title: Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.
abstract: We evaluated the short- and intermediate-term results of endovascular aneurysm repair (EVAR) for mycotic aneurysms. We reviewed all patients undergoing EVAR for mycotic aneurysms at our institution. To be consistent with the existing literature, patients with associated aortoaerodigestive fistulas were included. Aneurysm location, demographics, clinical findings, EVAR success, morbidity, and short- (<30 days) and long-term mortality were reviewed. From 2000 to 2007, 326 patients underwent EVAR. Nine of these (3%) had treatment of a mycotic aneurysm. The average age was 72 years (range 53-86), and seven patients were male. Four of the aneurysms were located in the thoracic aorta, two in the abdominal aorta, and three in the thoracoabdominal aorta. Four patients presented with gastrointestinal bleeding, two with hemoptysis, one with hemothorax, and two with fever. Etiologies included bacteremia from endocarditis and central catheter infection, erosion of anastomotic aneurysms from a previous aortic repair or endograft, erosion of a penetrating ulcer with pseudoaneurysm, infected aortic repair, left chest empyema, and unknown in one patient. Methicillin-resistant Staphylococcus aureus was the only bacteria isolated in 56% of the patients. EVAR successfully excluded the aneurysm or fistula in all nine patients; however, five patients experienced at least one postoperative complication. Two patients expired within 30 days. After 30 days, four additional patients expired; three of these deaths were procedure/aneurysm-related. Of the three survivors, over a mean follow-up of 257 days (range 60-417), one has required excision of an infected endograft with extra-anatomic bypass grafting but is now alive and well. All three surviving patients and two out of four patients expiring after 30 days had received long-term postoperative antibiotics. Despite an in-hospital mortality of 22.2%, EVAR can be used to treat acute complications from mycotic aneurysms and associated aortoaerodigestive fistulas, such as gastrointestinal bleeding, hemoptysis, or hemodynamic instability. As a definitive treatment, EVAR remains suspect and therefore should be considered a bridge to open surgical repair.
authors.affiliation: Department of Surgery, at the University of Southern California Cardiovascular Thoracic Institute, Los Angeles, CA. fweaver@surgery.hsc.usc.edu
authors.forename: Wesley K
authors.initials: WK
authors.lastname: Lew
authors.forename: Vincent L
authors.initials: VL
authors.lastname: Rowe
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Cunningham
authors.forename: Fred A
authors.initials: FA
authors.lastname: Weaver
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000785:Aneurysm, Infected / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D001027:Aortography; D016154:Digestive System Fistula / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D008875:Middle Aged; D012086:Reoperation; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality