Mycotic aneurysm of the abdominal aorta. Review and own clinical experience

• Maksimov A.V.
• Teregulov A.Yu.
• Plotnikov M.V.
• Postnikov A.V.

Abstract

Mycotic (infectious) aneurysm is a rare pathology resulting from infectious destruction of the artery. Approximately 0.65–2% of aortic aneurysms in Europe are of infectious nature, in Asia this rate is higher. The most common pathogens are salmonellae (predominant in Asia) and staphylococci (predominant in European and North American patient populations) – about 40% of the total number of cultured organisms.

Diagnosis is based on the clinical picture (pain, fever, sepsis), and laboratory tests include inflammatory markers. Characteristic morphological signs: baggy, sometimes multi-chambered arterial wall protrusion, perivascular edema, hematoma and/or fibrous tissue. The presence of perivascular gas and rapid aneurysm growth are pathognomonic symptoms.

Currently, there is no international consensus on the optimal treatment of mycotic aneurysms, but the extremely unfavorable prognosis makes surgical treatment necessary regardless of aneurysm size.

Two strategies are used – open aneurysm resection with in situ reconstruction or extra-anatomic revascularization and stent-graft implantation. In both cases, prolonged antibiotic therapy is required. According to the literature, its duration should be at least 6–8 weeks, and possibly longer, up to lifelong.

The main disadvantage of endovascular method is the lack of open surgical sanation of septic focus. Nevertheless, the available literature data suggest that the integral results of open surgery and X-ray endovascular techniques are comparable. It is impossible to draw statistically reliable conclusions due to the small number of observations – available clinical reports do not exceed dozens of cases.

This article describes two cases of mycotic aneurysm of the infrarenal aorta. In the first case (male, 60 years old), aortic endoprosthesis was performed, followed by open sanation and drainage of retroperitoneal space and antibacterial therapy for 6 weeks (until clinical and laboratory signs of systemic infection normalized). There was no recurrence at 14 months follow-up.

In the second observation (male, 62 years old), the diagnosis of mycotic aneurysm was not established. Endoprosthesis of a ruptured infrarenal aortic aneurysm was performed. Absence of massive antibiotic therapy resulted 3 months later in the manifestation of local infectious process with the development of fatal complication – aortoduodenal fistula with fatal bleeding.

Keywords:aortic aneurysm; mycotic aneurysm; open surgery; endovascular surgery; endoprosthetics

References

1. Hsu R.B., Tsay Y.G., Wang S.S., et al. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. Journal of Vascular Surgery. 2002; 36 (4): 746–750. DOI: https://doi.org/10.1067/mva.2002.126557

2. Kesiena O., Da Silva R.C., Kumar N. Contained Rupture of a Small Mycotic Abdominal Aneurysm in a Patient With Infective Endocarditis. Cureus. 2021; 13 (10): 18963. DOI: https://doi.org/10.7759/cureus.18963

3. Macedo T.A., Stanson A.W., Oderich G.S., et al. Infected aortic aneurysms: imaging findings. Radiology. 2004; 231 (1): 250–257. DOI: https://doi.org/10.1148/radiol.2311021700

4. Osler W. The Gulstonian Lectures, on Malignant Endocarditis. British Medical Journal. 1885; 1: 467–470. DOI: https://doi.org/10.1136/bmj.1.1262.467

5. Chu C., Wong M.Y., Chiu C.H., et al. Salmonella-Infected Aortic Aneurysm: Investigating Pathogenesis Using Salmonella Serotypes. Polish Journal of Microbiology. 2019; 68 (4): 439–447. DOI: https://doi.org/10.33073/pjm-2019-043

6. Hsu R.B., Lin F.Y. Risk factors for bacteraemia and endovascular infection due to non-typhoid salmonella: a reappraisal. QJM. 2005; 98 (11): 821–827. DOI: https://doi.org/10.1093/qjmed/hci126

7. Oishi A., Asai T., Kajimoto K., et al. Mycotic Aortic Arch Aneurysm Caused by Clostridium perfringens. Cureus. 2022; 14 (1): 211–235. DOI: https://doi.org/10.7759/cureus.21135

8. Chen M.T., Chung C.H., Ke H.Y., et al. Risk of Aortic Aneurysm and Dissection in Patients with Tuberculosis: A Nationwide Population-Based Cohort Study. International Journal of Environmental Research and Public Health. 2021; 18 (21): 110–175. DOI: https://doi.org/10.3390/ijerph182111075

9. Xue J., Yao Y., Liu L. Treatment of tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis: A case series and a literature review. Medicine (Baltimore). 2018; 97 (15): 382. DOI: https://doi.org/10.1097/MD.0000000000010382

10. Yi S., Sheng L., Li W. Therapeutic effectiveness of tuberculous aneurysm and risk factors for mortality: a systematic review. General Thoracic and Cardiovascular Surgery. 2022; 70 (6): 515–525. DOI: https://doi.org/10.1007/s11748-022-01811-9

11. Fourneau I., Nevelsteen A., Lacroix H., Suy R. Microbiological monitoring of aortic aneurysm sac contents during abdominal aneurysmectomy: results in 176 patients and review of the literature. Acta Chirurgica Belgica. 1996; 96 (3): 119–122.

12. Lee W.K., Mossop P.J., Little A.F., et al. Infected (mycotic) aneurysms: spectrum of imaging appearances and management. Radiographics. 2008; 28 (7): 1853–1868. DOI: https://doi.org/10.1148/rg.287085054

13. National guidelines for the management of patients with abdominal aortic aneurysms. Moscow, 2013; 72. (in Russian)

14. Chaikof E.L., Dalman R.L., Eskandari M.K., et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of Vascular Surgery. 2018; 67 (1): 1–77. DOI: https://doi.org/10.1016/j.jvs.2017.10.044

15. Erbel R., Aboyans V., Boileau C., et al. ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014; 35 (41): 2873–2926. DOI: https://doi.org/10.1093/eurheartj/ehu281

16. National guidelines for diagnosis and treatment of aortic diseases (2017). Kardiologiya i serdechno-sosudistaya khirurgiya. 2018; 1: 5–70. (in Russian)

17. Wanhainen A., Verzini F., Van Herzeele I., et al. 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. European Journal of Vascular and Endovascular Surgery. 2019; 57 (1): 8–93. DOI: https://doi.org/10.1016/j.ejvs.2018.09.020

18. Katz S.G., Andros G., Kohl R.D. Salmonella infections of the abdominal aorta. Surgery, Gynecology and Obstetrics. 1992; 175 (2): 102–106. DOI: https://doi.org/10.1093/clinids/5.2.227

19. Hsu R.B., Chen R.J., Wang S.S., Chu S.H. Infected aortic aneurysms: clinical outcome and risk factor analysis. Journal of Vascular Surgery. 2004; 40 (1): 30–35. DOI: https://doi.org/10.1016/j.jvs.2004.03.020

20. Soravia-Dunand V.A., Loo V.G., Salit I.E. Aortitis due to Salmonella: report of 10 cases and comprehensive review of the literature. Clinical Infectious Diseases. 1999; 29 (4): 862–868. DOI: https://doi.org/10.1086/520450

21. Chiba Y., Muraoka R., Ihaya A., et al. Surgical treatment of infected thoracic and abdominal aortic aneurysms. Cardiovascular Surgery. 1996; 4 (4): 476–479. DOI: https://doi.org/10.1067/mva.2002.126557