Outcomes of Open Repair of Mycotic Descending Thoracic and Thoracoabdominal Aortic Aneurysms

doi:10.1016/j.athoracsur.2015.05.067

The Annals of Thoracic Surgery

Volume 100, Issue 5, November 2015, Pages 1712-1717

https://doi.org/10.1016/j.athoracsur.2015.05.067 Get rights and content

Background

The purpose of this study was to evaluate the short- and intermediate-term outcomes of open repair of mycotic thoracic and thoracoabdominal aneurysms. Contemporary surgical and perioperative techniques were utilized.

Methods

From November 1997 to May 2014, 14 consecutive patients underwent open repair of descending thoracic (n = 9, 64.3%) and thoracoabdominal (n = 5, 35.7%) mycotic aortic aneurysms. All procedures were performed through the left side of the chest. Infected tissue was completely debrided and excised. Aortic continuity was restored in situ with a Dacron prosthesis (Macquet Corp, Oakland, NJ). Soft tissue coverage of the prosthesis was performed when anatomy and patient condition permitted. Perioperative outcomes, intermediate-term survival, and reinfection rates were examined.

Results

All patients presented with either aneurysm-related symptoms or a clinical picture of sepsis. Diagnosis was confirmed utilizing computed tomography imaging. Mean age was 66 ± 13 years, 8 patients (57.1%) were male, and mean aneurysm size was 5.9 ± 1.3 cm. All patients were hypertensive, 3 (21.4%) had prior coronary revascularization, 7 (50%) had chronic pulmonary disease, 5 (35.7%) had diabetes mellitus, and 2 (14.3%) had end-stage renal disease requiring dialysis. Twelve patients (85.7%) had aneurysm-related pain, and 9 (64.3%) of them had contained rupture. Mean time from onset of illness to surgery was 36 days (range, 0 to 153). On preoperative blood cultures, 4 (28.6%) grew Staphylococcus aureus, 4 (28.6%) grew gram negative organisms, 2 (14.3%) grew mycobacterium, and 4 cultures (28.6%) had negative results. Empiric broad-spectrum antibiotics were initiated on all patients and adjusted based on final cultures. A majority of patients underwent repair utilizing a clamp-and-sew technique (n = 10, 71.4%); the remainder (n = 4, 28.6%) required repair under profound hypothermic circulatory arrest. After radical debridement of the infected tissue, grafts were placed in the normal anatomic position; 6 (42.9%) patients had additional soft tissue coverage, 5 (35.7%) utilizing an omental flap and 1 (7.1%), a serratus muscle flap. There was 1 in-hospital death (7.1%) secondary to ischemic bowel. Four patients (28.6%) required tracheostomy, and 1 (7.1%) had recurrent nerve injury. None of the patients incurred spinal cord injury, stroke, or new onset renal failure requiring dialysis. After surgery, all patients were given 6 weeks of intravenous antibiotics. Lifelong suppression therapy was maintained with oral antibiotics. There were no episodes of prosthetic graft infection on follow-up. Univariate analysis revealed that New York Heart Association functional class, diabetes, and preoperative renal dysfunction were preoperative risk factors for major adverse events. Mean follow-up time was 26.5 months (median 8.2; range, 1 to 142). Actuarial 5-year survival was 71%.

Conclusions

Open repair of mycotic descending thoracic and thoracoabdominal aortic aneurysms remains the gold standard of therapy. Aggressive intraoperative debridement with in situ prosthetic reconstruction permits a high rate of success in this very high risk cohort of patients. Lifelong antibiotic suppression therapy may prevent late prosthetic graft infection.

Section snippets

Material and Methods

This study was approved by the Weill Cornell Medical College Institutional Review Board. The need for individual patient consent was waived.

We reviewed prospectively collected data from the Weill Cornell Medical College Department of Cardiothoracic Surgery aortic surgery database to identify patients who had repair of MTAA. Aneurysms were defined as mycotic if they were associated with clinical signs of infection, characteristic appearance of radiologic imaging or intraoperative examination,

Results

Patient characteristics are listed in Table 1. The cohort of 14 patients consisted of 9 patients (64%) who had descending thoracic and 5 patients (36%) who had thoracoabdominal mycotic aneurysms. All patients presented with either aneurysm-related back pain or a clinical picture of sepsis. Diagnosis was confirmed utilizing computed tomography imaging. Mean age was 66 ± 13 years, and mean aneurysm size was 5.9 ± 1.3 cm. All patients were hypertensive. Twelve patients (85.7%) had aneurysm-related

Comment

Mycotic aortic aneurysms are rare entities and comprise a minute proportion of all aneurysms, both abdominal and thoracic. One third originate in the thoracic aorta, and many theories have been put forth to explain the etiology of this highly lethal form of aortic pathology 1, 2, 3. Bacteremia in the setting of a preexisting aneurysm is thought to be the most common cause of mycotic aortic degeneration, as seeding of either disrupted aortic intima or mural thrombus can lead to an aggressive

References (26)

G.S. Oderich et al.
Infected aortic aneurysms: aggressive presentation, complicated early outcome but durable results
J Vasc Surg
(2001)
B.T. Muller et al.
Mycotic aneurysm of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases
J Vasc Surg
(2001)
R.B. Hsu et al.
Infected aortic aneurysms: clinical outcome and risk factor analysis
J Vasc Surg
(2004)
B.T. Weis-Müller et al.
Single-center experience with open surgical treatment of 36 infected aneurysms of the thoracic, thoracoabdominal, and abdominal aorta
Ann Vasc Surg
(2011)
R.B. Hsu et al.
Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries
J Vasc Surg
(2002)
Y.K. Huang et al.
Therapeutic opinion on endovascular repair for mycotic aortic aneurysm
Ann Vasc Surg
(2014)
C.D. Kan et al.
Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systemic review
J Vasc Surg
(2007)
A.C. Ting et al.
Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta
Am J Surg
(2005)
J.K. Johnstone et al.
Endovascular repair of mycotic aneurysm of the descending thoracic aorta
Ann Vasc Surg
(2013)
P. Sedivy et al.
Endovascular treatment of infected aortic aneurysms
Eur J Vasc Endovasc Surg
(2012)

L.N. Girardi et al.

Preoperative percutaneous coronary intervention in patients undergoing open thoracoabdominal and descending thoracic aneurysm repair

J Thorac Cardiovasc Surg

(2014)

L.N. Girardi et al.

Inflammatory aneurysm of the ascending aorta and aortic arch

Ann Thorac Surg

(1997)

S. Shahidi et al.

Detection of abdominal aortic graft infection: comparison of magnetic resonance imaging and indium-labeled white blood cell scanning

Ann Vasc Surg

(2007)

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Citation Excerpt :
In contrast to the gram-positive preponderance seen in the United States, gram-negative species such as Salmonella may be responsible for as much as three-quarters of MTAA in Asian countries.26,27 Although there are no standard guidelines for management, we have previously described our multimodal treatment algorithm.24,26 Suspicion for an infected aneurysm prompts empiric intravenous antibiotic administration until culture sensitivities can guide narrowing this coverage.
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To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA).
A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location.
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Mycotic aortic aneurysm and its associated complications are often catastrophic. In this study, we examined the early and late outcomes of surgical repair of mycotic aortic aneurysm at our center over the last 3 decades.
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Six hundred eighty-four patients underwent open thoracoabdominal aortic aneurysm repair. Ninety (13.1%) had Marfan syndrome, whereas 594 (86.9%) did not. Marfan patients were younger (46 years [range, 36-56 years] vs 69 years [range, 61-76 years]; P < .001). Extent II or III aneurysms (57 out of 90 [63.3%] vs 211 out of 594 [35.6%]; P < .001) and type I or III chronic dissection (77 out of 90 [85.3%] vs 242 out of 594 [40.8%]; P < .001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in major adverse events between groups (12 out of 90 [13.3%] vs 100 out of 594 [16.8%]; P = .49). Operative mortality was similar between groups (3 out of 90 [3.3%] vs 28 out of 594 [4.7%]; P = .75). Unweighted survival at 10 years was 78.7% vs 46.8% (P = .001). Weighted Kaplan-Meier curves showed no difference in long-term survival (adjusted hazard ratio, 0.79; 95% CI, 0.32-1.99; P = .62; Log-rank P = .12). At multivariable analysis, renal insufficiency (odds ratio, 2.29; 95% CI, 1.43-3.68; P < .01) and urgent/emergency procedure (odds ratio, 2.17; 95% CI, 1.35-3.48; P < .01) were associated with major adverse events, whereas Marfan syndrome was not (odds ratio, 1.56; 95% CI, 0.69-3.49; P = .28).
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Original articleAdult cardiacOutcomes of Open Repair of Mycotic Descending Thoracic and Thoracoabdominal Aortic Aneurysms

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

J Vasc Surg

J Vasc Surg

J Vasc Surg

Ann Vasc Surg

J Vasc Surg

Ann Vasc Surg

J Vasc Surg

Am J Surg

Ann Vasc Surg

Eur J Vasc Endovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Vasc Surg

Original article
Adult cardiac
Outcomes of Open Repair of Mycotic Descending Thoracic and Thoracoabdominal Aortic Aneurysms