A Rare Case of Mycotic Thoracic Aortic Aneurysm Treated with Minimally Invasive Techniques
Huong Truong, MD, Anthony Grieff, MD, Saum Rahimi, MD.
Robert Wood Johnson Rutgers, New Brunswick, NJ, USA.
A rare, but fatal disease, mycotic aortic aneurysms are traditionally treated with open repair, which in itself is a morbid procedure. Herein we present a case of Crawford extent I, contained rupture mycotic aneurysm treated with minimally invasive technique of TEVAR, rifampin-soaked graft and video-assisted thoracoscopic surgery of hemothorax evacuation.
Extensive literature review was performed for treatment of mycotic thoracic aneurysms. The types of repair were reviewed and treatments of post-operative complications were evaluated. Secondly, the morbidity and mortality rates of both short-term and long-term repair of open versus endovascular repair were compared.
Endovascular repair for mycotic aneurysms has been shown to be successful at sealing the aneurysm with resolution of infection. Furthermore, compared to traditional open surgical repair, endovascular treatment has been shown to improve early morbidity and mortality4. A meta-analysis performed by Kan et al showed that endovascular treatment of mycotic aneurysm was associated with a 90% 30-day survival and an 81% 1-year survival. Our patient is a 71-year-old female, who was transferred from outside hospital with acute shortness of breath and left-sided chest pain. Patient has had multiple hospitalizations in previous 3-4 months for pneumonia, CHF/COPD exacerbation, and right lower extremity cellulitis secondary to Staphylococcus aureus infection. Patient was found to have saccular descending thoracic aortic aneurysm measuring 5 cm in maximum diameter. She underwent urgent endovascular repair of thoracic aortic aneurysm with Cook graft soaked in rifampin. Patientís post-operative course was complicated by ventilator-dependent respiratory failure requiring left video-assisted thoracoscopic surgery with successful subsequent extubation. During two years follow-up, patient was found to have good stent placement in descending thoracic aorta with smaller aneurysm sac and no endoleak. Patient is currently asymptomatic and recovering well.
Endovascular repair of mycotic aortic aneurysms has been emerging as a suitable option. In particular, rifampin soaked and flushed stent graft with addition of IV antibiotics and video assisted thoracotomy can serve as adjunct therapies to help eradicate the infection with minimally invasive techniques. Our case study exemplifies a high-risk patient with contained mycotic thoracic aneurysm that was not only able to be extubated and discharged to rehabilitation facility, but also resolution of aneurysm and remained symptom free more than one year post-operation. Therefore, endovascular therapy should be considered in emergent presentations.
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