Recurrent Aorto-iliac mycotic false aneurysm Dr Jaffer Suleiman Dawood Dept Vascular surgery Royal Hospital

Challenging 64 YEARS Past history schistosomiasis -- Childhood urology follow up 2006

16 Nov 2009 Leaking large infra renal mycotic AAA

1 st Repair Laprotomy & Aorto-Bifemural graft

over three years presented repeatedly & acutely with recurrent anastomotic pseudoaneurysms of the groins and abdomen Required major revision .

5 months latter ----(April 2010 ) Right groin pulsatile swelling U/S & CT Angio- 4.5 x 4.6 cm Pseudoaneurysm with Mural thrombus

2 nd surgery Right limb of ABF graft was Shortened & Anastamosed to Right external Iliac Repair of CFA , SFA , PFA vein patch

Post OP No Recurrance

After 1 months -- May 2010 (After 6 months from 1 st operation ) Painful pulsatile Left groin swelling U/S --5x3x3 cm CT Angio- 3.5 x 3.6 cm Pseudoaneurysm with Partial thrombosis

Left groin

The 3 rd surgery ( May 2010 ) Repair done by : Shortening Left limb of ABF graft & continuity restored with Reversed great saphenious vein graft which was distally Anastamosed to SFA & PFA

In October 2010 (After 11 months from 1 st operation) 5 months after surgery on left groin Second Left groin pulsatile swelling

U/S large 8x 9 cm CT Angio- 8.5 x 7.6 cm Pseudoaneurysm with Mural thrombus

Was Arising from anastamotic line between the left Dacron limb and the inter positioned great Saphnous vein graft.

4 th Repair 10 th october 2010 Exploration of the pseudoaneurysim done . Continuty of flow restored with reversed superficial femoral vein

13 months latter from 4 th operation (After 24 months from 1 st op ) Presented with . lower abdominal pain CT Angio—6.5 x5 cm saculler Pseudoaneurym of the Left limb of the graft .

5 th intervation 19 Nov 2011 Ligation left graft limb Axillo –Unifem bypass

3 months from 5 th operation (After 27 months from 1 st operation) pulsatile swelling in the left infra clavicular region CT Angio—2.5 x2.3 cm Pseudoaneurym with wide neck

Small adjacent haematoma seen No active leak Graft occluded in the medial and distally parts

6 th intarvation ------22 Feb 2012 Small aneurysm of the right iliac artey Removal of old aorto- bifemural graft (where the left limb was ligated before ) Removal of axillo-unifem graft

Implantation of new silver coated aorto-bifemural graft Repair of subclavian Pseudoaneurysm with Vein patch

7 months latter (After 34 months from 1 st op ) Left groin pulsatile painful swelling CT Angio—4.7 x4.2x35 Pseudoaneurysm of left CFA Repaired with Reversed Vein graft

Multiple admissions and procedures . ? Castleman syndrom. Several histology were not conclusive . Blood cultures –staph epid Consultations with infection disease team Closely followed by Rh team asked for cascade of investigations which were negative . He never complaned --

CRP & ESR Monitoring

Behcet disease ? Currently Admitted. No clinical symptoms apart from this CT finding & multiple aphthous ulcers Started on steroids Waiting for stanting

Thank you