, a treatment course of at least six to 12 weeks is generally recommended, and antibiotics are often given for 6 or 12 months, or even lifelong on an individual case basis (51). A fulminant clinical course of IA and complications such as aortic rupture, especially in cases of IA caused by Gram-negative bacteria, is not unusual (20,52).…”

“…Ideally, the operation is performed after the acute infection and inflammation have resolved. Although open surgery is currently regarded as the gold-standard treatment for IA complicated with aortic aneurysm (51,53), endovascular aortic repair is associated with superior short-term survival and may be considered particularly for critically ill high-risk patients. Infection-related complications and long-term survival were studied in a large European multicenter study of 123 patients treated for mycotic aortic aneurysms with endovascular aortic repair (54).…”