Treatment of Ruptured Infected Suprarenal Abdominal Aortic Aneurysm with hybrid procedure Dr. Nabil Batheeb Dr. Bader Alsuwailem Dr. Mohammed Alqarni

Treatment of Ruptured Infected Suprarenal Abdominal Aortic Aneurysm with hybrid procedure 82/M S/P LRRT on Aug DM, HTN, treated Pulm TB on PUO of 6wks duration.

Abdominal pain with back pain. Cough & SOB. Mildly tender abdominal mass.

WBC 16.4 Hb 10.4 ESR 100 RF, LFT WNL

+ve Blood culture of Salmonella Tazocine Ceftriaxone ( culture based)

CTA

Revascularization of SMA from Lt EIA. Cannulation of Celiac Axis. Stent graft of Abdominal Aorta covering SMA Tapered stent (26 – 21mm x 10cm)

Extubated GCS 13/15 Stable V/S Good U.O Labs WNL

Mild SOB Mild Abd distension +ve B.S S. amylase 66 RF, LFT WNL ALP 370, LDH 423 PH 7.37

POD 10

POD 14

Case # 2 65/M Small cell Lung Ca on chemotherapy. Diffuse metastasis to brain, liver & bone. V. poor prognosis.

Abd pain. Diarrhea. H/o Fever.

Endovascular Stent graft of the Abd Aorta

Extubated. Stable V/S. +ve Bld Culture Salmonella. Culture based Antibiotics.

Discharged Home Antibiotics

Case # 3 82/M. HTN, DM, CVA. Bedridden. Pulm TB on treatment since 2mon.

Endovascular Thoracic Aortic Stent Graft

Discharged home Anti TB

Discussion Osler W. (BMJ 1885) first described mycotic aortic aneurysms after performing an autopsy on a patient who had malignant endocarditis and died of a ruptured mycotic aneurysm. Mycotic aortic aneurysms are a rare yet life-threatening disease.

Discussion The majority of mycotic aortic aneurysms in the United States are caused by bacterial pathogens, with S aureus being the most common, followed by Streptococcus and Salmonella species. Clinical presentation is insidious, making their diagnosis difficult and often delayed.

Discussion A broad-spectrum antibiotic therapy has a high significance in the treatment of patients with mycotic aneurysm. ( Marjanovic I. et al, ThoracoCardiovasc Surg Dec 6 ) Despite an advancement in antibiotic regimens, purely medical management for mycotic aneurysms is inadequate because of persistent infection, subsequent aneurysm rupture, and death.

Discussion The current standard of care consists of surgical resection, in situ or extra-anatomic revascularization, and antibiotic therapy. This treatment carries a high operative mortality, especially for suprarenal and thoracic mycotic aortic aneurysms, with surgical mortality rates as high as 30-50%.

Discussion Endovascular repair of degenerative TAAs has been shown to be safe and effective with decreased perioperative morbidity and mortality. ( Jill K. Johnstone, et al 2011) Its use in mycotic TAAs is considered controversial because the infected tissue, including the aneurysm, is not resected, which may lead to recurrent sepsis and infection of the endoprosthesis.

Discussion Semba et al; 1998; first described the use of enodovascular stent grafts for the treatment of mycotic aortic aneurysms in 3 case reports, all of which demonstrated successful aneurysm exclusion and no evidence of reinfection during his follow-up period of 17 months

Discussion Late mortality is frequently related to underlying comorbidities, rather than complications from the aortic disease itself, (Patel HJ. et al Ann Thorac Surg 2009) A case series of TEVAR for MTAA (27 pt) that had infected thoracic aortic pathology showed an in-hospital survival rate of 88.5% and a 3-year survival of 57.8%. (Patel HJ. et al, J Vasc Surg 2010)

Discussion endovascular repair of MTAAs was associated with favorable perioperative and short-term mortality and morbidity. ( Jill K. Johnstone, et al 2011) Despite this theoretical disadvantage, endovascular repair of mycotic TAAs has the advantage of being a less invasive treatment, which may decrease the operative morbidity and mortality, especially in a high-risk surgical population. ( Jill K. Johnstone, et al 2011 )

Discussion 32 patients with IAA underwent endovascular treatment (40.6%) survived to 3-year follow-up (Sedivy P. et al, Eur J Vasc Endovasc Surg Oct) Infected Aneurysms of the central part of the thoracic or abdominal aorta have a more favorable prognosis with endovascular treatment. (Sedivy P. et al, Eur J Vasc Endovasc Surg Oct)

Discussion A systematic review of 22 reports with total of 48 cases of Mycotic Aortic Aneurysm treated with stent graft identified perioperative fever and ruptured aneurysms as predictive factors associated with persistent infection. (Chung-Dann Kan et al, J Vasc Surg 2007;46:906-12).

Discussion Another review of 52 articles with 91 patients showed the presence or development of an ongoing source of infection such as an aortoenteric fistula is the most common prognostic indicator of poor outcome. Stent-grafts can be used acutely as a temporary measure to achieve hemodynamic stability before definitive surgery can be performed on an elective basis. Mahmood K. Razavi et al, J Vasc Interv Radiol 2008; 19:S51–S56.

Conclusion Endovascular repair of Mycotic AA is associated with favorable perioperative and midterm mortality and morbidity. It should be considered a viable treatment option for patients who are at high surgical risk. Long-term followup is still needed to evaluate the effectiveness and durability of this treatment.

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