joint hospital surgical ground round 17-7-2010 the management of mycotic aneurysm chan hoi yee...

Joint Hospital Surgical Ground Round 17-7-2010Joint Hospital Surgical Ground Round 17-7-2010

The Management of Mycotic Aneurysm

Chan Hoi Yee

Princess Margaret Hospital

Mycotic AneurysmMycotic Aneurysm

First case was described in 1885 by Osler First case was described in 1885 by Osler Dilatation of aorta > 50% of the luminal diameter with Dilatation of aorta > 50% of the luminal diameter with signs of infection (biochemical markers or imaging) signs of infection (biochemical markers or imaging)

infective aortic aneurysm, first used in 1975infective aortic aneurysm, first used in 19750.7-2.6% aortic aneurysm are complicated by infection 0.7-2.6% aortic aneurysm are complicated by infection 80% due to microbial arteritis (most commonly caused 80% due to microbial arteritis (most commonly caused by Streptococcus and Samonella) by Streptococcus and Samonella)

Pathogenesis Pathogenesis

Septic emboli lodged in vessel lumen Septic emboli lodged in vessel lumen

Inflammatory process outside vessel wall Inflammatory process outside vessel wall

Inoculation of bacteria at time of accidental Inoculation of bacteria at time of accidental arterial traumaarterial trauma

Self induced vascular manipulation Self induced vascular manipulation

Intimal defect seeded by concurrent bacteremiaIntimal defect seeded by concurrent bacteremia

Mycotic AneurysmMycotic Aneurysm

Infected Aortic Aneurysms: Aggressive Presentation, Complicated Early Outcome, but Durable Result. Gustavo S et al. J Vasc Surg 2001;34:900-8

Presentation Presentation

Classic triad:Classic triad:

Fever Fever

Leukocytosis Leukocytosis

Pulsatile massPulsatile mass


VariablesVariables n (N=43) n (N=43) %%

symptomatic 40 93

elevated ESR 18 86

fever 33 77

Abdominal or back pain 28 65

Leukocytosis >12.000 23 54

chillschills 2222 5151

sweatssweats 1212 2828

Enlarging aneurysmEnlarging aneurysm 1212 2828

GI symptoms (eg. GI symptoms (eg. Nausea/vomiting/diarrhea) Nausea/vomiting/diarrhea)

1010 2525

rupturerupture 99 2121

Pulsatile massPulsatile mass 77 1616

Haemodynamic instablility Haemodynamic instablility 33 77

Investigations Investigations


Organisms Organisms Culture obtained from Culture obtained from blood (n=32)blood (n=32)

Culture obtained from Culture obtained from aneurysm wall (n=42) aneurysm wall (n=42)

Total (N = 43) %Total (N = 43) %

Culture positive Culture positive 25 (78) 25 (78) 27 (64) 27 (64) 33 (77) 33 (77)

StaphylococcusStaphylococcus 77 1010 11 (26) 11 (26)

E coliE coli 66 33 6 (14) 6 (14)

StreptococcusStreptococcus 44 33 5 (12) 5 (12)

SalmonellaSalmonella 44 44 4 (9) 4 (9)

Listeria monocytogenesListeria monocytogenes 00 11 1 (2) 1 (2)

Bacteroides fragilisBacteroides fragilis 00 11 1 (2) 1 (2)

CandidaCandida 00 11 1 (2) 1 (2)

Mycobacterium Mycobacterium 00 11 1 (2) 1 (2)

H. InfluenzaH. Influenza 11 11 1 (2) 1 (2)

Clostridium Clostridium 11 11 1 (2) 1 (2)

Coccidioides immitisCoccidioides immitis 11 11 1 (2) 1 (2)

CT imaging CT imaging

A Comparison of Computed Tomography, Magnetic Resonance Imaging, and Digital Subtraction Angiography Findings in the Diagnosis of Infected Aortic Aneurysm. MP Lin et al. J Comput Assist Tomogr. 2008;32:616-620

Imaging Imaging

A Comparison of Computed Tomography, Magnetic Resonance Imaging, and Digital Subtraction Angiography Findings in the Diagnosis of Infected Aortic Aneurysm. MP Lin et al. J Comput Assist Tomogr. 2008;32:616-620

Treatment of Mycotic aneurysmTreatment of Mycotic aneurysm

Antibiotics vs

Antibiotics + surgery

Medical Treatment Medical Treatment

Medical treatment:Medical treatment:

- more effective antibiotics - more effective antibiotics

- surgery carries high risk - surgery carries high risk

- salmonella infections: - salmonella infections:

iv ceftriaxone 1000-2000gm Q12Hiv ceftriaxone 1000-2000gm Q12H

- non-salmonella infections:- non-salmonella infections:

according to the culture result and according to the culture result and

sensitivity test sensitivity test

Medical Treatment Medical Treatment

Selective Medical Treatment of Infected Aneurysms of the Aorta in High Risk Patients. RB Hsu et al. J Vasc Surg 2009;49:66-70

In-hospital Mortality50%

Aneurysm Related Mortality

54.2%

Surgical Treatment Surgical Treatment

Aneurysm resection + soft tissue debridement + Aneurysm resection + soft tissue debridement + extra-anatomical bypass (eg. Axillo-bifemoral extra-anatomical bypass (eg. Axillo-bifemoral bypass)bypass)

Aneurysm resection + debridement + in-situ graft repair

Endovascular stenting

Combined Medical and Surgical Combined Medical and Surgical Treatment Treatment

P= 0.314

Infected Aortic Aneurysm: Clinical Outcome and Risk Factor Analysis. RB. Hsu et al. J Vasc Surg 2004;40:30-5

0

10

20

30

40

50

60

70

30-daymortality

90-daymortality

1-yearmortality

medical + surgicaltreatment

medical treatmentalone


Clinical outcomes of 6137 patients who underwent aortic Clinical outcomes of 6137 patients who underwent aortic reconstruction for aortic aneurysms at Mayo Clinic reconstruction for aortic aneurysms at Mayo Clinic between Jan 1976 to Jan 2000 were reviewed between Jan 1976 to Jan 2000 were reviewed

43 patients had mycotic aneurysms underwent 43 patients had mycotic aneurysms underwent aneurysm resection + debridement + extra-anatomic aneurysm resection + debridement + extra-anatomic bypass (6) or in-situ aortic graft (35) bypass (6) or in-situ aortic graft (35)

Operative mortality rate: Operative mortality rate: 21 %21 % ( in-situ repair (20%) vs extra-anatomic bypass (16%) )( in-situ repair (20%) vs extra-anatomic bypass (16%) )

Infected Aortic Aneurysms: Aggressive Presentation, Complicated Early Outcome, but Infected Aortic Aneurysms: Aggressive Presentation, Complicated Early Outcome, but Durable Results. Gustavo S et al. J Vasc Surg 2001;34:900-8Durable Results. Gustavo S et al. J Vasc Surg 2001;34:900-8


Infected Aortic Aneurysms: Aggressive Presentation, Complicated Early Outcome, Infected Aortic Aneurysms: Aggressive Presentation, Complicated Early Outcome, but Durable Results. Gustavo S et al. J Vasc Surg 2001;34:900-8but Durable Results. Gustavo S et al. J Vasc Surg 2001;34:900-8

No difference in late graft complication


Disadvantages for aneurysm resection + Disadvantages for aneurysm resection + debridement + extra-anatomical bypass : debridement + extra-anatomical bypass :

- late disruption of aortic stump (20%) due to persistent infection --> - late disruption of aortic stump (20%) due to persistent infection --> fetal fetal

- lower limb ischemia required amputation 20-29% - lower limb ischemia required amputation 20-29% - lower patency rates of axillary-femoral bypass (19-50%) - lower patency rates of axillary-femoral bypass (19-50%) - extra-anatomic reconstruction is difficult for thoracoabdominal - extra-anatomic reconstruction is difficult for thoracoabdominal

aneurysmsaneurysms Wide debridement of necrotic tissue + copious Wide debridement of necrotic tissue + copious

saline irrigation + in-situ repair with aortic graftsaline irrigation + in-situ repair with aortic graft

Treatment of infected abdominal aortic aneurysms with extra-anatomic bypass, aneurysm excision and drainage. Taylor LM et al. Am J Surg. 98;155:655-8

Surgical Treament Surgical Treament

Surgical Treatment for Primary Infected Aneurysm of the Descending Thoracic Aorta, Abdominal Aorta and Iliac Arteries.RB Hsu et al. J Vasc Surg 2002;36:746-50

Case No Case No AgeAge SexSex FeverFever PainPain ShockShock OperationOperation Hospital Hospital OutcomeOutcome

PathogenPathogen

11 7878 MM ++ -- ++ ++ DeadDead BacteroidesBacteroides

22 5151 MM ++ ++ -- ++ AliveAlive SalmonellaSalmonella

33 7474 MM ++ -- -- ++ AliveAlive SalmonellaSalmonella

44 5858 MM ++ ++ ++ ++ AliveAlive SalmonellaSalmonella

55 6262 MM ++ ++ ++ AliveAlive SalmonellaSalmonella

66 6161 FF ++ ++ ++ AliveAlive SalmonellaSalmonella

77 5454 MM ++ ++ ++ AliveAlive StaphylococcusStaphylococcus

88 7272 FF ++ ++ ++ ++ AliveAlive SalmonellaSalmonella

99 7676 FF ++ ++ ++ AliveAlive SalmonellaSalmonella


1111 6161 FF -- -- ++ AliveAlive StreptococcusStreptococcus

1212 6969 FF ++ -- ++ AliveAlive SalmonellaSalmonella


1414 8484 FF -- ++ ++ AliveAlive TuberculosisTuberculosis





1919 8585 FF -- ++ ++ ++ AliveAlive StreptococcusStreptococcus

2020 8282 FF ++ ++ ++ -- DeadDead E coliE coli

2121 8080 MM ++ ++ ++ -- DeadDead SalmonellaSalmonella



2424 8181 MM ++ ++ -- -- AliveAlive E coliE coli

Hospital mortality5%


No perioperative intestinal ischemia or peri-operative No perioperative intestinal ischemia or peri-operative limb loss limb loss Survival rate after mean follow-up period of 23.6 months: Survival rate after mean follow-up period of 23.6 months: 84.2 % 84.2 % No patient has graft infection during follow-up period No patient has graft infection during follow-up period

Surgical Treatment for Primary Infected Aneurysm of the Descending Thoracic Aorta, Abdominal Aorta and Iliac Arteries. RB Hsu et al. J Vasc Surg 2002;36:746-50

Endovascular Stenting Endovascular Stenting

Permanent treatment Permanent treatment Bridge to open surgery Bridge to open surgery First report of successful case by Semba et al in 1998First report of successful case by Semba et al in 1998

Can avoid:Can avoid: - large incisions - large incisions - aortic clamping - aortic clamping - need for massive blood transfusion - need for massive blood transfusion


Disadvantages:Disadvantages:

- aneurysm is not excised - aneurysm is not excised facilitate re-infection, facilitate re-infection, recurrent sepsis and infection of stent recurrent sepsis and infection of stent

- no culture can be harvested from wall of aneurysms - no culture can be harvested from wall of aneurysms

could residual infection be overcome by could residual infection be overcome by

antibiotics ???antibiotics ???

would placement of foreign body in would placement of foreign body in

infective bed aggravate the infection ???infective bed aggravate the infection ???


A retrospective study included 48 patients A retrospective study included 48 patients from Jan 1998 to Jan 2007 with a mean from Jan 1998 to Jan 2007 with a mean follow-up period of 22 months follow-up period of 22 months

30-day mortality rate: 30-day mortality rate: 10.4% 10.4% due to sepsis or massive bleeding Outcome After Endovascular Stent Graft Treatment for Mycotic Aortic Aneurysm: A Systemic Review. DK Chung et al. J Vasc Surg 2007;46:906-12


Outcome After Endovascular Stent Graft Treatment for Mycotic Aortic Aneurysm: A Systemic Review. DK Chung et al. J Vasc Surg 2007;46:906-12

• age > 65 • ruptured aneurysm or fever

at presentation

25%

Duration of Post-operative Duration of Post-operative antibiotics antibiotics

Not well studiedNot well studied

6-8 weeks to lifelong 6-8 weeks to lifelong

No signs of infection No signs of infection

- fever subsided - fever subsided

- low leukocytes count - low leukocytes count

- low titer of CRP - low titer of CRP

Conclusions Conclusions Rare disease Rare disease Reported hospital mortality rate after combined medical Reported hospital mortality rate after combined medical and surgical treatment was 16-44% and surgical treatment was 16-44%

Classical surgical treatment was aneurysm resection + Classical surgical treatment was aneurysm resection + soft tissue debridement + extra-anatomical bypass soft tissue debridement + extra-anatomical bypass In-situ graft repair also showed good results (survival In-situ graft repair also showed good results (survival rate 82.4% without graft infection or other complication) rate 82.4% without graft infection or other complication) EVAR is the new trend of treatment EVAR is the new trend of treatment However, all studies only have small case number and However, all studies only have small case number and results may not show clinically significance results may not show clinically significance Larger study with longer period of follow-up is required Larger study with longer period of follow-up is required

References References

Infected aortic aneurysms: aggressive presentation, complicated early Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. Gustavo S et al. J Vasc Surg 2001;34:900-8outcome, but durable results. Gustavo S et al. J Vasc Surg 2001;34:900-8A comparison of computed tomography, magnetic resonance imaging, and A comparison of computed tomography, magnetic resonance imaging, and digital subtraction angiography findings iin the diagnosis of infected aortic digital subtraction angiography findings iin the diagnosis of infected aortic aneurysm. MP Lin et al. J Comput Assist Tomogr 2008;32:616-620aneurysm. MP Lin et al. J Comput Assist Tomogr 2008;32:616-620Selective medical treatment of infected aneurysms of the aorta in high risk Selective medical treatment of infected aneurysms of the aorta in high risk patients. RB Hsu et al. J Vasc Surg 2009;49:66-70patients. RB Hsu et al. J Vasc Surg 2009;49:66-70Surgical treatment for primary infected aneurysm of the descending thoracic Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. RB Hsu et al. J Vasc Surg aorta, abdominal aorta, and iliac arteries. RB Hsu et al. J Vasc Surg 2002:36;746-502002:36;746-50Infected aortic aneurysm, a changing entity. Mario N. Gomes et al. Ann Infected aortic aneurysm, a changing entity. Mario N. Gomes et al. Ann Surg 1992(5);435-442Surg 1992(5);435-442Outcome after endovacsular stent graft treatment for mycotic aortic Outcome after endovacsular stent graft treatment for mycotic aortic aneurysm: a systemic review. CD Kan et al. J Vasc Surg 2007;46:906-12aneurysm: a systemic review. CD Kan et al. J Vasc Surg 2007;46:906-12Infected aortic aneurysms: clinical outcome and risk factor analysis. RB Hsu Infected aortic aneurysms: clinical outcome and risk factor analysis. RB Hsu et al. J Vasc Surg 2004;40:30-5 et al. J Vasc Surg 2004;40:30-5

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joint hospital surgical ground round 17-7-2010 the management of mycotic aneurysm chan hoi yee...

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