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Management of Aortic Brucellosis With Infection of a Descending Thoracic Aortic Stent Graft

2010; Elsevier BV; Volume: 89; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2009.10.076

1552-6259

Charles Bakhos, Sidhu P. Gangadharan, Graham M. Snyder, Michael T. Wong, Robert Hagberg,

Aortic aneurysm repair treatments

A 74-year-old Iranian-born man initially presented with a penetrating atherosclerotic ulcer of the descending thoracic aorta. He underwent endovascular stenting of the lesion, but later presented with recurrent back pain and fever. He was then diagnosed with brucellosis and started on antimicrobial therapy, including 2 weeks of parenteral gentamicin and two oral agents that were poorly tolerated. Two years later he presented with fever, recurrent back pain, and new hemoptysis. He underwent successful resection of the descending thoracic aorta with in situ interposition graft reinforced with an omental wrap. Ten months postoperatively, the patient remains on lifelong suppressive antimicrobial therapy with ciprofloxacin and rifampin, without any sign of infection. No similar case has been previously reported in the English literature. A 74-year-old Iranian-born man initially presented with a penetrating atherosclerotic ulcer of the descending thoracic aorta. He underwent endovascular stenting of the lesion, but later presented with recurrent back pain and fever. He was then diagnosed with brucellosis and started on antimicrobial therapy, including 2 weeks of parenteral gentamicin and two oral agents that were poorly tolerated. Two years later he presented with fever, recurrent back pain, and new hemoptysis. He underwent successful resection of the descending thoracic aorta with in situ interposition graft reinforced with an omental wrap. Ten months postoperatively, the patient remains on lifelong suppressive antimicrobial therapy with ciprofloxacin and rifampin, without any sign of infection. No similar case has been previously reported in the English literature. Brucellosis is a bacterial zoonosis usually transmitted by the consumption of contaminated milk or meat, or by direct contact with feces or other body fluids. Although uncommon in developed countries, it remains a public health problem around the Mediterranean Sea and parts of Asia, Africa, and South America [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Diagnosis can be made by serologic studies; blood, bone marrow, or affected tissue culture; or polymerase chain reaction of blood or tissue. Endovascular infections due to Brucella (most commonly endocarditis) account for less than 5% of all cases, but disproportionately account for the mortality due to the infection [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Prosthetic material infections with Brucella (typically prosthetic joints or cardiac valves) have been uncommonly reported in the literature; infections associated with thoracic aortic aneurysms are even more rare [2Kusztal M. Dorobisz A. Kuzniar J. et al.Dissecting aneurysm of the thoracic aorta in a patient with nephritic syndrome and brucellosis.Int J Urol Nephrol. 2007; 39: 641-645Crossref PubMed Scopus (8) Google Scholar, 3Tsioufis K. Stefanadis C. Kallikazaros I. A footprint of Brucella infection: enormous saccular aneurysm of the ascending aorta.Heart. 2006; 92: 1308Crossref PubMed Scopus (8) Google Scholar].A 74-year-old Iranian-born man was suspected of having a penetrating atherosclerotic ulcer of the descending thoracic aorta at the T9 to T10 level during the workup for epigastric and back pain. The ulcer was associated with a crescent-shaped intramural hematoma without contrast extravasation on a computed tomographic scan of the chest (Figs 1A,1B). The patient was afebrile, with a normal peripheral white blood cell count and three sets of surveillance blood cultures without growth.The patient underwent endovascular repair of the ulcer with a 31 mm × 10 cm Gore Tag endograft (W. L. Gore and Associates, Flagstaff, AZ) with an unremarkable early postoperative course. Four weeks later he presented with new onset fevers, rigors, and mid-back pain. His wife had recently been diagnosed with brucellosis, and he acknowledged that prior to this admission he visited farms and consumed unpasteurized dairy products while in Iran. Anti-immunoglobin (Ig) M and IgG were reactive at 3 and 27 units, respectively ( 11 units were considered positive) (Quest Diagnostics, San Juan Capistrano, CA). Blood cultures obtained on admission revealed Brucella melitensis. A computerized tomographic scan of the chest demonstrated only postoperative changes with no overt signs of infection. Vertebral magnetic resonance imaging ruled out thoracic spine involvement. Antimicrobial therapy included intravenous gentamicin and oral doxycycline and trimethoprim-sulfamethoxazole for 2 weeks. Due to drug intolerance, the oral component was changed to rifampin and ciprofloxacin. Although surgical resection of the stent graft and the affected aorta was offered to the patient, he declined that option. He was to remain on lifelong suppressive antibiotic therapy due to concerns that the stent and graft had become infected, but he discontinued his medications 3 months after returning to Iran.His intervening course was unremarkable. Two years after his initial aortic repair, he had recurrent back pain and a new hemoptysis occurred. An aortobronchial fistula was confirmed on imaging studies, and he underwent further stent grafting of the aorta from just distal to the left subclavian artery to above the celiac artery while still in Iran. His symptoms resolved after the procedure. He returned to the United States and re-presented to our institution 4 months later with recurrent intermittent mild hemoptysis. The patient was otherwise afebrile and his peripheral white blood cell count was 9,000 K/μL. Brucella IgG and IgM by enzyme-linked immunoassay were 20 and < 9, respectively. Routine and Brucella-specific blood cultures were negative. The findings of a computed tomographic chest scan were concerning for graft infection with gas in the aortic wall, but without evidence of contrast extravasation (Figs 2A and 2B). A flexible bronchoscopy and esophagoscopy did not show any clear evidence of fistulae, although several small areas of thinning and discoloration of the esophageal mucosa were noted. A transesophageal echocardiogram demonstrated no vegetations. A decision was then made to surgically remove the entire descending thoracic aorta and grafts.Fig 2(A, B) Computed tomographic scan of the chest showing air around the graft but without evidence of contrast extravasation.View Large Image Figure ViewerDownload (PPT)The surgical approach was through a left thoracoabdominal incision. Under deep hypothermic circulatory arrest, the proximal descending aorta was resected and replaced with a 24-mm Vascutek Dacron single side-arm branched graft (Vascutek Terumo, Ann Arbor, MI). During rewarming, we proceeded to resect the entire descending thoracic aorta and remove all stent graft material. Several fistulae between the aorta and esophagus were identified and were primarily repaired. There was no evidence of an aortobronchial fistula, although the lung was densely adherent to the aorta near the distal aspect of the original stent graft. The Dacron graft was fully covered with an omental wrap. Gastrostomy and jejunostomy tubes were placed in the abdomen to conclude the procedure.The postoperative course was significant for complete heart block which eventually required a permanent transvenous pacemaker, and a chylothorax that responded to conservative management. Intraoperative cultures grew only gastrointestinal flora; however, polymerase chain reaction for Brucella was performed on the resected specimen, and was positive (Massachusetts Department of Public Health, Jamaica Plain, MA). The patient was discharged on postoperative day 18 to a rehabilitation facility and received 3 weeks of parenteral antimicrobial therapy, including gentamicin for all indentified flora. He was transitioned to enteral doxycycline and rifampin, and was later changed to a suppressive regimen of oral ciprofloxacin and rifampin due to gastrointestinal intolerance. At 10 months after his open repair, the patient was in good health with no signs of infection, he was ambulating independently and was eating a normal diet.CommentWe believe this is the first confirmed case reported in the English literature of a descending thoracic aortic atherosclerotic ulcer repair complicated by infection with Brucella melitensis.The diagnosis of endovascular infection by Brucella may be difficult to make based on clinical criteria, particularly due to protean manifestations of disease, possible subacute course, and significant risk of chronic infection or recurrence. Given his epidemiologic history, a clearly defined site of infection and positive blood cultures, his presentation is one of hematogenous seeding of the newly placed aortic endograft. As in this case, symptoms often begin 2 to 4 weeks after inoculation. Antibody assays may be a nonspecific diagnostic test; IgM antibodies manifest within a week of exposure and conversion from IgM to IgG antibodies may occur within the first 2 weeks. The IgG response often wanes over time, and persistent elevation may suggest chronic infection or re-infection, as is suspected in our patient's second presentation. The role of polymerase chain reaction in the diagnosis of Brucella is not fully elucidated, but seems to be an accurate method of detection including testing of nonblood specimens [4Morata P. Queipo-Ortuno M.I. Reguera J.M. Miralles F. Lopez-Gonzalez J.J. Colmenero J.D. Diagnostic yield of a PCR assay in focal complications of Brucellosis.J Clin Microbiol. 2001; 39: 3743-3746Crossref PubMed Scopus (75) Google Scholar].The management of mycotic aneurysm in general remains challenging in light of the risk of catastrophic rupture. Surgical excision is considered to be the mainstay of treatment, especially in the presence of symptoms or fistulas. Surgical options include in situ graft interposition with debridement of all infected tissue, or extra-anatomic bypass with aortic ligation [5Müller B.T. Wegener O.R. Grabitz K. et al.Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases.J Vasc Surg. 2001; 33: 106-113Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar]. Omental wrapping is advocated to decrease the risk of secondary graft infection, and prevent the occurrence of fistulas. Cryopreserved human allografts could be an alternative for aortic reconstruction [6Brown K.E. Heyer K. Rodriguez H. et al.Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up.J Vasc Surg. 2009; 49: 660-666Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar], but were not ideal in our case because multiple segments and anastomoses would have been necessary, with the risk of future dehiscence-pseudoaneurysm formation. Endovascular stent grafting has been proposed as another alternative in high-risk patients or as a bridge to definitive open repair, especially in the presence of aorto-digestive or aorto-bronchial fistulas [7Lew W.K. Rowe V.L. Cunningham M.J. Weaver F.A. Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.Ann Vasc Surg. 2009; 23: 81-89Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Lower perioperative morbidity has been reported with stenting, but follow-up imaging is necessary to rule out endoleaks or secondary infection of the stent. This usually requires open surgical excision although endovascular removal of an infected endoprosthethesis using a wire cutter has been recently reported in a high-risk patient [8Dolmans D.E. Ho G.H. Te Slaa A. et al.Surgical removal of an infected aortic endoprosthesis using a wire cutter.J Cardiovasc Surg (Torino). 2009; 50: 411-414PubMed Google Scholar].Medical treatment of infections due to Brucella typically includes two or more agents with intracellular activity. Atlhough therapy with rifampin, tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycocides have all been studied, no single regimen has proven superior in practice, and drug selection is often tailored to specific circumstances [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Suppressive therapy is usually recommended as an adjunct to surgical resection, but the duration of treatment is not well established. Given the complexities of this case, including the presence of artificial graft material placed in the setting of active infection and likely future re-exposure to Brucella on his eventual return to Iran, we have recommended lifelong antimicrobial therapy. Brucellosis is a bacterial zoonosis usually transmitted by the consumption of contaminated milk or meat, or by direct contact with feces or other body fluids. Although uncommon in developed countries, it remains a public health problem around the Mediterranean Sea and parts of Asia, Africa, and South America [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Diagnosis can be made by serologic studies; blood, bone marrow, or affected tissue culture; or polymerase chain reaction of blood or tissue. Endovascular infections due to Brucella (most commonly endocarditis) account for less than 5% of all cases, but disproportionately account for the mortality due to the infection [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Prosthetic material infections with Brucella (typically prosthetic joints or cardiac valves) have been uncommonly reported in the literature; infections associated with thoracic aortic aneurysms are even more rare [2Kusztal M. Dorobisz A. Kuzniar J. et al.Dissecting aneurysm of the thoracic aorta in a patient with nephritic syndrome and brucellosis.Int J Urol Nephrol. 2007; 39: 641-645Crossref PubMed Scopus (8) Google Scholar, 3Tsioufis K. Stefanadis C. Kallikazaros I. A footprint of Brucella infection: enormous saccular aneurysm of the ascending aorta.Heart. 2006; 92: 1308Crossref PubMed Scopus (8) Google Scholar]. A 74-year-old Iranian-born man was suspected of having a penetrating atherosclerotic ulcer of the descending thoracic aorta at the T9 to T10 level during the workup for epigastric and back pain. The ulcer was associated with a crescent-shaped intramural hematoma without contrast extravasation on a computed tomographic scan of the chest (Figs 1A,1B). The patient was afebrile, with a normal peripheral white blood cell count and three sets of surveillance blood cultures without growth. The patient underwent endovascular repair of the ulcer with a 31 mm × 10 cm Gore Tag endograft (W. L. Gore and Associates, Flagstaff, AZ) with an unremarkable early postoperative course. Four weeks later he presented with new onset fevers, rigors, and mid-back pain. His wife had recently been diagnosed with brucellosis, and he acknowledged that prior to this admission he visited farms and consumed unpasteurized dairy products while in Iran. Anti-immunoglobin (Ig) M and IgG were reactive at 3 and 27 units, respectively ( 11 units were considered positive) (Quest Diagnostics, San Juan Capistrano, CA). Blood cultures obtained on admission revealed Brucella melitensis. A computerized tomographic scan of the chest demonstrated only postoperative changes with no overt signs of infection. Vertebral magnetic resonance imaging ruled out thoracic spine involvement. Antimicrobial therapy included intravenous gentamicin and oral doxycycline and trimethoprim-sulfamethoxazole for 2 weeks. Due to drug intolerance, the oral component was changed to rifampin and ciprofloxacin. Although surgical resection of the stent graft and the affected aorta was offered to the patient, he declined that option. He was to remain on lifelong suppressive antibiotic therapy due to concerns that the stent and graft had become infected, but he discontinued his medications 3 months after returning to Iran. His intervening course was unremarkable. Two years after his initial aortic repair, he had recurrent back pain and a new hemoptysis occurred. An aortobronchial fistula was confirmed on imaging studies, and he underwent further stent grafting of the aorta from just distal to the left subclavian artery to above the celiac artery while still in Iran. His symptoms resolved after the procedure. He returned to the United States and re-presented to our institution 4 months later with recurrent intermittent mild hemoptysis. The patient was otherwise afebrile and his peripheral white blood cell count was 9,000 K/μL. Brucella IgG and IgM by enzyme-linked immunoassay were 20 and < 9, respectively. Routine and Brucella-specific blood cultures were negative. The findings of a computed tomographic chest scan were concerning for graft infection with gas in the aortic wall, but without evidence of contrast extravasation (Figs 2A and 2B). A flexible bronchoscopy and esophagoscopy did not show any clear evidence of fistulae, although several small areas of thinning and discoloration of the esophageal mucosa were noted. A transesophageal echocardiogram demonstrated no vegetations. A decision was then made to surgically remove the entire descending thoracic aorta and grafts. The surgical approach was through a left thoracoabdominal incision. Under deep hypothermic circulatory arrest, the proximal descending aorta was resected and replaced with a 24-mm Vascutek Dacron single side-arm branched graft (Vascutek Terumo, Ann Arbor, MI). During rewarming, we proceeded to resect the entire descending thoracic aorta and remove all stent graft material. Several fistulae between the aorta and esophagus were identified and were primarily repaired. There was no evidence of an aortobronchial fistula, although the lung was densely adherent to the aorta near the distal aspect of the original stent graft. The Dacron graft was fully covered with an omental wrap. Gastrostomy and jejunostomy tubes were placed in the abdomen to conclude the procedure. The postoperative course was significant for complete heart block which eventually required a permanent transvenous pacemaker, and a chylothorax that responded to conservative management. Intraoperative cultures grew only gastrointestinal flora; however, polymerase chain reaction for Brucella was performed on the resected specimen, and was positive (Massachusetts Department of Public Health, Jamaica Plain, MA). The patient was discharged on postoperative day 18 to a rehabilitation facility and received 3 weeks of parenteral antimicrobial therapy, including gentamicin for all indentified flora. He was transitioned to enteral doxycycline and rifampin, and was later changed to a suppressive regimen of oral ciprofloxacin and rifampin due to gastrointestinal intolerance. At 10 months after his open repair, the patient was in good health with no signs of infection, he was ambulating independently and was eating a normal diet. CommentWe believe this is the first confirmed case reported in the English literature of a descending thoracic aortic atherosclerotic ulcer repair complicated by infection with Brucella melitensis.The diagnosis of endovascular infection by Brucella may be difficult to make based on clinical criteria, particularly due to protean manifestations of disease, possible subacute course, and significant risk of chronic infection or recurrence. Given his epidemiologic history, a clearly defined site of infection and positive blood cultures, his presentation is one of hematogenous seeding of the newly placed aortic endograft. As in this case, symptoms often begin 2 to 4 weeks after inoculation. Antibody assays may be a nonspecific diagnostic test; IgM antibodies manifest within a week of exposure and conversion from IgM to IgG antibodies may occur within the first 2 weeks. The IgG response often wanes over time, and persistent elevation may suggest chronic infection or re-infection, as is suspected in our patient's second presentation. The role of polymerase chain reaction in the diagnosis of Brucella is not fully elucidated, but seems to be an accurate method of detection including testing of nonblood specimens [4Morata P. Queipo-Ortuno M.I. Reguera J.M. Miralles F. Lopez-Gonzalez J.J. Colmenero J.D. Diagnostic yield of a PCR assay in focal complications of Brucellosis.J Clin Microbiol. 2001; 39: 3743-3746Crossref PubMed Scopus (75) Google Scholar].The management of mycotic aneurysm in general remains challenging in light of the risk of catastrophic rupture. Surgical excision is considered to be the mainstay of treatment, especially in the presence of symptoms or fistulas. Surgical options include in situ graft interposition with debridement of all infected tissue, or extra-anatomic bypass with aortic ligation [5Müller B.T. Wegener O.R. Grabitz K. et al.Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases.J Vasc Surg. 2001; 33: 106-113Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar]. Omental wrapping is advocated to decrease the risk of secondary graft infection, and prevent the occurrence of fistulas. Cryopreserved human allografts could be an alternative for aortic reconstruction [6Brown K.E. Heyer K. Rodriguez H. et al.Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up.J Vasc Surg. 2009; 49: 660-666Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar], but were not ideal in our case because multiple segments and anastomoses would have been necessary, with the risk of future dehiscence-pseudoaneurysm formation. Endovascular stent grafting has been proposed as another alternative in high-risk patients or as a bridge to definitive open repair, especially in the presence of aorto-digestive or aorto-bronchial fistulas [7Lew W.K. Rowe V.L. Cunningham M.J. Weaver F.A. Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.Ann Vasc Surg. 2009; 23: 81-89Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Lower perioperative morbidity has been reported with stenting, but follow-up imaging is necessary to rule out endoleaks or secondary infection of the stent. This usually requires open surgical excision although endovascular removal of an infected endoprosthethesis using a wire cutter has been recently reported in a high-risk patient [8Dolmans D.E. Ho G.H. Te Slaa A. et al.Surgical removal of an infected aortic endoprosthesis using a wire cutter.J Cardiovasc Surg (Torino). 2009; 50: 411-414PubMed Google Scholar].Medical treatment of infections due to Brucella typically includes two or more agents with intracellular activity. Atlhough therapy with rifampin, tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycocides have all been studied, no single regimen has proven superior in practice, and drug selection is often tailored to specific circumstances [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Suppressive therapy is usually recommended as an adjunct to surgical resection, but the duration of treatment is not well established. Given the complexities of this case, including the presence of artificial graft material placed in the setting of active infection and likely future re-exposure to Brucella on his eventual return to Iran, we have recommended lifelong antimicrobial therapy. We believe this is the first confirmed case reported in the English literature of a descending thoracic aortic atherosclerotic ulcer repair complicated by infection with Brucella melitensis. The diagnosis of endovascular infection by Brucella may be difficult to make based on clinical criteria, particularly due to protean manifestations of disease, possible subacute course, and significant risk of chronic infection or recurrence. Given his epidemiologic history, a clearly defined site of infection and positive blood cultures, his presentation is one of hematogenous seeding of the newly placed aortic endograft. As in this case, symptoms often begin 2 to 4 weeks after inoculation. Antibody assays may be a nonspecific diagnostic test; IgM antibodies manifest within a week of exposure and conversion from IgM to IgG antibodies may occur within the first 2 weeks. The IgG response often wanes over time, and persistent elevation may suggest chronic infection or re-infection, as is suspected in our patient's second presentation. The role of polymerase chain reaction in the diagnosis of Brucella is not fully elucidated, but seems to be an accurate method of detection including testing of nonblood specimens [4Morata P. Queipo-Ortuno M.I. Reguera J.M. Miralles F. Lopez-Gonzalez J.J. Colmenero J.D. Diagnostic yield of a PCR assay in focal complications of Brucellosis.J Clin Microbiol. 2001; 39: 3743-3746Crossref PubMed Scopus (75) Google Scholar]. The management of mycotic aneurysm in general remains challenging in light of the risk of catastrophic rupture. Surgical excision is considered to be the mainstay of treatment, especially in the presence of symptoms or fistulas. Surgical options include in situ graft interposition with debridement of all infected tissue, or extra-anatomic bypass with aortic ligation [5Müller B.T. Wegener O.R. Grabitz K. et al.Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases.J Vasc Surg. 2001; 33: 106-113Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar]. Omental wrapping is advocated to decrease the risk of secondary graft infection, and prevent the occurrence of fistulas. Cryopreserved human allografts could be an alternative for aortic reconstruction [6Brown K.E. Heyer K. Rodriguez H. et al.Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up.J Vasc Surg. 2009; 49: 660-666Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar], but were not ideal in our case because multiple segments and anastomoses would have been necessary, with the risk of future dehiscence-pseudoaneurysm formation. Endovascular stent grafting has been proposed as another alternative in high-risk patients or as a bridge to definitive open repair, especially in the presence of aorto-digestive or aorto-bronchial fistulas [7Lew W.K. Rowe V.L. Cunningham M.J. Weaver F.A. Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.Ann Vasc Surg. 2009; 23: 81-89Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Lower perioperative morbidity has been reported with stenting, but follow-up imaging is necessary to rule out endoleaks or secondary infection of the stent. This usually requires open surgical excision although endovascular removal of an infected endoprosthethesis using a wire cutter has been recently reported in a high-risk patient [8Dolmans D.E. Ho G.H. Te Slaa A. et al.Surgical removal of an infected aortic endoprosthesis using a wire cutter.J Cardiovasc Surg (Torino). 2009; 50: 411-414PubMed Google Scholar]. Medical treatment of infections due to Brucella typically includes two or more agents with intracellular activity. Atlhough therapy with rifampin, tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycocides have all been studied, no single regimen has proven superior in practice, and drug selection is often tailored to specific circumstances [1Pappas G. Akritidis N. Bosilovski M. Tsianos E. Brucellosis.N Engl J Med. 2005; 352: 2325-2336Crossref PubMed Scopus (1005) Google Scholar]. Suppressive therapy is usually recommended as an adjunct to surgical resection, but the duration of treatment is not well established. Given the complexities of this case, including the presence of artificial graft material placed in the setting of active infection and likely future re-exposure to Brucella on his eventual return to Iran, we have recommended lifelong antimicrobial therapy.