Delayed Stent Infection after Deployment of a Carotid Dual Layer Stent in Dialysis Cases.

Objective: Infection after carotid artery stenting (CAS) is rare. We report two dialysis cases of delayed stent infection associated with a carotid dual-layer stent (DLS), which occurred several months after deployment of the stent. Case Presentations: Case 1: A 74-year-old man receiving dialysis underwent CAS with DLS. Three months after CAS, the patient developed a high fever, neck pain, and neck swelling. Neck CT and carotid ultrasonography (CUS) indicated an abscess around the inserted DLS. The patient was treated with antibiotic agents and fully recovered. Case 2: A 73-year-old man receiving dialysis underwent CAS with DLS. Two months after CAS, this patient also developed a high fever, neck pain, and neck swelling. Contrast-enhanced neck CT indicated inflammatory effusion with an abscess and a giant infectious pseudoaneurysm. Endovascular stent graft reconstruction was employed urgently under antibiotic therapy to prevent its rupture. However, intracranial hemorrhage occurred postoperatively and left hemiparesis remained. Conclusion: Delayed carotid stent infection is a rare but severe complication. The use of a DLS might be avoided during CAS for dialysis cases.

Transarterial embolization for an infected internal iliac artery aneurysm without recurrence for a long period: A case report.

We report an 85-year-old man who underwent transarterial embolization (TAE) for an infected internal iliac artery aneurysm. The patient presented with fever and left lower abdominal pain. Computed tomography (CT) revealed the expansion of a left internal iliac artery aneurysm. We planned surgical treatment for an infected internal iliac artery aneurysm; however, the patient's age and general condition made the surgery high-risk. Therefore, we performed emergency TAE. The patient was administered antibiotics for 4 weeks and discharged on day 33 after the procedure with good progression. A 3-year follow-up CT scan showed aneurysm reduction and no recurrent infections. This case report highlights that TAE can be a treatment option for patients with an infected artery aneurysm.

Ruptured Mycotic Aneurysm of the Superior Mesenteric Artery: A Case Report.

An infected (mycotic) aneurysm of the visceral arteries is an uncommon entity, which may arise from a secondary infection of a preexisting aneurysm or be due to degeneration from a primary infection. Mycotic aneurysms require prompt recognition and definitive treatment; otherwise, there can be devastating morbidity and mortality. We present the case of a 51-year-old female with HIV and Crohn's disease who presented with subacute abdominal pain, nausea, and vomiting and was found to have an ultimately fatal mycotic aneurysm of the superior mesenteric artery. In addition, we discuss the characteristic imaging features of mycotic aneurysms on computed tomography and magnetic resonance imaging.

Infective Native Aortic Aneurysm: a Delphi Consensus Document on Treatment, Follow Up, and Definition of Cure.

OBJECTIVE: Evidence is lacking to guide the management of infective native aortic aneurysm (INAA). The aim of this study was to establish expert consensus on surgical and antimicrobial treatment and follow up, and to define when an INAA is considered cured. METHODS: Delphi methodology was used. The principal investigators invited 47 international experts (specialists in infectious diseases, radiology, nuclear medicine, and vascular and cardiothoracic surgery) via email. Four Delphi rounds were performed, three weeks each, using an online questionnaire with initially 28 statements. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements were revised and added or deleted, and the results were presented in the iterative rounds. Consensus was defined as ≥ 75% of the panel rating a statement as strongly agree or agree on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha > 0.80. RESULTS: All 49 panellists completed all four rounds, resulting in 100% participation. One statement was added based on the results and comments of the panel, resulting in 29 final statements: three on need for consensus, 20 on treatment, five on follow up, and one on definition of cure. All 29 statements reached agreement of ≥ 86%. Cronbach's alpha increased for each consecutive round; round 1, 0.85; round 2, 0.90; round 3, 0.91; and round 4, 0.94. Thus, consensus was reached for all statements. CONCLUSION: INAAs are rare, and high level evidence to guide optimal management is lacking. This consensus document was established with the aim of helping clinicians manage these challenging patients, as a supplement to current guidelines. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Clinical outcomes of in situ graft reconstruction in treating infected abdominal aortic stent grafts following endovascular aortic aneurysm repair: a single-center experience.

Purpose: This study aimed to review our experience with the explantation of infected endovascular aneurysm repair (EVAR) grafts. Methods: This single-center, retrospective, observational study analyzed the data of 12 consecutive patients who underwent infected aortic stent graft explantation following EVAR between January 1, 2010 and December 31, 2019, of which 11 underwent in situ graft reconstruction following graft removal. The presentation symptoms, infection route, original pathology of abdominal aortic aneurysms (AAA), graft materials, and clinical outcomes were analyzed. Results: Six patients underwent total explantation, whereas 5 underwent removal of only the fabric portions. For in situ reconstructions, prosthetic grafts and banked allografts were used in 8 and 3 patients, respectively. Four mechanisms of graft infection were noted in 11 patients: 4 had bacteremia from systemic infections, 3 had persistent infections following EVAR of primary infected AAA, 3 had ascending infections from adjacent abscesses, and 1 had an aneurysm sac erosion resulting in an aortoenteric fistula. No infection-related postoperative complications or reinfections occurred during the mean 65.27-month (standard deviation, ±52.51) follow-up period. One patient died postoperatively because of the rupture of the proximal aortic wall pseudoaneurysm that had occurred during forceful bare stent removal. Conclusion: Regardless of graft material, in situ graft reconstruction is safe for interposition in treating an infected aortic stent graft following EVAR. In our experience, the residual bare stent is no longer a risk factor for reinfection. Therefore, it is important not to injure the proximal aortic wall when removing the bare stent by force.

A case of lymphoma mimicking infected internal iliac artery aneurysm.

BACKGROUND: Malignant lymphoma rarely mimics an infected arterial aneurysm and a ruptured arterial aneurysm because of similar imaging findings, leading to misdiagnosis. The hematomas of ruptured aneurysms are radiologically difficult to distinguish from those of malignant lymphoma in emergency settings. Hence, a definitive diagnosis is crucial to avoid unnecessary surgery. CASE PRESENTATION: A man in his 80s with hematuria and shock vital had right internal iliac artery aneurysm (IIAA) and perianeurysmal fluid retention, which appeared to be a ruptured or an infected aneurysm. Treatment was initiated for infected IIAA instead of for ruptured IIAA. Systemic inflammatory response syndrome developed, and the infectious sources were assessed. Pacemaker lead and urinary tract infections were identified and treated; however, blood pressure was unstable. The aneurysm was treated with endovascular aortic aneurysm repair following antibiotic therapy; however, fluid retention increased, and inflammatory status and hematuria deteriorated. Open surgical conversion was performed to manage the infected lesions. Although an iliopsoas abscess was detected during surgery and nephrectomy and ureterectomy were performed to control the hematuria, analysis of the removed tissues led to the pathological diagnosis of diffuse large B-cell lymphoma (DLBCL). CONCLUSIONS: We encountered a case of DLBCL with imaging findings mimicking an infected internal iliac artery aneurysm, and definitive diagnosis was made more than 2 months after the initial examination. Definitively diagnosing malignant lymphoma around an iliac artery aneurysm based merely on symptoms and imaging findings is extremely difficult. Thus, histological examination should be actively performed in atypical infected aneurysms.

Infected False Aneurysm of Brachiocephalic Trunk - Rare but Highly Lethal Cause of Dyspnea.

False aneurysm of the brachiocephalic trunk is a very rare but highly lethal, life-threatening, and difficult-to-treat condition. In this report, we present a case of a patient who suffered from rapidly worsening dyspnea caused by infected false aneurysm of the brachiocephalic trunk compressing the trachea that was successfully treated by stent graft implantation. The main purpose of this article is to consider other, less common causes of dyspnea and to explain the pathogenesis of infected true/false aneurysm and its management. Due to the rarity, history-taking and physical examination should be thorough, and symptoms and signs should be analyzed deeply. Simplification should be avoided during diagnosis. In addition, we would like to highlight the option of stent grafts as an alternative to surgery in the management of patients suffering from infected aneurysm who are at high surgical risk.

Treatment of superior mesenteric artery mycotic aneurysm by synthetic vascular graft: A case report.

Superior mesenteric artery (SMA) aneurysm is a rare disease, especially if it is mycotic (infective) in origin. It is difficult to detect the problem during its initial natural course and usually presents in late phase due to its complications such as rupture, dissection, haemorrhage, and mesenteric ischaemia. Initially, the patient present with non-specific symptoms like vague colicky abdominal pain, nausea, vomiting, discomfort, malaise, and low-grade fever but prompt workup and intervention can lead to definitive diagnosis and uneventful outcome. This report describes the case of a 60-year-old male patient who presented with non-specific abdominal symptoms and, on workup, was diagnosed with superior mesenteric artery mycotic aneurysm. It was successfully treated surgically by resection of aneurysm and reconstruction of superior mesenteric artery by inter-positional Polytetrafluoroethylene (PTFE) synthetic vascular graft.

Infección de endoprótesis aórtica abdominal. Experiencia de una década y revisión de la literatura / Abdominal aortic endograft infection. A decade of experience and literature review

Introducción: La infección de endoprótesis de aorta abdominal (EVAR) es una entidad infrecuente, pero con una elevada mortalidad. Son escasas las publicaciones al respecto en nuestro país y no hay un consenso definitivo acerca de su manejo. Se acepta como gold standard la cirugía de explante, planteándose como alternativas la antibioterapia asociada a drenaje o limpieza del saco. Métodos: Revisión retrospectiva descriptiva de las endoprótesis aórticas tipo EVAR infectadas en nuestro centro terciario (Hospital Universitario de Cruces) en la última década (2010-2019). Resultados: Describimos las características clínicas y microbiológicas de 10 infecciones de EVAR, así como su manejo y resultados obtenidos. La incidencia de infección de EVAR fue del 3%. El tiempo medio hasta la presentación clínica de la infección fue de 16,9 meses (mediana de 4,5 meses). Se logró el diagnóstico microbiológico en el 100% de los casos (predominio de cocos grampositivos). La mortalidad global fue del 50% (sin embargo, la supervivencia fue del 100% tras limpieza quirúrgica del saco). Conclusiones: El cultivo de muestras de colecciones periprotésicas y saco aneurismático muestra una gran rentabilidad, llegando al diagnóstico microbiológico en todos los casos, a pesar de ser negativos los hemocultivos en un 50%. Destacan los buenos resultados obtenidos con la limpieza quirúrgica y preservación del dispositivo, asociada a antibioterapia. Sin embargo, en nuestra serie de casos se aprecia una importante heterogeneidad, lo que dificulta elaborar recomendaciones de manejo y obliga a individualizar el tratamiento.(AU)

Introduction: Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the “gold standard” treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. Methods: We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010–2019). Results: We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). Conclusions: Perigraft or aneurysm sac aspiration culture shows their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.(AU)

Autologous vein graft repair of mycotic innominate artery aneurysm: A case report.

INTRODUCTION: Innominate artery aneurysm (IAA) is an extremely rare fatal condition with an overall prevalence of less than 3 % of all supra-aortic artery aneurysms. These infrequent lesions usually present as an emergency and require challenging surgical procedures. CASE PRESENTATION: We report an interesting case of mycotic IAA in a 25 years old male patient. He was a known intravenous drug abuser having mycotic aneurysm arising from brachiocephalic artery with eccentric thrombus causing adjacent mass effect over the trachea. He underwent successful emergent surgical management of aneurysm with autologous vein graft using superficial femoral vein. Unfortunately, he died due to massive upper gastrointestinal bleeding leading to multi-organ failure after a prolonged post-operative course. CLINICAL DISCUSSION: Mycotic aneurysms of the IA are extremely rare with an overall incidence of 1-2.7 % cases of all IAA. Presentation of the IAA can be quite variable from asymptomatic to symptoms exhibiting mass effect over surrounding structures. Rupture of IAA can be fatal and can occur if not treated promptly. There are no current recommendations or guidelines for treatment and interventions in IAA. Surgical management involves complete excision of the aneurysm and then revascularization. CONCLUSION: Infected Innominate artery aneurysm is a rare surgical entity requiring early diagnosis, detailed investigation and prompt surgical management involving multidisciplinary team approach. Our case describes a relatively innovative approach to this scarce condition.

Emphysematous Salmonella-Infected Aneurysm of the Aortic Arch: Case Report.

BACKGROUND: Infected aortic aneurysm is a relatively rare disease with significant morbidity and mortality. Because of its deeper position, patients with infected aortic arch aneurysms may present with only fever and other vague symptoms, such as weakness, fatigue, dizziness, anorexia, and functional decline. It is difficult confirm a diagnosis that is based solely on history or physical examination, and it may only be apparent on imaging studies. CASE REPORT: We present a brief case report of a patient presenting to the emergency department with unexplained fever who was diagnosed with emphysematous salmonella-infected aneurysm of the aortic arch. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Infected aortic arch aneurysm is an extremely unusual disease entity that emergency physicians encounter. Because of the high mortality and morbidity of this catastrophic disease, an infected aortic aneurysm should be considered as a possible diagnosis in patients with persistent fever and vague symptoms without a specific infection focus. To avoid delayed diagnosis, emergency physicians should be aware of infected aortic arch aneurysm.

Abdominal aortic endograft infection. A decade of experience and literature review.

INTRODUCTION: Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the "gold standar" treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. METHODS: We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010-2019). RESULTS: We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). CONCLUSION: Perigraft or aneurysm sac aspiration culture show their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Aneurisma aórtico abdominal infeccioso por Salmonella en un paciente con diabetes mellitus / Infected abdominal aortic aneurysm due to Salmonella in a patient with diabetes mellitus

Resumen Presentamos el caso de un paciente de edad avanzada, con diabetes mellitus descompensada, quien presentó un cuadro clínico de fiebre y dolor abdominal recurrente, tras lo cual fue diagnosticado con un aneurisma infeccioso de la aorta abdominal, los cuales representan solamente un 1% de todos los aneurismas. El paciente fue sometido a resección quirúrgica del aneurisma, injerto con dacrón impregnando con rifampicina y tratamiento antibiótico intravenoso. La microbiología del aneurisma confirmó infección por Salmonella. Actualmente, el paciente se encuentra asintomático y sin evidencia laboratorial de proceso inflamatorio.

Abstract We present a case of an elderly patient with uncontrolled diabetes mellitus, who presented with recurrent fever and abdominal pain, after which he was diagnosed with an infected abdominal aortic aneurysm, which represents only 1% of all aneurysms. The patient underwent surgical resection of the aneurysm, rifampicine-impregnated Dacron graft placement and intravenous antibiotic treatment. Microbiology reported Salmonella infection in the aneurysm. Currently, the patient is asymptomatic and without laboratory evidence of inflammatory process.

A rare case of ruptured anterior cerebral artery infected aneurysm with angioinvasion secondary to disseminated Nocardia otitidiscaviarum: A case report and literature review.

Background: The cases of ruptured infected aneurysms secondary to disseminated nocardiosis are exceptionally rare. Therefore, there is no guideline for investigation or optimal treatment. Case Description: A 51-year-old man with immunocompromised status was first presented with pneumonia and cerebral infarction, where the infected aneurysm was ruptured thereafter. Intraoperative findings revealed left anterior cerebral artery thrombosis and occlusion with evidence of angioinvasion along with pus discharge which was later identified with Nocardia otitidiscaviarum. Our case was the first to report on the angioinvasive nature of cerebral nocardiosis, which occurs concurrently with a ruptured infected aneurysm and an unusual presentation that made the diagnosis and treatment challenging. Conclusion: Cerebral nocardiosis may cause ruptured infected aneurysms in patients with risk factors, especially for immunocompromised hosts. Furthermore, Nocardia can present with severe cerebral manifestation due to angioinvasion causing cerebral infarction accompanied by a ruptured infected aneurysm.

A minimally invasive approach to the infected aorta with novel endovascular use of biocomposite antibiotic material.

We have presented the case of a symptomatic, primarily infected aortic pseudoaneurysm treated with endovascular stent graft exclusion and adjunctive use of a long-acting biocomposite antibiotic material injected directly into the pseudoaneurysm sac. We have described preparation of the biocomposite antibiotic material and the catheter-directed delivery technique in detail. Although the use of long-acting antibiotic materials such as antibiotic beads has been well described when performing open surgery in an infected field, the application of these materials in endovascular procedures has been less certain. The techniques we have described have the potential to promote field sterilization in a minimally invasive manner for patients with aortic infections who could be poor candidates for open surgery.

Infected abdominal aortic aneurysm due to Salmonella in a patient with diabetes mellitus.

We present a case of an elderly patient with uncontrolled diabetes mellitus, who presented with recurrent fever and abdominal pain, after which he was diagnosed with an infected abdominal aortic aneurysm, which represents only 1% of all aneurysms. The patient underwent surgical resection of the aneurysm, rifampicine-impregnated Dacron graft placement and intravenous antibiotic treatment. Microbiology reported Salmonella infection in the aneurysm. Currently, the patient is asymptomatic and without laboratory evidence of inflammatory process.

Presentamos el caso de un paciente de edad avanzada, con diabetes mellitus descompensada, quien presentó un cuadro clínico de fiebre y dolor abdominal recurrente, tras lo cual fue diagnosticado con un aneurisma infeccioso de la aorta abdominal, los cuales representan solamente un 1% de todos los aneurismas. El paciente fue sometido a resección quirúrgica del aneurisma, injerto con dacrón impregnando con rifampicina y tratamiento antibiótico intravenoso. La microbiología del aneurisma confirmó infección por Salmonella. Actualmente, el paciente se encuentra asintomático y sin evidencia laboratorial de proceso inflamatorio.

In situ repair or reconstruction of the abdominal aorta-iliac artery by autologous fascia-peritoneum with posterior rectus sheath for the treatment of the infected abdominal aortic and iliac artery aneurysms: A case series and literature review.

Background: Infected abdominal aortic and iliac artery aneurysms are considered acute and severe diseases with insidious onset, rapid development, and high mortality in vascular surgery. Currently, there is no better treatment, either anatomic or extra-anatomical repair. Case presentation: From February 2018 to April 2022, 7 patients with infected abdominal aortic and iliac artery aneurysms did not have sufficient autologous venous material for repair. With the consent of the Ethics Committee of the hospital, it uses the autologous peritoneal fascial tissue with rectus sheath to repair or reconstruct the infected vessels in situ. There were 5 cases of infected abdominal aortic aneurysm, 1 case of an infected common iliac aneurysm, and 1 case of the infected internal iliac aneurysm. Aortoduodenal fistula was found in 3 cases, all of them were given duodenal fistula repair and gastrojejunostomy and cholecystostomy. Three cases of infected abdominal aortic aneurysms were repaired with the autologous peritoneal fascial tissue patch, and 2 cases of infected abdominal aortic aneurysms were reconstructed by the autologous peritoneal fascial tissue suture to bifurcate graft in situ, the autologous peritoneal fascial tissue suture reconstructed the rest 2 cases of infected iliac aneurysm to tubular graft in situ. It was essential that Careful debridement of all infected tissue and adequate postoperative irrigation and drainage. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics based on bacterial culture and susceptibility results of infected tissues and blood. All 7 patients had underwent surgery successfully. But there were 2 cases died of anastomotic infection or massive hemorrhage after the operation, the other 5 cases survived. The follow-up time was 2-19 months. The enhanced CT of postoperation showed that the reconstructed arteries were smooth without obvious stenosis or expansion, and no abdominal wall hernia occurred. Conclusion: In situ repair or reconstruction with autologous peritoneal fascial tissue with rectus sheath is a feasible treatment for the infected aneurysm patients without adequate autologous venous substitute, but it still needs long-term follow-up and a large sample to be further confirmed.

Case report: Remedial surgical treatment of aorto-duodenal fistula with infected aneurysm after endovascular aortic repair.

Aorto-duodenal fistula (ADF) is a rare cause of upper gastrointestinal bleeding, but it is associated with high mortality. It usually occurs in patients with prior aortic surgery or who have undergone aortic graft placement. Abdominal aortic aneurysm (AAA) might be a cause of primary ADF, which could develop into sudden shock. Because ADF is difficult to diagnose, surgery to correct it has a poor outcome. We here report the successful treatment of an ADF complicated with infected AAA after endovascular repair of a ruptured aneurysm of the iliac artery.

Clinical and microbiological characteristics and challenges in diagnosing infected aneurysm: a retrospective observational study from a single center in Japan.

BACKGROUND: It is challenging to diagnose infected aneurysm in the early phase. This study aimed to describe the clinical and microbiological characteristics of infected aneurysm, and to elucidate the difficulties in diagnosing the disease. METHODS: Forty-one cases of infected aneurysm were diagnosed in Nagasaki University Hospital from 2005 to 2019. Information on clinical and microbiological characteristics, radiological findings, duration of onset, and type of initial computed tomography (CT) imaging conditions were collected. Factors related to diagnostic delay were analyzed by Fisher's exact test for categorical variables or by the Wilcoxon rank-sum test for continuous variables. RESULTS: Pathogens were identified in 34 of 41 cases; the pathogens were Gram-positive cocci in 16 cases, Gram-negative rods in 13 cases, and others in five cases. Clinical characteristics did not differ in accordance with the identified bacteria. At the time of admission, 16 patients were given different initial diagnoses, of which acute pyelonephritis (n = 5) was the most frequent. Compared with the 22 patients with an accurate initial diagnosis, the 19 initially misdiagnosed patients were more likely to have been examined by plain CT. The sensitivities of plain CT and contrast-enhanced CT were 38.1% and 80.0%, respectively. CONCLUSIONS: In cases of infected aneurysm, diagnostic delay is attributed to non-specific symptoms and the low sensitivity of plain CT. Clinical characteristics of infected aneurysm mimic various diseases. Contrast-enhanced CT should be considered if infected aneurysm is suspected.

Stent-Graft Removal and Extra-Anatomical Bypass for the Treatment of Stent-Graft Infection after Endovascular Aneurysm Repair.

Stent-graft infection is a rare but potentially life-threatening complication of endovascular aortic repair. There are currently no consensus guidelines for treating stent-graft infections, but surgical treatment is generally considered preferable due to the low overall survival rate of patients receiving conservative therapy; however, the revascularization method remains controversial. We report a case in which stent-graft infection after endovascular aneurysm repair was successfully treated by stent-graft removal and extra-anatomical bypass (EAB). EAB is an effective method of revascularization for stent-graft infection.