Infected aortic aneurysm

Transcription

1 Infected aortic aneurysm Glenda F. Medina MSN, RN, ACNP-BC Department of Cardiothoracic and Vascular Surgery McGovern Medical School The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute

2 Infected (Mycotic) aneurysm Aneurysmal degeneration of the arterial wall secondary to infection. A serious clinical condition that is associated with significant morbidity and mortality

3 Case Study CC: Abdominal Pain, Nausea HPI: 68 yo female with PMHX of Hep C and HTN who presented to urgent care clinic for abdominal pain and nausea for 1 month. Abdominal US demonstrated small abdominal aortic aneurysm and was discharged. Her PCP referred to GI services, and EGD was performed with findings of gastritis. The patient was further planned for colonoscopy. However, abdominal pain increased and she presented to ED with the following findings: VS: HR 100 BPM, BP 169/92, RR 11, O2 SAT 98% RA, TEMP 97.2 F LABS: K 2.8, CR 0.9, BUN 6, ALT 55, AST 124, LIPASE 133, LACTIC ACIC 1.3, WBC 12.4, HBG 11.0, UA Negative CT A/P w contrast: 4.1cm saccular abdominal aneurysmal without evidence rapture or dissection. Correlate clinically for aortitis

4 Case CT image

5 Case Study 10 days after initial presentation to ED patient returned to facility with complains of persistent severe abdominal, nausea, tarry stools and loss of appetite VS: HR 121 BPM, BP 196/103, RR 20, O2 SAT 98% RA, TEMP 97.0 F LABS: K 2.9, CR 0.73, BUN 7, ALT 51, AST 133, LACTIC ACID 1.4, WBC 18.7, HGB 12.1, UA Negative, INR 1.37 CTA C/A/P: contained rupture of a juxtarenal abdominal aortic aneurysm, poor perfusion to right kidney

6 Case CT image

7 Case CT image

8 Case Study CVS evaluation : mycotic thoracoabdominal aortic aneurysm Recommendation: emergent repair HD#1 Emergency repair of thoracoabdominal aortic aneurysm using 26 mm Dacron tube graft and bypass to left renal artery with 10 mm Dacron graft with delayed closure for second look HD#3 Exploration of left chest and retroperitoneum with omental mobilization and covering of woven Dacron graft with formal closure of chest and abdomen Surgical tissue culture : Streptococcus pneumoniae BC Negative x 2 ABX: Ceftriaxone 2gm IV Q24 HRS, x 2 months Discharged to LTAC

9 Etiology Direct bacterial inoculation Bacteremic seeding Contiguous/antecedent infection Endocarditis/septic emboli Impaired immunity

10 Microbiology Only 50-75% of cases are noted with positive blood cultures Most common bacteria found: Staphylococcus spp and Salmonella spp Fungal infections are rare and seen mostly on immunosuppressed population

11 Clinical Manifestations Acute Phase Chest/abdomen/back pain Fever Malaise Weight loss N/V Late Phase Pulsatile or enlarging mass GI Bleeding HF Acute or chronic mesenteric ischemia Dysphagia/hoarseness Hemoptysis

12 CTA MRI/MRA TEE PET CT US Imaging

13 Medical Management Antibiotic therapy Blood and fungal cultures prior to any antibiotic infusion Vancomycin, Ceftriaxone, Zosyn ID consult 6 weeks of IV ABX Possible need for life long suppressive oral antibiotic therapy

14 Surgical Management Open Surgical repair Pt with low or tolerable comorbidities Cryopreserved homograft Prosthetic grafts Antibiotic beads Omentum flap Endovascular repair Pt with high comorbidities Pt with high mortality rates Location of aneurysm Increased risk of persistent/recurrent infections

15 Take home points History and physical exam Blood test can be normal Diagnostic imaging CTA Saccular aneurysm

16 References Macbeth GA, Rubin JR, McIntyre KE JR, et al. The relevance of arterial wall microbiology to the treatment of prosthetic graft infections: graft infection vs arterial wall infection. J Vasc Surg 1984; 1:750 Mazzalai F, Ragazzi R, lurilli V, et al. Pseudomonas aeruginosa-infected infrarenal abdominal aorta pseudoaneurysm secondary to laparoscopic colorectal surgery: failure of endovascular stent graft treatment after primary open repair failed. Can J Surg 2009; 52:E193 Grab M. Appendicitis: an unusual cause of infected abdominal aortic aneurysm. Australas radiol 1994; 38:68 Dieter RA. Dental mycotic abdominal aneurysm. J Am Coll Surg 2005; Serracino-Inglott F, Snow D, Madan M. A rapidly expanding mycotic abdominal aortic aneurysm. J Am Coll Surg 2005; 200:138 Oderic GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001; 34:900 Mercadal L, Chiche L, Isnard-Bagnis C, et al. Mycotic aneurysm in hemodialysis. Clin Nephrol 2005; 64:493 Maeda H, Umezawa H, Goshima M, et al. Primary infected abdominal aortic aneurysm: surgical procedures, early monrtality rates and a surgery of the prevalenceof infectious organisms over a 30 year period. Surg Today 2011; 41:346 Brossier J, Lesprit P, Marzelle J, et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: a single centre experience. Eur J Vasc Endovasc Surg 2010; 40:582

17 References Marques da Silva R, Caugant DA, Eribe ER, et al. Bacterial diversity in aortic aneurysms determined by 16S ribosomal RNA gene analysis. J Vasc Surg 2006; 44:1055 Pennell RC, Hollier LH, Lie JT, et al. Inflammatory abdominal aortic aneurysms: a thirty-year review. J Vasc Surg 1985; 2:859 Vogelzang RL, Sohaey R. Infected aortic aneurysms: CT appearance. J Comput Assist Tomogr 1988; 12:109 Walsh DW, Ho VB. Mycotic aneurysm of the aorta: MRI and MRA features. J Magn Reason Imaging 1997; 7:312 Murakami M, et al. Fluorine-18-fluorodeoxyglucose positron emission tomography-computed tomography for diagnosis of infected aortic aneurysms. Ann Vasc Surg 2014; 28:575 Sorelius K, Wanheinen A, Furebring M, et al. Nationwide Study of the treatment of Mycotic Aortic Abdominal Aortic Aneurysm Comparing Open and Endovascular repair. Circulation 2016; 134:1822 Cina CS, Arena GO, Fiture AO, et al. Raptured mycotic thoracoabdominal aortic aneurysm; a report of three cases and a systematic review. J Vasc Surg 2001; 33:861 Sorelius K, Summa P, et al. On the diagnosis of Mycotic Aortic Aneurysms. Clinic Medicine Insights Volume 12:1-8 Jia, X, Dong Y, et al. Open and endovascular repair of primary mycotic aortic aneurysms: a 10 year single center study. J Endovascular Theraphy 2013;20(3):

18 THANK YOU UTCVSurgery