Infected aortic aneurysm.ppt - PowerPoint Presentation

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Infected aortic aneurysm.ppt - PowerPoint Presentation

  1. 1. Infected aneurysms of aorta (MYCOTIC ANEURYSMS) "infected aneurysm" has gradually replaced the original designation "mycotic aneurysm“ (avoid confusion with infections truly of fungal origin ) Ri 陳宏彰
  2. 2. Reference books Mandell: Principles and Practice of Infectious Diseases, 5th ed. Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed.
  3. 3. Infected aneurysms of aorta Infected aortic aneurysms are rare . most infected aortic aneurysms occur in elderly men. Saccular aneurysms are seen most commonly . Operative mortality in patients with infected aortic aneurysms remains high .
  4. 4. Epidemiology of Infected aortic aneurysms Infected abdominal aortic aneurysms were first described in 1935 and account for 5 to 10% of abdominal aortic aneurysms. The lesions are usually infrarenal and often lead to ureteral obstruction (owing to the densely adherent fibrotic mass surrounding the vessel ).
  5. 5. Epidemiology of Infected aortic aneurysms In a large series of 2816 patients undergoing repair of abdominal aortic aneurysms, 127 (4.5%) had inflammatory abdominal aortic aneurysms. Most patients (123/127) were men and heavy smokers.
  6. 6. Pathogenesis The most common cause of an infected aneurysm is direct deposition of circulating bacteria in a diseased, atherosclerotic, or traumatized aortic intima, after which organisms penetrate the aortic wall through breeches in intimal integrity to cause microbial arteritis.
  7. 7. Pathogenesis  Recent reports suggest that the majority of aortic infections occur in patients with impaired immunity as a consequence of chronic disease, immunosuppressive therapy, or immune deficiency.  A septic embolus from bacterial endocarditis was once the most common etiology but has become rare in the era of efficacious antibiotic treatment of septicemia.
  8. 8. Microbiology  Staphylococcus aureus and Salmonella species are consistently the most frequently identified organisms. Salmonella commonly infects atherosclerotic arteries but may also adhere to a normal aortic wall and directly penetrate an intact intima.
  9. 9. Microbiology Secondary aortic infection may develop in 1/4 of patients > 50 y/o who experience Salmonella bacteremia. Aortic infections with unusual organisms are now seen with increasing frequency in the overtly immunocompromised population.  http://medinfo.ufl.edu/year2/mmid/bms5300/bugs/index.html
  10. 10. Antibiotic treatment to typhoid Salmonella (Salmonella typhi )  Antibiotic treatment of typhoid fever Oxford Textbook of Surgery
  11. 11. Antibiotic treatment to non typhoid Salmonella non typhoid Salmonella Antibiotics Salmonella cholerasuis ceftriaxone Salmonella enteriditis ceftriaxone
  12. 12. Clinical Manifestations Fever is present in over 70% of the patients. Back pain or abdominal pain each occur in about a third of the cases(30 to 50% ). A draining cutaneous sinus may be present.
  13. 13. Clinical Manifestations Leukocytosis and an Elevated erythrocyte sedimentation rate (in 73% of the cases) weight loss The aneurysm is palpable in 50 to 60% of the cases and almost always tender . The onset is insidious, and a low- grade fever may be present for several months before diagnosis .
  14. 14. Clinical Manifestations The nonspecificity of the clinical manifestations is reflected by the 75% preoperative rupture rate . Rupture may occur into the retroperitoneal space or peritoneal cavity (56%), pleural cavity (9%), duodenum (12%), esophagus (6%), mediastinum (3%), or pericardium (3%).
  15. 15. Clinical Manifestations A tender and pulsatile abdominal mass in a febrile patient should be considered an infected aneurysm until proved otherwise. The natural of Infected aortic aneurysms history is expansion and eventual rupture, with extremely rapid progression.
  16. 16. Clinical Manifestations Salmonella and gram-negative infections have a greater tendency to early rupture and death. Overall mortality from infected aortic aneurysms is over 50 % despite advances in therapy.
  17. 17. Diagnosis Blood cultures are helpful in suggesting the diagnosis and identifying the pathogen (though 25 % negative) . Abdominal ultrasonography. Aortography is generally performed preoperatively to assist in surgical planning.
  18. 18. Diagnosis CT scanning (superior in demonstrating associated pathological findings suggestive of an infectious etiology ). Sometimes the aorta is normal in size when first evaluated, if fever,leukocytosis, and pain persist, follow-up imaging should be performed because the aorta may rapidly dilate during the course of the infection.
  19. 19. Diagnosis
  20. 20. Management Infected aortic aneurysms are treated with intravenous antibiotics and surgical excision. Antibiotic therapy must be continued postoperatively for at least 6 weeks.
  21. 21. Management  The standard surgical approach involves 1.Resection of the infected aneurysm and infected retroperitoneal tissue, 2.Oversewing of the native aorta as stumps 3.Restoration of distal perfusion by placement of an extra-anatomical bypass graft tunneled through unaffected tissue planes to avoid placing a graft in a contaminated region.
  22. 22. Journals
  23. 23. Surgical mortality in patients with infected aortic aneurysms BACKGROUND: The purpose of this study was to examine the possible contribution of infection-related risk factors and the systemic inflammatory response syndrome (SIRS) to outcomes of patients with infected aortic aneurysms. Fillmore AJ - J Am Coll Surg - 01-Mar-2003; 196(3): 435-41
  24. 24. Surgical mortality in patients with infected aortic aneurysms  STUDY DESIGN: 10 patients with infected aortic aneurysms presenting to our institution over a recent 6-year period were studied.  RESULTS:  7 patients met criteria for SIRS  4 patients died of sepsis , and 6 patients survived to discharge after a mean of 23 ± 12 days in the hospital .  The combination of SIRS and suprarenal extension was present in all four patients who died. Locations Thoracoabdomi nal aorta Suprarenal aorta Juxtarenal aorta Infrarenal aorta n 4 1 1 4 Fillmore AJ - J Am Coll Surg - 01-Mar-2003; 196(3): 435-41
  25. 25. Surgical mortality in patients with infected aortic aneurysms  CONCLUSIONS: 1. Although rare, infected aortic aneurysms are associated with marked morbidity and mortality . 2. Sepsis is the leading cause of death. 3. A combination of host- and infection- specific variables may be more predictive of outcomes than any single risk factor. 4. Longterm outlook is good after successful treatment. Fillmore AJ - J Am Coll Surg - 01-Mar-2003; 196(3): 435-41
  26. 26. Comparison of Present Results with Other Modern Studies of Infected Aortic Aneurysms First author n Male (%) Mean age (y) Ruptured (%) Positive cultures (%) Organisms Suprarenal extension (%) Mortality by aneurysm type Oderich 43 74 71 53 77 49% gram+ 39% gram− 51 14% suprarenal; 7% infrarenal Moneta 17 59 No stated No stated 88 47% gram+ 29% gram− 41 43% suprarenal; 10% infrarenal Müller 33 76 64 80 85 42% gram+ 18% gram− 52 38% suprarenal; 50% infrarenal Ihaya 9 78 70 22 89 22% gram+ 56% gram− 0 44% infrarenal Present study 10 90 63 70 90 60% gram+ 30% gram− 50 80% suprarenal; 0% infrarenal Fillmore AJ - J Am Coll Surg - 01-Mar-2003; 196(3): 435-41
  27. 27. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries OBJECTIVE AND METHOD: In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  28. 28. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries RESULTS: 1.19 patients with infected aortic aneurysm were treated with surgery. (October 1996 to October 2001 ) 2. 19 10 infra-renal 9 supra-renal 8 2 4 3 2 infra-renal abdominal aortic aneurysms Iliac aortic aneurysms Proximal descendin g thoracic aortic aneurysms supra-renal abdominal aortic aneurysms distal descendin g thoracic aortic aneurysm s Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  29. 29. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries RESULTS: 3. All had a positive blood or tissue culture 4. 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. 5. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%) . (9/10 infrarenal infections were caused by Salmonella organisms.) Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  30. 30. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries RESULTS: 6. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. 7. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. 8. Acute renal failure occurred in two patients with suprarenal infection. Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  31. 31. In situ prosthetic graft
  32. 32. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries RESULTS: 9. Late deaths have occurred in 3 patients 10. 16 patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). 11. During the same period, there were 5 unoperated patients, 4 of whom died of shock during hospitalization. Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  33. 33. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries CONCLUSIONS: 1. Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. 2. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  34. 34. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries 3. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. Hsu RB - J Vasc Surg - 01-Oct-2002; 36(4): 746-50
  35. 35. Surgical treatment of infected aortic aneurysm BACKGROUND: 1.We report results of infected aortic aneurysms treated by a single group over 20 years. (Retrospective review ) 2. 17 patients were treated, 10 with infrarenal and 7 suprarenal infections . Moneta GL - Am J Surg - 01-MAY-1998; 175(5): 396-9
  36. 36. Surgical treatment of infected aortic aneurysm  RESULTS: 1. All had abdominal/back pain, 88% were febrile, 71% had leukocytosis, and 24% were hemodynamically unstable. 2. The most common responsible organism was Staphylococcus aureus (29%) followed by Salmonella organisms (24%). Moneta GL - Am J Surg - 01-MAY-1998; 175(5): 396-9
  37. 37. Surgical treatment of infected aortic aneurysm 3. Infrarenal infections were treated with preliminary axillofemoral bypass followed by aortic resection. Suprarenal infections were treated with either in situ prosthetic graft or patch repairs. 4. Operative survival was 90% for infrarenal and 57% for suprarenal infections. Moneta GL - Am J Surg - 01-MAY-1998; 175(5): 396-9
  38. 38. Surgical treatment of infected aortic aneurysm 5. Operative deaths occurred in the setting of overwhelming sepsis and/or severe preoperative hemodynamic instability. 6. Late deaths occurred in 4 patients postoperatively and were unrelated to their aortic repairs. 9 patients remain alive with a median follow-up of 2 years. Moneta GL - Am J Surg - 01-MAY-1998; 175(5): 396-9
  39. 39. Surgical treatment of infected aortic aneurysm CONCLUSIONS: In the absence of hemodynamic instability and uncontrolled sepsis, infected aortic aneurysms can be successfully repaired with durable results. Moneta GL - Am J Surg - 01-MAY-1998; 175(5): 396-9
  40. 40. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. OBJECTIVE: Review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976- 2000) were reviewed. Oderich GS - J Vasc Surg - 01-NOV-2001; 34(5): 900-8
  41. 41. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.  CONCLUSION: 1. Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. 2. Late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate . 3. In situ aortic grafting is a safe and durable option in most patients. Oderich GS - J Vasc Surg - 01-NOV-2001; 34(5): 900-8
  42. 42. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. Risks of vascular complications 1.Extensive periaortic infection 2.Female sex, 3.Leukocytosis 4.Hemodynamic instability were positively associated (P <.05). Oderich GS - J Vasc Surg - 01-NOV-2001; 34(5): 900-8
  43. 43. MY CONCLUSIONS 1. Infected aortic aneurysms are rare but associated with marked morbidity and mortality . 2. Almost every P’t manifest abdominal/back pain, febrile, leukocytosis and poditive blood culture. 3. Salmonella species were the most common responsible microorganisms in Taiwan.
  44. 44. MY CONCLUSIONS 4. In situ graft replacement and post op abx provided a good outcome. 5. Risks factors: SIRS, suprarenal lesions, sepsis and Hemodynamic instability . 6. Sepsis and/or severe preoperative hemodynamic instability are the leading causes of death.
  45. 45. Thanx for your attention

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