Successful total endovascular repair of a giant salmonella-infected painful thoraco-abdominal aortic pseudoaneurysm

Successful total endovascular repair of a giant salmonella-infected painful thoraco-abdominal... Abstract Endovascular approach is now a safe and effective technique for the elective treatment of a thoraco-abdominal aneurysm. This technique has significantly reduced the morbi-mortality for elective surgery. Moreover, it can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm. Here, we present the case of an 81-year-old man who had a rapidly evolving salmonella-infected aortic thoraco-abdominal Type IV pseudoaneurysm. Total endovascular treatment using aortic endoprosthesis, chimneys for coeliac trunk and superior mesenteric artery and periscopes for renal arteries was performed and permitted to obtain the complete exclusion of the pseudoaneurysm. The patient was event free and discharged from hospital after a few days with an antibiotic treatment adapted for salmonella. He was still event free 10 months after surgery. Endovascular technique might be a viable option even for an emergency infected complex thoraco-abdominal aortic aneurysm. Secondary open surgery should be discussed under the benefit–risk balance. Endovascular treatment, Thoraco-abdominal aneurysm, Chimney, Periscope, Salmonella INTRODUCTION Endovascular approach is now a safe and effective technique for the elective treatment of thoraco-abdominal aneurysm [1, 2]. This technique has significantly reduced the morbi-mortality for elective surgery. It can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm [3]. CASE REPORT An 81-year-old man with a history of hypertension and sigmoiditis was referred in emergency to our vascular surgery department for abdominal pain, haemorrhagic collapse and sepsis. He had an aortic thoraco-abdominal Type IV aneurysm, which measured 43 mm 3 months before. On the emergency computed tomography (CT) scan, the aneurysm was measured as 85 mm with a left pleural effusion and retroperitoneal infiltration. Coeliac trunk and superior mesenteric artery ostia were present in the aneurysm. There was a short neck of approximately 10 mm between the distal part of the aneurysm and the ostia of renal arteries (Fig. 1). Blood cultures revealed a salmonella. The patient did not have fever. C-reactive protein was negative, and white blood cells were at 11–32 Giga/l. Because of his old age and poor general state, we decided after a multidisciplinary discussion to attempt endovascular repair. The technique consisted of 2 aortic endoprostheses (GORE TAG®, 31 × 100 mm and 28 × 100 mm) with 1 chimney for the coeliac trunk, 1 for the superior mesenteric artery and 1 periscope for each renal artery. The technique was performed by 1 left axillar and 2 femoral accesses. The chimneys were fitted with self-expanding nitinol-covered stents (FLUENCY®, Bard, 10 × 120 and 9 × 100 mm) and self-expanding nitinol stent (LUMINEX®, Bard) inside to prevent compression by the aortic endoprosthesis. The periscopes were fitted with self-expanding nitinol-covered stents (FLUENCY, Bard, 6 × 40 mm) (Fig. 2A and B). The final angiography revealed permeability of the 4 visceral arteries and the exclusion of the pseudoaneurysm (Fig. 2C). This good result was confirmed by a CT scan (Fig. 2D). The patient was event free and discharged from the hospital after a few days with an antibiotic therapy adapted for salmonella (Ofloxacin® and Rocephin®). He was still event free 10 months after surgery. He received an adapted oral antibiotic therapy (Amoxicillin® after 6 weeks) with a C-reactive protein at 12 mg/l. A CT scan showed a good regression of the aneurysmal sac and a good permeability of the 4 visceral stented arteries without signs of infection. Figure 1: View largeDownload slide Preoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the pseudoaneurysm and its location relative to the visceral arteries. Figure 1: View largeDownload slide Preoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the pseudoaneurysm and its location relative to the visceral arteries. Figure 2: View largeDownload slide Preoperative and postoperative control examinations. (A) Preoperative front view of the surgical reconstruction. (B) Preoperative profile view of the surgical reconstruction. (C) Final angiography. (D) Postoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the exclusion of the pseudoaneurysm and the permeability of the 4 visceral arteries. Figure 2: View largeDownload slide Preoperative and postoperative control examinations. (A) Preoperative front view of the surgical reconstruction. (B) Preoperative profile view of the surgical reconstruction. (C) Final angiography. (D) Postoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the exclusion of the pseudoaneurysm and the permeability of the 4 visceral arteries. DISCUSSION Endovascular technique might be a viable option even for an emergency infected thoraco-abdominal aortic aneurysm. Its main limiting factor is the permanent availability of a large amount of specific endovascular material. Moreover, a secondary open surgery should be discussed to remove prosthetic material if the patient can support a very high-risk surgery. The other possibility is to treat the patient with a long-term antibiotic therapy to conserve the endoprosthesis. Even if the open surgical repair with infected tissue removal and in situ allograft replacement remains the gold standard for selected patients with several comorbidities, the benefit–risk equation seems to be favourable for conservative option [4, 5]. However, lifelong clinical and morphological surveillance remains mandatory. Conflict of interest: none declared. REFERENCES 1 Hu Z, Li Y, Peng R, Liu J, Jia X, Liu X et al.   Multibranched stent-grafts for the treatment of thoracoabdominal aortic aneurysms: a systematic review and meta-analysis. J Endovasc Ther  2016; 23: 626– 33. Google Scholar CrossRef Search ADS PubMed  2 Li Y, Hu Z, Bai C, Liu J, Zhang T, Ge Y et al.   Fenestrated and chimney technique for juxtarenal aortic aneurysm: a systematic review and pooled data analysis. Sci Rep  2016; 6: 20497. Google Scholar CrossRef Search ADS PubMed  3 Melissano G, Mascia D, Atique SG, Bertoglio L, Chiesa R. Treatment of acute thoracoabdominal aortic aneurysms. J Cardiovasc Surg (Torino)  2017; 58: 228– 37. Google Scholar PubMed  4 Setacci C, De Donato G, Setacci F. Endografts for the treatment of aortic infection. Semin Vasc Surg  2011; 24: 242– 9. Google Scholar CrossRef Search ADS PubMed  5 Leon LR, Mills JL. Diagnosis and management of aortic mycotic aneurysms. Vasc Endovascular Surg  2010; 44: 5– 13. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Successful total endovascular repair of a giant salmonella-infected painful thoraco-abdominal aortic pseudoaneurysm

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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1569-9285
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10.1093/icvts/ivy142
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Abstract

Abstract Endovascular approach is now a safe and effective technique for the elective treatment of a thoraco-abdominal aneurysm. This technique has significantly reduced the morbi-mortality for elective surgery. Moreover, it can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm. Here, we present the case of an 81-year-old man who had a rapidly evolving salmonella-infected aortic thoraco-abdominal Type IV pseudoaneurysm. Total endovascular treatment using aortic endoprosthesis, chimneys for coeliac trunk and superior mesenteric artery and periscopes for renal arteries was performed and permitted to obtain the complete exclusion of the pseudoaneurysm. The patient was event free and discharged from hospital after a few days with an antibiotic treatment adapted for salmonella. He was still event free 10 months after surgery. Endovascular technique might be a viable option even for an emergency infected complex thoraco-abdominal aortic aneurysm. Secondary open surgery should be discussed under the benefit–risk balance. Endovascular treatment, Thoraco-abdominal aneurysm, Chimney, Periscope, Salmonella INTRODUCTION Endovascular approach is now a safe and effective technique for the elective treatment of thoraco-abdominal aneurysm [1, 2]. This technique has significantly reduced the morbi-mortality for elective surgery. It can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm [3]. CASE REPORT An 81-year-old man with a history of hypertension and sigmoiditis was referred in emergency to our vascular surgery department for abdominal pain, haemorrhagic collapse and sepsis. He had an aortic thoraco-abdominal Type IV aneurysm, which measured 43 mm 3 months before. On the emergency computed tomography (CT) scan, the aneurysm was measured as 85 mm with a left pleural effusion and retroperitoneal infiltration. Coeliac trunk and superior mesenteric artery ostia were present in the aneurysm. There was a short neck of approximately 10 mm between the distal part of the aneurysm and the ostia of renal arteries (Fig. 1). Blood cultures revealed a salmonella. The patient did not have fever. C-reactive protein was negative, and white blood cells were at 11–32 Giga/l. Because of his old age and poor general state, we decided after a multidisciplinary discussion to attempt endovascular repair. The technique consisted of 2 aortic endoprostheses (GORE TAG®, 31 × 100 mm and 28 × 100 mm) with 1 chimney for the coeliac trunk, 1 for the superior mesenteric artery and 1 periscope for each renal artery. The technique was performed by 1 left axillar and 2 femoral accesses. The chimneys were fitted with self-expanding nitinol-covered stents (FLUENCY®, Bard, 10 × 120 and 9 × 100 mm) and self-expanding nitinol stent (LUMINEX®, Bard) inside to prevent compression by the aortic endoprosthesis. The periscopes were fitted with self-expanding nitinol-covered stents (FLUENCY, Bard, 6 × 40 mm) (Fig. 2A and B). The final angiography revealed permeability of the 4 visceral arteries and the exclusion of the pseudoaneurysm (Fig. 2C). This good result was confirmed by a CT scan (Fig. 2D). The patient was event free and discharged from the hospital after a few days with an antibiotic therapy adapted for salmonella (Ofloxacin® and Rocephin®). He was still event free 10 months after surgery. He received an adapted oral antibiotic therapy (Amoxicillin® after 6 weeks) with a C-reactive protein at 12 mg/l. A CT scan showed a good regression of the aneurysmal sac and a good permeability of the 4 visceral stented arteries without signs of infection. Figure 1: View largeDownload slide Preoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the pseudoaneurysm and its location relative to the visceral arteries. Figure 1: View largeDownload slide Preoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the pseudoaneurysm and its location relative to the visceral arteries. Figure 2: View largeDownload slide Preoperative and postoperative control examinations. (A) Preoperative front view of the surgical reconstruction. (B) Preoperative profile view of the surgical reconstruction. (C) Final angiography. (D) Postoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the exclusion of the pseudoaneurysm and the permeability of the 4 visceral arteries. Figure 2: View largeDownload slide Preoperative and postoperative control examinations. (A) Preoperative front view of the surgical reconstruction. (B) Preoperative profile view of the surgical reconstruction. (C) Final angiography. (D) Postoperative contrast-enhanced computed tomography, 3-dimensional reconstruction, showing the exclusion of the pseudoaneurysm and the permeability of the 4 visceral arteries. DISCUSSION Endovascular technique might be a viable option even for an emergency infected thoraco-abdominal aortic aneurysm. Its main limiting factor is the permanent availability of a large amount of specific endovascular material. Moreover, a secondary open surgery should be discussed to remove prosthetic material if the patient can support a very high-risk surgery. The other possibility is to treat the patient with a long-term antibiotic therapy to conserve the endoprosthesis. Even if the open surgical repair with infected tissue removal and in situ allograft replacement remains the gold standard for selected patients with several comorbidities, the benefit–risk equation seems to be favourable for conservative option [4, 5]. However, lifelong clinical and morphological surveillance remains mandatory. Conflict of interest: none declared. REFERENCES 1 Hu Z, Li Y, Peng R, Liu J, Jia X, Liu X et al.   Multibranched stent-grafts for the treatment of thoracoabdominal aortic aneurysms: a systematic review and meta-analysis. J Endovasc Ther  2016; 23: 626– 33. Google Scholar CrossRef Search ADS PubMed  2 Li Y, Hu Z, Bai C, Liu J, Zhang T, Ge Y et al.   Fenestrated and chimney technique for juxtarenal aortic aneurysm: a systematic review and pooled data analysis. Sci Rep  2016; 6: 20497. Google Scholar CrossRef Search ADS PubMed  3 Melissano G, Mascia D, Atique SG, Bertoglio L, Chiesa R. Treatment of acute thoracoabdominal aortic aneurysms. J Cardiovasc Surg (Torino)  2017; 58: 228– 37. Google Scholar PubMed  4 Setacci C, De Donato G, Setacci F. Endografts for the treatment of aortic infection. Semin Vasc Surg  2011; 24: 242– 9. Google Scholar CrossRef Search ADS PubMed  5 Leon LR, Mills JL. Diagnosis and management of aortic mycotic aneurysms. Vasc Endovascular Surg  2010; 44: 5– 13. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: May 10, 2018

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