Aditya Safaya, Ansab Haider, Arun Goyal, MD, Francis Carroll, MD, Romeo Mateo, Igor Laskowski, MD, Sateesh Babu, MD.
Westchester Medical Center, Valhalla, NY, USA.
DEMOGRAPHICS: Emphysematous aortitis (EA) has been described as primary (native aorta) or secondary (aortic stent-graft) infections of the aorta with gas forming microbes. Although rare, infections with clostridium septicum have been reported. Rarer still, are infections with clostridium perfringens. Mortality associated with EA is extremely high and in some studies described as inevitable without any operative intervention.
HISTORY: We present two patients. Patient A, was a 64-year old male with a history of worsening dysphagia and dyspnea. Imaging studies revealed a large mushroom shaped thoracic aortic mycotic aneurysm with peri-aortic gas, stranding and a contained rupture suggestive of emphysematous aortitis. Patient B- a 58-year old with a history significant for an endovascular abdominal aortic aneurysm repair (EVAR) 6-years back presented with abdominal pain. Imaging was impressive for peri-graft and aortic sac stranding with gas, consistent with a graft infection
PLAN: Patient A underwent an emergent temporizing endovascular stent-graft aneurysm exclusion (TEVAR) with a plan for definitive resection and debridement of the infected aneurysm tissue. Blood cultures were positive for Clostridium septicum and the patient was treated with appropriate antibiotics. However, patient succumbed to a cardiac arrest on post-op day (POD)- 3. Imaging studies did not reveal any esophago-gastrointestinal tumors or masses.
Patient B underwent a staged extra-anatomic axillo-bifemoral bypass followed by explantation of the infected abdominal aortic endograft in 2 days. Blood cultures were positive for Clostridium perfringens. Patient was treated post-operatively with appropriate antibiotics and was discharged home on POD-24. Imaging and colonoscopy did not reveal any gastrointestinal tumors or masses.
DISCUSSION: Emphysematous aortitis is a dreadful aortic disease with a high mortality considered analogus to necrotizing infection of the extremities. Prompt recognition of anaerobic infection along with early medical and surgical management is key for a successful outcome. A staged procedure is associated with a better outcome. Endovascular interventions using aortic stent grafts for primary aortic infections may help in temporizing an impending catastrophe. However, aggressive surgical excision and liberal debridement of the infected tissue and/or explantation of the infected graft (in secondary aortitis due to graft infection) is quintessential to prevent recurrent infection and enhance survival. Although not detected in our series, an evaluation of the gastro-intestinal tract to look for occult malignancies is important.
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