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Bridge Use of Endovascular Repair and Delayed Open Operation for Infected Aneurysm of Aortic Arch

2013; Elsevier BV; Volume: 96; Issue: 4 Linguagem: Inglês

10.1016/j.athoracsur.2013.01.095

1552-6259

Kentaro Tamura, Hidenori Yoshitaka, Toshinori Totsugawa, Yoshimasa Tsushima, Genta Chikazawa, Tsukasa Ohno, Taichi Sakaguchi,

Vascular Procedures and Complications

We present the first clinical report of the successful treatment of an infected thoracic aortic arch aneurysm with the use of endovascular repair as a bridge to second-stage open operation. A 70-year-old patient underwent urgent endovascular repair through the right femoral approach because of a diagnosis of sepsis and impending rupture of an infected thoracic aortic arch aneurysm. After 2 weeks of medical treatment, we successfully performed explantation of the stent graft, wide debridement of the surrounding tissue, and in-situ replacement using a rifampicin-bonded four-branched prosthetic graft with omental flap. We present the first clinical report of the successful treatment of an infected thoracic aortic arch aneurysm with the use of endovascular repair as a bridge to second-stage open operation. A 70-year-old patient underwent urgent endovascular repair through the right femoral approach because of a diagnosis of sepsis and impending rupture of an infected thoracic aortic arch aneurysm. After 2 weeks of medical treatment, we successfully performed explantation of the stent graft, wide debridement of the surrounding tissue, and in-situ replacement using a rifampicin-bonded four-branched prosthetic graft with omental flap. Infected aortic aneurysm is rare and remains challenging to treat. The standard treatment is an open surgical procedure, including wide debridement of the infected aorta and surrounding tissue, in-situ or extraanatomic reconstruction, and long-term antibiotic therapy. Recently, several reports have described acceptable short-term results of endovascular repair for infected aortic aneurysms [1Kan C.D. Yen H.T. Kan C.B. et al.The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.J Vasc Surg. 2012; 55: 55-60Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 2Kritpracha B. Premprabha D. Sungsiri J. et al.Endovascular therapy for infected aortic aneurysms.J Vasc Surg. 2011; 54: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. However, its role remains controversial because persistent infection is always a concern. Endovascular repair for infected aortic aneurysm should be considered as a bridge to improve a patient’s condition during the wait for an open operation. However, few publications have described the use of this strategy. We describe the first clinical report of successful management of an infected thoracic aortic aneurysm with endovascular repair followed by a delayed open surgical procedure.A 70-year-old man with diabetes mellitus was referred to our hospital for management of thoracic aortic aneurysm. He had a 6-day history of high-grade fever and back pain, and bloody sputum was identified just before admission to our hospital. Klebsiella pneumoniae had already been detected in a blood culture, and antibiotic treatment had been initiated in the previous hospital. Physical examination revealed a blood pressure of 164/56 mm Hg and a heart rate of 68 beats/min. The white blood cell count was 20,300/μL, and the C-reactive protein level was 14.3 mg/dL. Enhanced computed tomography (CT) showed a large thoracic aortic arch aneurysm with diffused gas inclusion, which was much larger than that seen 3 days before (Fig 1). A diagnosis of impending rupture of the infected aortic arch aneurysm was confirmed. We decided to perform endovascular repair as a bridge procedure to prevent lethal rupture, followed by continuation of medical therapy for infection. With the patient under general anesthesia, urgent thoracic endovascular repair (TEVAR) was performed with the use of a Cook Zenith TX2 34- × 30- × 150-mm (Cook Medical, Bloomington, IN) thoracic endovascular stent graft through the right common femoral artery. The proximal left subclavian artery was occluded by coils to prevent potential type II endoleak. Persistent chest pain radiating to the back subsided immediately after TEVAR, and the patient’s inflammatory signs, including white blood cell count and C-reactive protein level, returned to almost normal levels within 5 days after the operation. Postoperative CT showed no endoleaks (Fig 2). A second-stage open operation was performed 2 weeks after TEVAR. The patient’s chest was entered through a standard midline sternotomy along with a left thoracotomy at the fourth intrercostal space. After the establishment of cardiopulmonary bypass, the stent graft was explanted with relative ease, followed by debridement of the aortic wall and surrounding tissues while the patient was under circulatory arrest with selective cerebral perfusion, at a rectal temperature of 25°C. The aortic arch was replaced with a four-branched gelatin-impregnated Dacron graft (Gelseal four-branch plexus; Vascutek, Terumo, Renfrewshire, UK) soaked in a rifampicin solution (Wako Pure Chemical Industries, Osaka, Japan). The coils were also resected, and the proximal left subclavian artery was closed. The left axillary artery was reconstructed from the second branch of the four-branched Dacron graft. Finally, the prosthetic graft was covered with the omental flap. Bacterial culture from the aneurysmal wall demonstrated no bacteria, probably owing to preoperative antibiotic treatment. A postoperative CT scan showed correct graft replacement (Fig 3). The patient was discharged without any recurrent signs of infection.Fig 2Endovascular repair was performed and the proximal left subclavian artery was covered by coils.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3After explantation of the stent graft and wide debridement, the aortic arch was replaced with a refampicin-bonded four-branched Dacron graft. The left axillary artery was reconstructed by the second branch of the graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)CommentAn infected aortic aneurysm is a rare but life-threatening condition, and it remains clinically demanding to treat. An open operation for infected aneurysm carries significant mortality and morbidity, resulting from patient instability caused by sepsis or rupture [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar, 4Fillmore A.J. Valentine R.J. Surgical mortality in patients with infected aortic aneurysms.J Am Coll Surg. 2003; 196: 435-441Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 5Muller B.T. Wegener O.R. Grabitzs L. 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]. The operative mortality is especially higher in patients with infected aneurysms involving the suprarenal or thoracic aorta compared with infrarenal involvement [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar]. However, Oderich and colleagues [6Oderich G.S. Panneton J.M. Bower T.C. et al.Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.J Vasc Surg. 2001; 34: 900-908Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar] reported that the late outcome was favorable, with no aneurysm-related death and a low related complication rate.Recently, several reports have described acceptable early outcomes of endovascular repair for infected aortic aneurysm [1Kan C.D. Yen H.T. Kan C.B. et al.The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.J Vasc Surg. 2012; 55: 55-60Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 2Kritpracha B. Premprabha D. Sungsiri J. et al.Endovascular therapy for infected aortic aneurysms.J Vasc Surg. 2011; 54: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. However, they mentioned mainly abdominal aneurysms, and the long-term result is still unknown. Stent graft placement in the infected field may not be optimal, and its acceptability remains controversial. The gold standard of treatment for an infected thoracic aortic aneurysm is still surgical debridement of infected tissue followed by in situ revascularization or extraanatomic grafting with long-term antibiotic therapy. Endovascular repair should be an alternative for high-risk patients or used as a bridge while they await an open procedure.In the present case, extraanatomic repair was considered to be inappropriate because the aneurysm was in the distal arch, and the aortic arch was heavily calcified. Therefore, we performed in situ replacement of the aortic arch with a rifampicin-bonded prosthetic graft. The use of a rifampicin-bonded graft has been associated with favorable outcomes for graft infection, and this has recently been applied to the treatment of infected aortic aneurysms [7Totsugawa T. Kuinose M. Yoshitaka H. et al.Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in situ replacement with rifampicin-bonded prosthesis: report of three cases.Circ J. 2007; 71: 1317-1320Crossref PubMed Scopus (10) Google Scholar].Sugimoto and colleagues [8Sugimoto M. Banno H. Idetsu A. et al.Surgical experience of 13 infected infrarenal aortoiliac aneurysms: pre-operative control of septic condition determines early outcome.Surgery. 2011; 149: 699-704Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] reported that timely surgical intervention after control of sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was high. Although it is needless to say that preoperative medical treatment is crucial, the risk of lethal rupture always exists even when antibiotic therapy is given; that is the dilemma of the treatment of an infected aortic aneurysm. In this regard, the bridge use of TEVAR to prevent early rupture and temporarily stabilize the patient’s condition before a second-stage open operation can be a reasonable treatment option. We consider this strategy beneficial to patients with an infected thoracic aortic arch aneurysm. It decreases the risk of perioperative complications related to cardiopulmonary bypass with the patient under circulatory arrest, and it prevents the recurrence of infection, compared with a one-stage corrective open operation. Infected aortic aneurysm is rare and remains challenging to treat. The standard treatment is an open surgical procedure, including wide debridement of the infected aorta and surrounding tissue, in-situ or extraanatomic reconstruction, and long-term antibiotic therapy. Recently, several reports have described acceptable short-term results of endovascular repair for infected aortic aneurysms [1Kan C.D. Yen H.T. Kan C.B. et al.The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.J Vasc Surg. 2012; 55: 55-60Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 2Kritpracha B. Premprabha D. Sungsiri J. et al.Endovascular therapy for infected aortic aneurysms.J Vasc Surg. 2011; 54: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. However, its role remains controversial because persistent infection is always a concern. Endovascular repair for infected aortic aneurysm should be considered as a bridge to improve a patient’s condition during the wait for an open operation. However, few publications have described the use of this strategy. We describe the first clinical report of successful management of an infected thoracic aortic aneurysm with endovascular repair followed by a delayed open surgical procedure. A 70-year-old man with diabetes mellitus was referred to our hospital for management of thoracic aortic aneurysm. He had a 6-day history of high-grade fever and back pain, and bloody sputum was identified just before admission to our hospital. Klebsiella pneumoniae had already been detected in a blood culture, and antibiotic treatment had been initiated in the previous hospital. Physical examination revealed a blood pressure of 164/56 mm Hg and a heart rate of 68 beats/min. The white blood cell count was 20,300/μL, and the C-reactive protein level was 14.3 mg/dL. Enhanced computed tomography (CT) showed a large thoracic aortic arch aneurysm with diffused gas inclusion, which was much larger than that seen 3 days before (Fig 1). A diagnosis of impending rupture of the infected aortic arch aneurysm was confirmed. We decided to perform endovascular repair as a bridge procedure to prevent lethal rupture, followed by continuation of medical therapy for infection. With the patient under general anesthesia, urgent thoracic endovascular repair (TEVAR) was performed with the use of a Cook Zenith TX2 34- × 30- × 150-mm (Cook Medical, Bloomington, IN) thoracic endovascular stent graft through the right common femoral artery. The proximal left subclavian artery was occluded by coils to prevent potential type II endoleak. Persistent chest pain radiating to the back subsided immediately after TEVAR, and the patient’s inflammatory signs, including white blood cell count and C-reactive protein level, returned to almost normal levels within 5 days after the operation. Postoperative CT showed no endoleaks (Fig 2). A second-stage open operation was performed 2 weeks after TEVAR. The patient’s chest was entered through a standard midline sternotomy along with a left thoracotomy at the fourth intrercostal space. After the establishment of cardiopulmonary bypass, the stent graft was explanted with relative ease, followed by debridement of the aortic wall and surrounding tissues while the patient was under circulatory arrest with selective cerebral perfusion, at a rectal temperature of 25°C. The aortic arch was replaced with a four-branched gelatin-impregnated Dacron graft (Gelseal four-branch plexus; Vascutek, Terumo, Renfrewshire, UK) soaked in a rifampicin solution (Wako Pure Chemical Industries, Osaka, Japan). The coils were also resected, and the proximal left subclavian artery was closed. The left axillary artery was reconstructed from the second branch of the four-branched Dacron graft. Finally, the prosthetic graft was covered with the omental flap. Bacterial culture from the aneurysmal wall demonstrated no bacteria, probably owing to preoperative antibiotic treatment. A postoperative CT scan showed correct graft replacement (Fig 3). The patient was discharged without any recurrent signs of infection. CommentAn infected aortic aneurysm is a rare but life-threatening condition, and it remains clinically demanding to treat. An open operation for infected aneurysm carries significant mortality and morbidity, resulting from patient instability caused by sepsis or rupture [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar, 4Fillmore A.J. Valentine R.J. Surgical mortality in patients with infected aortic aneurysms.J Am Coll Surg. 2003; 196: 435-441Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 5Muller B.T. Wegener O.R. Grabitzs L. 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]. The operative mortality is especially higher in patients with infected aneurysms involving the suprarenal or thoracic aorta compared with infrarenal involvement [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar]. However, Oderich and colleagues [6Oderich G.S. Panneton J.M. Bower T.C. et al.Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.J Vasc Surg. 2001; 34: 900-908Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar] reported that the late outcome was favorable, with no aneurysm-related death and a low related complication rate.Recently, several reports have described acceptable early outcomes of endovascular repair for infected aortic aneurysm [1Kan C.D. Yen H.T. Kan C.B. et al.The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.J Vasc Surg. 2012; 55: 55-60Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 2Kritpracha B. Premprabha D. Sungsiri J. et al.Endovascular therapy for infected aortic aneurysms.J Vasc Surg. 2011; 54: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. However, they mentioned mainly abdominal aneurysms, and the long-term result is still unknown. Stent graft placement in the infected field may not be optimal, and its acceptability remains controversial. The gold standard of treatment for an infected thoracic aortic aneurysm is still surgical debridement of infected tissue followed by in situ revascularization or extraanatomic grafting with long-term antibiotic therapy. Endovascular repair should be an alternative for high-risk patients or used as a bridge while they await an open procedure.In the present case, extraanatomic repair was considered to be inappropriate because the aneurysm was in the distal arch, and the aortic arch was heavily calcified. Therefore, we performed in situ replacement of the aortic arch with a rifampicin-bonded prosthetic graft. The use of a rifampicin-bonded graft has been associated with favorable outcomes for graft infection, and this has recently been applied to the treatment of infected aortic aneurysms [7Totsugawa T. Kuinose M. Yoshitaka H. et al.Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in situ replacement with rifampicin-bonded prosthesis: report of three cases.Circ J. 2007; 71: 1317-1320Crossref PubMed Scopus (10) Google Scholar].Sugimoto and colleagues [8Sugimoto M. Banno H. Idetsu A. et al.Surgical experience of 13 infected infrarenal aortoiliac aneurysms: pre-operative control of septic condition determines early outcome.Surgery. 2011; 149: 699-704Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] reported that timely surgical intervention after control of sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was high. Although it is needless to say that preoperative medical treatment is crucial, the risk of lethal rupture always exists even when antibiotic therapy is given; that is the dilemma of the treatment of an infected aortic aneurysm. In this regard, the bridge use of TEVAR to prevent early rupture and temporarily stabilize the patient’s condition before a second-stage open operation can be a reasonable treatment option. We consider this strategy beneficial to patients with an infected thoracic aortic arch aneurysm. It decreases the risk of perioperative complications related to cardiopulmonary bypass with the patient under circulatory arrest, and it prevents the recurrence of infection, compared with a one-stage corrective open operation. An infected aortic aneurysm is a rare but life-threatening condition, and it remains clinically demanding to treat. An open operation for infected aneurysm carries significant mortality and morbidity, resulting from patient instability caused by sepsis or rupture [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar, 4Fillmore A.J. Valentine R.J. Surgical mortality in patients with infected aortic aneurysms.J Am Coll Surg. 2003; 196: 435-441Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 5Muller B.T. Wegener O.R. Grabitzs L. 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]. The operative mortality is especially higher in patients with infected aneurysms involving the suprarenal or thoracic aorta compared with infrarenal involvement [3Moneta G.L. Taylor Jr., L.M. Yeager R.A. et al.Surgical treatment of infected aortic aneurysm.Am J Surg. 1998; 175: 396-399Abstract Full Text PDF PubMed Scopus (145) Google Scholar]. However, Oderich and colleagues [6Oderich G.S. Panneton J.M. Bower T.C. et al.Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.J Vasc Surg. 2001; 34: 900-908Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar] reported that the late outcome was favorable, with no aneurysm-related death and a low related complication rate. Recently, several reports have described acceptable early outcomes of endovascular repair for infected aortic aneurysm [1Kan C.D. Yen H.T. Kan C.B. et al.The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.J Vasc Surg. 2012; 55: 55-60Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 2Kritpracha B. Premprabha D. Sungsiri J. et al.Endovascular therapy for infected aortic aneurysms.J Vasc Surg. 2011; 54: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. However, they mentioned mainly abdominal aneurysms, and the long-term result is still unknown. Stent graft placement in the infected field may not be optimal, and its acceptability remains controversial. The gold standard of treatment for an infected thoracic aortic aneurysm is still surgical debridement of infected tissue followed by in situ revascularization or extraanatomic grafting with long-term antibiotic therapy. Endovascular repair should be an alternative for high-risk patients or used as a bridge while they await an open procedure. In the present case, extraanatomic repair was considered to be inappropriate because the aneurysm was in the distal arch, and the aortic arch was heavily calcified. Therefore, we performed in situ replacement of the aortic arch with a rifampicin-bonded prosthetic graft. The use of a rifampicin-bonded graft has been associated with favorable outcomes for graft infection, and this has recently been applied to the treatment of infected aortic aneurysms [7Totsugawa T. Kuinose M. Yoshitaka H. et al.Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in situ replacement with rifampicin-bonded prosthesis: report of three cases.Circ J. 2007; 71: 1317-1320Crossref PubMed Scopus (10) Google Scholar]. Sugimoto and colleagues [8Sugimoto M. Banno H. Idetsu A. et al.Surgical experience of 13 infected infrarenal aortoiliac aneurysms: pre-operative control of septic condition determines early outcome.Surgery. 2011; 149: 699-704Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] reported that timely surgical intervention after control of sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was high. Although it is needless to say that preoperative medical treatment is crucial, the risk of lethal rupture always exists even when antibiotic therapy is given; that is the dilemma of the treatment of an infected aortic aneurysm. In this regard, the bridge use of TEVAR to prevent early rupture and temporarily stabilize the patient’s condition before a second-stage open operation can be a reasonable treatment option. We consider this strategy beneficial to patients with an infected thoracic aortic arch aneurysm. It decreases the risk of perioperative complications related to cardiopulmonary bypass with the patient under circulatory arrest, and it prevents the recurrence of infection, compared with a one-stage corrective open operation.