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Ann Thorac Surg 2008;85:1463-1465. doi:10.1016/j.athoracsur.2007.08.029
© 2008 The Society of Thoracic Surgeons
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How To Do It

Customized Endoluminal Graft to Treat a Suspected Saccular Thoracoabdominal Mycotic Aneurysm

Jacques Kpodonu, MDa,*, Venkatesh G. Ramaiah, MDb, Grayson H. Wheatley, III, MDb, Julio A. Rodriguez-Lopez, MDb, Edward B. Diethrich, MDb

a Northwestern Memorial Hospital, Bluhm Cardiovascular Institute, Chicago, Illinois
b Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, Arizona

Accepted for publication August 14, 2007.

* Address correspondence to Dr Kpodonu, Northwestern Memorial Hospital, Bluhm Cardiovascular Institute, 201 East Huron Street, Galter 11-140, Chicago, IL 60611 (Email: jkpodonu{at}yahoo.com).


   Abstract
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Open surgical repair of mycotic aneurysm is associated with a high surgical morbidity and mortality. The role of endovascular graft repair of mycotic aneurysm remains controversial because the graft material remains in contact with possibly infected tissue. We report an endovascular technique of customizing an abdominal endoluminal graft component to treat a suspected saccular thoracoabdominal mycotic aneurysm involving the takeoff of the celiac trunk.


   Introduction
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Pseudoaneurysms of the thoracic and abdominal aorta are being diagnosed with more frequency because of the increased use of imaging procedures. Previous aortic surgeries, trauma, and infection are identifiable causes of pseudoaneurysms. Open surgical repair of such aneurysms can be challenging and associated with an increased surgical morbidity and mortality. We report the endovascular repair of a suspected mycotic aneurysm.


   Technique
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A 71-year-old frail-looking man with a history of hypertension presented with fever, chills, and back pain. He was diagnosed with a discitis complicated by a paraspinal abscess and underwent paraspinal abscess drainage with disc repair by a neurosurgeon. Cultures from the abscess cavity grew methicillin-resistant Staphylococcus aureus (MRSA). His hospitalization was complicated by MRSA septicemia, from which he recovered. He was discharged home on vancomycin and clindamycin therapy.

He experienced left flank pain 4 months after the neurosurgical intervention, without any fevers or leucocytosis and a decrease in sedimentation rate from 85 during his hospitalization to 10 whilst he was taking antibiotics.

A computed tomography (CT) scan of the chest and abdomen and an angiogram (Figs 1A and B) demonstrated resolution of the spinal abscess cavity with a 3.8 x 2.5-cm saccular aneurysm of the thoracoabdominal aorta involving the takeoff of the celiac trunk, which was not present on a CT scan performed before the intervention. A strong suspicion of a mycotic aneurysm was entertained, given his recent history of a paraspinal abscess drainage and staphylococcus septicemia. Because of the risk associated with open surgical repair, he was enrolled in an investigational device exemption protocol, and a planned angiogram and intravascular ultrasound (IVUS) imaging were performed to determine if he was a candidate for an endovascular approach.


Figure 1
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  		Fig 1. (A) A computed tomography scan of the chest and an (B) angiogram demonstrate a 3.8- x 2.5-cm pseudoaneurysm of the thoracoabdominal aorta involving the takeoff of the celiac trunk.

 
Under local anesthesia, percutaneous access of the right common femoral artery was performed and a 9F sheath was inserted. A 5F angiographic catheter was advanced into the thoracic aorta, and an angiogram was performed. It demonstrated a saccular pseudoaneurysm of the thoracoabdominal aorta (Fig 1B) involving the celiac trunk takeoff. A selective visceral angiogram demonstrated adequate collateralization between the celiac trunk and the superior mesenteric artery (SMA) from the gastroduodenal branch of the common hepatic artery.

The angiographic catheter was exchanged for a 7F IVUS probe, which confirmed the angiographic picture. The proximal and distal neck of the thoracic aortic pseudoaneurysm was measured to be 24 mm and 26 mm, respectively. The shortest length of aorta to be covered was 5.0 cm.

The patient was taken to the operating room the next day. A 9F sheath was used for open retrograde cannulation of the right groin, and a 9F sheath was used for retrograde percutaneous access of the left groin. Heparin was administered. A road map angiogram was performed with a 5F angiographic catheter, selective cannulation of the SMA was performed with a 5F internal mammary (LIMA) catheter, and a 0.035-inch Glidewire (Terumo Interventional Systems, Ann Arbor, MI) was positioned. Percutaneous retrograde cannulation of the left brachial artery was performed, and with the help of a long LIMA catheter, cannulation of the celiac trunk was achieved and the LIMA catheter left into position.

A Powerlink (Endologix, Irvine, CA) abdominal endoluminal graft cuff measuring 28 mm x 5.5 cm was selected on the basis of the IVUS measurements. Exchange of the right groin 9F sheath for the device sheath was performed, and under fluoroscopic visualization, the endoluminal graft was deployed to exclude the pseudoaneurysm with the distal landing zone about 2 mm above the SMA. Coil embolization of the celiac trunk was performed through the existing LIMA catheter in the celiac trunk by deploying two 8 x 10 mm coils and six 5 x 8 mm coils to seal off the ostium of the celiac trunk to prevent any endoleaks .A selective celiac angiogram performed demonstrated satisfactory embolization of the celiac trunk.

The device sheath was exchanged for a 12F sheath and a 32-mm CODA (Cook Inc, Bloomington, IN) balloon was used to balloon angioplasty the endoluminal graft for good apposition to the aortic wall. Because of concerns about the possibility of the endoluminal graft migrating distally to occlude the ostium of the superior mesenteric artery, a planned deployment of a balloon expandable stent into the SMA partially sticking out into the aorta was contemplated .The angled Glidewire positioned into the SMA was exchanged to a stiff 0.035-inch Amplatz (Cook Inc) wire using an exchange catheter. A 7F renal curved guiding catheter was positioned at the ostium of the SMA and an Express LD (Boston Scientific, Natick, MA) stent (6 x 17 mm) was deployed at the ostium, making sure part of the stent was within the lumen of the aorta to prevent distal migration of the endoluminal graft.

A completion angiogram demonstrated satisfactory exclusion of the pseudoaneurysm, with no endoleak and a patent SMA with collateralization of the common hepatic, splenic, and left gastric arteries from the gastroduodenal artery. The wire and sheaths were removed, and the right common femoral artery was repaired. Closure devices were deployed to the left common femoral and left brachial artery.

The patient had an uncomplicated hospital stay and was discharged on postoperative day 2 with Rocephin (Hoffmann-La Roche Inc, Nutley, NJ) therapy, with recommendations to continue the antibiotic regimen for 6 weeks. A predischarge CT scan demonstrated satisfactory exclusion of pseudoaneurysm and no endoleak. A CT scan performed 12 months after the procedure (Fig 2) demonstrated satisfactory positioning of endoluminal graft and regression of pseudoaneurysm sac with no identifiable endoleak.


Figure 2
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  		Fig 2. A postoperative computed tomography scan of the chest demonstrates satisfactory exclusion of pseudoaneurysm with an abdominal Powerlink (Endologix, Irvine, CA) cuff device with no endoleak. Coils are visualized in the celiac trunk (large arrow). A superior mesenteric artery stent (small arrow) was placed to prevent distal migration of the endoluminal graft.

 

   Comment
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Mycotic aneurysms comprise less than 1% of aortic aneurysms and have a high risk of rupture if not treated urgently. Endovascular graft therapy of thoracic aneurysms is associated with lower morbidity, mortality, and a lower risk of paraplegia compared with open surgical repair [1]. Results of open surgical repair consisting of intensive antibiotic administration, extensive excision, and débridement of the infected field associated with extraanatomic or in situ prosthetic bypass grafting are associated with mortality rates of 5% to 75% [2, 3].

The endovascular approach to mycotic aneurysm avoids the extensive excision and débridement of the infected field. The potential benefit of the endovascular approach is thus compared with the obvious risk of recurrence of the infection. The few series of patients reported in the literature whose mycotic aneurysms were managed by an endovascular approach have shown encouraging results, with patients alive as long as 62 months [4]. Despite the advantages with the endovascular approach, perioperative rupture [4], stent migration [5], and malposition with a type I endoleak have been reported [4].

Stent grafts chosen should be selected for availability size and conform to the lesion to be covered. In our patient, a 28 mm x 5.5 cm abdominal endoluminal graft cuff enabled us to use a short graft with appropriate sizing of the aorta that would not be achievable with the commercially available thoracic endoluminal graft cuffs. Before coil embolization, a visceral angiogram was performed to make sure that once we coil-embolized the celiac trunk, the patent gastroduodenal artery would still supply blood flow to the branches of the celiac trunk. The technique of coil embolization of the celiac trunk was done to prevent a type II endoleak. The deployment of a stent partially into the ostium of the SMA and the aortic lumen served to prevent distal migration of the cuff, which could lead to devastating consequences should the SMA ostium be covered.

In conclusion, patients considered ineligible for open surgery for a mycotic aneurysm should be offered the endovascular approach to palliate rupture and death. The duration of antibiotic therapy remains debatable: some authors have not used antibiotics, but others use 6-week, 6-month, and others life-long therapy [5]. Generally, antibiotic coverage should be tailored to the individual patient according to the patient’s general condition and results of blood cultures. All patients should be on a life-long surveillance protocol with routine CT scans and lateral and posterior anterior chest roentgenograms to monitor for recurrent infection.


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  1. Makaroun MS, Dillavou ED, Kes ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the Gore TAG thoracic endoprosthesis J Vasc Surg 2005;41:1-9.[Medline]
  2. Hsu RB, Tsay YG, Wang SS, Chu SH. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta and iliac arteries J Vasc Surg 2002;36:746-750.[Medline]
  3. Cina CS, Arena GO, Fiture AO, Clase CM, Doobay B. Ruptured mycotic thoracoabdominal aortic aneurysms: a report of three cases and a systematic review J Vasc Surg 2001;33:861-867.[Medline]
  4. Jones KG, Bell RE, Sabharwal T, Aukett M, Reidy JF, Taylor PR. Treatment of mycotic aortic aneurysms with endoluminal grafts Eur J Vasc Endovasc Surg 2005;29:139-144.[Medline]
  5. Stanley M, Semmens JB, Lawrence-Brown MM, Denton M, Grosser D. Endoluminal repair of mycotic aneurysms J Endovasc Ther 2003;10:29-32.[Medline]



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