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Updates on management of
Infective Aortopathy

Boonprasit Kritpracha, MD
Prince of Songkla University
Hat Yai, Thailand


Prince of Songkla University
Hat Yai, Thailand


Infected Aneurysms

Classification
1. Mycotic aneurysms (from septic emboli)
2. Microbial arteritis with aneurysm

3. Infected prexisting aneurysms
4. Post-traumatic infected false aneurysms

Reddy DJ, Weaver MR. “Infected Aneurysms” in
Rutherford’s textbook of vascular surgery 2005, p 1581-96

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
Diagnosis
Fever

Abdominal/back or chest pain

A phase

V phase

Leukocytosis
Characteristics in imaging studies
Saccular aneurysm in normal-appearing vessel
Inflammatory tissue around aorta
Leakage
Erosion of vertebral body

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
We are dealing with 2 problems

1) Aortic infection
2) Weakened aortic wall that leads to rupture.
Antibiotics alone???

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
Medical treatment is almost always failed.

32 patients1:
Medical treatment alone, mortality, 57%
Operated-on, mortality, 28%

1 Hsu RB et al. J Vasc Surg 2008; 47:270-6

Prince of Songkla University
Hat Yai, Thailand


Retrospective study, 11 years (Jan 2000 – Dec 2010)
16 no aortic resection
9 patients - medical treatment alone
Hospital mortality 78% (7/9)
7 deaths – 4 ruptured aortic aneurysms
2 sepsis
1 stroke

7 patients – EVAR + medical treatment
Hospital mortality 0%

Yu SY, et al; J Vasc Surg 2012;56:943-50

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms

Aug 28, 2008

5.3 cm

19 days

Sep 16, 2008

8.5 cm

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
Dec 23, 2010

62x67 mm

3 days

Dec 26, 2010

68x76 mm

Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
We are dealing with 2 problems

1) Aortic infection
2) Weakened aortic wall that leads to rupture.
I. Antibiotics alone does not work.
> 50% chance of MR

Any other choices?
Prince of Songkla University
Hat Yai, Thailand


Infected Aortic Aneurysms
Management
Surgery:
Operation
Excision and debridement of infected aorta,
+ Extra-anatomic bypass (Axillo-bifemoral bypass)

Options: In situ graft interposition

High mortality in open surgery (up to 44%)


1983 - 2008
10 patients – open repair
in-situ graft with homograft
Hospital mortality 0%

Lee CG, et al; Ann Vasc Surg 2014;28:568-574

Prince of Songkla University
Hat Yai, Thailand


Aortitis with early aneurysmal dilatation ???

Respectable BUT……..
I want to know… have you ever seen the rain?....

Lee CG, et al; Ann Vasc Surg 2014;28:568-574

Prince of Songkla University
Hat Yai, Thailand


Have you ever seen the rain?....

Open repair?

With LOW morbidity & mortality?
Prince of Songkla University
Hat Yai, Thailand


1/2007 – 3/2008
16 patients
6 Infrarenal AAA
2 Juxtaranal AAA
1 Pararenal AAA
5 CIAA

1 EIAA
1 IAAA

13 in situ graft replacement
2 Extra-anatomical bypass
1 EVAR

Hospital mortality 31%

Laohapensang K., et al; Ann Vasc Dis 2012;3:331-341

Prince of Songkla University
Hat Yai, Thailand


1983 – 2008
36 patients
5 TAA
13 TAAA
18 AAA

24 in situ graft replacement
4 Extra-anatomical bypass
4 Dacron patch plasty

Hospital mortality 36%

Ann Vasc Surg 2011;25:1020-1025

Prince of Songkla University

Hat Yai, Thailand


Infected Aortic Aneurysms
I. Medical treatment alone: >50% MR.
II. Surgical treatment alone: >30% MR.
Endovascular therapy?

Prince of Songkla University
Hat Yai, Thailand


Roles of EVAR in Infected Aneurysms
Semba CP, et al JVIR 1998;91:33-40

3 cases of infected thoracic aorta
Follow up: 1 died @ 25 months PO to unrelated condition
2 were well @ 4, 24 months PO

Prince of Songkla University
Hat Yai, Thailand


Reported 21 cases
Today, 90 cases

Prince of Songkla University
Hat Yai, Thailand

September 2005 – September 2015
Endovascular therapy of infected aortic aneurysms
90 cases: 72 males, 18 females
Thoracic
aorta

16
Thoracoabdominal

6

average age 64 years (39-88)
Excluded previous aortic surgery

Thoracic & Abdominal 3

Abdominal

65
Prince of Songkla University
Hat Yai, Thailand


EVAR for Infected Aortic Aneurysms

90 patients
Non-fistula group 74
Microbial aortitis
Infection of preexisting aortic aneurysm

Fistula group 16
6 Aorto-bronchial
4 Aorto-enteric

4 Aorto-esophageal
2 Aorto-caval
Prince of Songkla University
Hat Yai, Thailand


Clinical presentations Non-fistula group
(n = 74)

Periaortic inflammation

96%

Prince of Songkla University
Hat Yai, Thailand


Clinical presentations Non-fistula group
(n = 74)

Leakage

75%

Prince of Songkla University
Hat Yai, Thailand

Caval thrombosis

Clinical presentations

Vertebral erosion

Prince of Songkla University
Hat Yai, Thailand


Organisms
Salmonella

32%

Burkholderia pseudomalliei

19%

S. aureus

19%

E. coli

6%

Klebseilla spp

3%

Streptococcus spp.

9%

Mycobacterium

3%
Prince of Songkla University
Hat Yai, Thailand