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6 Mycotic Aneurysm oftheAbdominal Aorta
Fig. 6.1 Infrarenal saccular aneurysm of the aorta
Fig. 6.2 Operative specimen with aortic dissection in the
aneurysm
Fig. 6.3 Showing osteomyelitis of 2nd, 3rd, and 4th lum-
bar vertebrae
References
Fig. 6.4 Postoperative aortogram following prosthetic
graft (Dacron)
biopsy of the 3rd lumbar vertebra was negative
for any microorganisms. His general condition
improved, and patient became afebrile following 4 weeks on intravenous antibiotics with
slight deterioration in his renal function.
Patient’s back pain diminished, and he was discharged on May 15, 1982, after 12weeks of parenteral antibiotics.
Discussion
29
tic wall, and characteristic finding of a saccular nature of the aneurysm on imaging studies.
Isolation of E. coli from the aneurysm wall
and its contents and preaortic lymph nodes
and isolation of same organisms from blood
showed that the patient had generalized bacteremia, but a source of the original infection
could not be identified. There was no history
of substance abuse or bacterial endocarditis.
The cause of osteomyelitis of the spine was
not obvious. The patient remained well for
subsequent 5 years and was then lost to
follow-up.
Infected aneurysms of abdominal aorta are
potentially life-threatening if not detected
adequately. Aortic resection and extra-anatomic bypass were recommended by Scher
et al. [2]. This patient was relatively young,
without any evidence of primary source of
bacteremia, and under antibiotic coverage, it
was decided to resect the aneurysm and replace
it with an in situ Dacron graft. At the present
time, the author would have preferred
rifampin-soaked prosthetic graft. In the contemporary practice, rifampin-soaked Dacron
graft, cryopreserved vein graft, or use of
autogenous reconstruction with deep veins
(femoral- popliteal) is the preferred method of
reconstruction [2–4].
Recently in a nationwide study in Sweden,
Sorelius etal. demonstrated that endovascular
aneurysm repair (EVAR) is the preferred
modality because of improved short-term survival in comparison with direct open repair
without associated increased incidence of serious infection- related complications or incidence of reoperations [5].
Hsu etal. reported infected aortic aneurysms in
19 patients with salmonella species being the
most common responsible microorganisms [1].
They reported excellent results with wide
debridement of infected aorta, in situ replacement with a Dacron graft or patch repair, and prolonged course of intravenous antibiotics.
Mycotic aneurysms of the abdominal aorta
are rare. Such aneurysms should be suspected
in patients with high fever, non-calcified aor-
References
1. 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;36:746–50.
2. Scher LA, Brener DJ, Goldenkranz RJ, et al.
Infected aneurysm of abdominal aorta. Arch Surg.
1980;115:1975–8.
30
6 Mycotic Aneurysm oftheAbdominal Aorta
3. Muller BT, Vegeuer OR, Grabitz K, Pillny M, Thomas
L, Sandmann W. Mycotic aneurysms of the thoracic
and abdominal aorta and iliac arteries; experience
with anatomic and extraanatomical repair in 33 cases.
J Vasc Surg. 2001;33(1):106–13.
4. Nypaver TJ.Primary and secondary aorto enteric stula. In: Hans SS, Shephard AD, Weaver MR, Bove
PG, Long GW, editors. Endovascular and open vascu-
lar reconstruction: a practical approach. Boca Raton:
CRC Press; 2018. p.257–62.
5. Sorelius K, Wanhainen A, Furebring M, Bjork
M, et al. Nationwide study of the treatment of
mycotic abdominal aortic aneurysm comparing open and endovascular repair. Circulation.
2016;134(23):1822–32.
Open Abdominal Aortic andIliac
Aneurysm Repair inaPatient
withCirrhosis oftheLiver
7
Physical Examination
A 75-year-old male was presented with 5.5 cm
infrarenal saccular abdominal aortic aneurysm,
3.0 cm diameter bilateral common iliac aneurysms, and 2.5cm right hypogastric aneurysm in
May 2005. The aortic aneurysm measured 4.0cm
in transverse diameter in 2004 by CTA abdomen
and pelvis. Patient’s comorbidities include coronary artery disease, atrial brillation (on warfarin),
and a history of deep vein thrombosis of the left
lower extremity. Preoperative cardiolite testing
showed ischemia in the territory of the left anterior
descending artery. Coronary arteriography showed
60% mid left anterior descending artery stenosis
with a negative ow wire study.
Procedure
On May 4, 2005, patient underwent open repair
of abdominal aortic aneurysm (AAA), bilateral
common iliac aneurysm, and left hypogastric
aneurysm via transperitoneal midline approach.
Micronodular cirrhosis of the liver and portal
venous hypertension in the retroperitoneum were
encountered. Left common iliac aneurysm and its
bifurcation into external iliac and hypogastric
artery were exposed by mobilizing the sigmoid
colon along the incision in the white line of Toldt
with excessive bleeding in the pelvic area secondary to venous hypertension.
Aneurysm was juxtarenal. Proximal vascular
clamp was applied above the left and below the
right renal artery, and interrupted horizontal
mattress sutures using 4.0 CV Prolene were
used, with an outer layer of running sutures for
reconstruction of proximal anastomosis. Right
common iliac aneurysm extended to involve the
rst centimeter of the right hypogastric artery
with laminated thrombus. Right hypogastric
aneurysm was ligated with 3.0 CV polypropylene (Ethicon, Somerville, NJ), and an end-toend anastomosis of an 18×9mm knitted Dacron
graft to the divided proximal end of the right
external iliac artery was performed in a continuous fashion. Left limb of the Dacron graft was
anastomosed to the left common iliac bifurcation preserving left hypogastric artery ow. This
anastomosis was performed in an end-to-end
fashion after resecting the anterior wall of the
left common iliac aneurysm. Wedge liver biopsy
was performed during the aneurysm repair
which showed fatty change. His postoperative
course was complicated by dilutional coagulopathy, respiratory complications, and mild ascites
with elevation of alkaline phosphatase, bilirubin, and SGPT. Patient had a satisfactory post
operative course and was discharged to the rehabilitation unit after an 18 day stay in the hospital. There was gradual improvement in the level
of liver enzymes. Patient died in 2011 following
low anterior resection for carcinoma of the
rectum.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_7
31
32
7 Open Abdominal Aortic andIliac Aneurysm Repair inaPatient withCirrhosis oftheLiver
Discussion
Marrocco-Trischetta et al. reported 25 patients
who underwent open AAA repair in the presence
of biopsy-proven cirrhosis of liver and did not
observe any difference in perioperative complications between cirrhotic patients and controls
[1]. However, there were higher intraoperative
blood loss, operative time, and increased length
of stay in patients with cirrhosis. From their
study they concluded that in compensated cirrhosis, open AAA repair can be performed
safely. However, the reduced life expectancy in
cirrhotic patients with MELD score > 10 suggests that the repair should not be offered in that
subgroup of patients. Recently, Chu et al.
reported promising short-term results after
EVAR and TEVAR in patients with liver cirrhosis who otherwise have a poor long-term outcome [2]. The author has performed seven open
AAA repairs in patients with cirrhosis including
two patients presenting with ruptured AAA.Both
patients with ruptured AAA in the presence of
associated cirrhosis died in perioperative period.
Patients undergoing open repair without rupture
had increased intraoperative bleeding, transient
liver dysfunction by liver function tests, and
increased length of stay, but all survived open
repair.
References
1. Marrocco-Trischetta MM, Kahlberg A, Astore D,
Tshiombo G, Mascia D, Chiesa R. Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm. J Vasc Surg. 2011;53:906–11.
2. Chu A, Chen C, Lyn Y, Lin M, Wu VC, Ting P, Chen
S.A population– based analysis of endovascular stent
graft therapy in patients with liver cirrhosis. J Vasc
Surg. 2019;69:1395–404.
Major Venous Injury During Repair
ofAbdominal Aortic andIliac
Aneurysm
8
History andProcedure
A 62-year-old male was scheduled to undergo
open repair of 6.0 cm (transverse diameter)
abdominal aortic aneurysm (AAA), 4.0cm transverse diameter right common iliac artery aneurysm, and a 3.0cm left common iliac aneurysm
(Fig. 8.1) on September 3, 2009. Patient’s past
medical history included stable coronary artery
disease, hypertension, and hyperlipidemia. Open
repair was performed via midline transperitoneal
approach. Proximal aortic clamp was applied to
the aorta below the level of renal arteries and to
external and hypogastric arteries on both sides.
An 18×9mm knitted Dacron graft was anastomosed to the aortic neck. During the mobilization
of the right common iliac aneurysm, its wall was
found to be adherent to the right common iliac
vein. There was an inadvertent injury to the right
common iliac vein. With local pressure proximally and distally from the site of the tear in the
iliac vein, the anterior wall of the vein was
sutured with running 5.0 cardiovascular polypropylene suture (Ethicon Somerville, NJ), and an
end-to-end anastomosis of the 9mm limb of the
Dacron graft to the divided common iliac artery
was performed just above its bifurcation. As the
right femoral pulse was not satisfactory, the graft
was extended to the right common femoral artery
by suturing the divided limb end to end just above
the iliac anastomosis and end to side to common
femoral artery. On the left side, the left limb of
the graft was anastomosed to the common iliac
artery after resection of the aneurysm just above
the bifurcation. During sudden and signicant
bleeding from right common iliac vein, two units
of packed RBC were transfused.
On September 6 patient developed swelling of
the right leg and was found to have thrombosis of
right common femoral and proximal supercial
femoral vein. Patient was anticoagulated with
intravenous heparin and received Coumadin therapy for 6 months with gradual improvement in
the swelling of the right lower extremity. Patient
was last seen in September of 2018in satisfactory condition with postoperative CTA of the
abdomen and pelvis showing no abnormalities
(Fig.8.1).
Discussion
Major venous injury, though uncommon, negatively impacts patient’s outcome following aortic
reconstruction. Iliac vein injury is the most common of all major venous injuries and occurs more
frequently with repair of ruptured AAA.Other
contributing factors for such injury include
inammatory aortic aneurysm, presence of periarterial inammation, and large iliac aneurysms
[1]. Following iliac vein injury, there is increased
incidence of deep venous thrombosis, and
patients should undergo duplex venous evaluation of the lower extremity. If there are no
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_8
33
34
Fig. 8.1 Showing abdominal aortic aneurysm and large bilateral common iliac aneurysm with adherent right common
iliac vein
8 Major Venous Injury During Repair ofAbdominal Aortic andIliac Aneurysm
contradictions, patient should be anticoagulated
for 6 months. Eighteen major venous injuries
(1.9%) are discovered during open aortic reconstruction consisting of inferior vena cava (<4),
iliac vein (<10), and left renal vein (<4). Of the
18 major venous injuries (dened by sudden
blood loss of approximate 500 cc), 7 occurred
during open AAA repair for rupture, and 9
occurred during repair of intact AAA (p 0.001)
[1]. Author has encountered deep venous thrombosis of lower extremities without iliac vein
injury following open repair of unruptured
abdominal aortic aneurysm with fatal pulmonary
embolism in 1988 secondary to heparin-induced
thrombocytopenia.
Reference
1. Hans SS, Vang S, Sachwani-Daswani G. Iatrogenic
major venous injury is associated with increased
morbidity of aortic reconstruction. Ann Vasc Surg.
2018;47:200–4.
Secondary Aortoduodenal Fistula Following Abdominal Aortic Aneurysm Repair
9
History andPhysical Examination
A 74-year-old male presented to his primary care
physician with a 3-month history of weight loss,
anorexia, and back pain. His past medical history
was signicant for hypertension, hyperlipidemia,
kidney stones, and post-thrombotic syndrome
involving both lower extremities. Past surgical
history included staged bilateral carotid endarterectomy and open repair of juxtarenal abdominal
aortic aneurysm (AAA) with reconstruction
using an 18 mm knitted tube graft in 2014.
Ligation of the left renal vein close to the inferior
vena cava was performed in order to facilitate
proximal control of the aorta. Postoperative
nuclear renal scan showed normal renal function
on the left. Patient was followed for three and
half years and was asymptomatic. Patient underwent extraction of a tooth, secondary to an
abscess on October 2017. On examination
(January of 2018), he was found to have poor
dental hygiene and non-pitting edema of the
lower extremities with brawny pigmentation.
Patient was afebrile with a heart rate of 108 beats
per minute, and leukocyte count was 11,600/cm
(normal 4000–11,000/cm), with 84% polymorphic neutrophils (normal <75%). Erythrocyte
sedimentation rate was 57 mm/hg (normal
0–10 mm/hg), and C-reactive protein was
15.9 mg/dl (normal <0.6 mg/dl). Computed
tomographic angiography of abdomen and pelvis
showed postsurgical changes of the abdominal
aorta with the presence of mural uid and a small
amount of gas at the site of proximal anastomosis. There was a saccular outpouching of the
abdominal aorta containing gas at the proximal
anastomotic sites inseparable from the duodenum
with associated fat stranding (Fig. 9.1). An
indium-111-labeled WBC scan (Fig. 9.2)
revealed abnormal uptake at the midline suggestive of an aortic graft infection, with an increased
uptake inferiorly consistent with a developing
abscess. Patient developed bright red rectal
bleeding and was emergently taken to operative
room.
Procedure
Proximal aortic control was obtained using a balloon catheter (Z-MED, Braun) near the celiac
axis. Laparotomy revealed an infra-mesenteric
mass near the third and fourth portion of the duodenum that was adherent to the proximal anastomosis of the aortic graft. There was a small
perforation in the duodenum which was adherent
to the proximal anastomosis of the unincorporated Dacron graft.
Cultures of the purulent material around the
graft was positive for Streptococcus constella-
tus. The opening in the duodenum was closed
in two layers. The proximal aortic stump was
closed with 3.0cm cardiovascular polypropylene suture (Ethicon, Somerville, NJ).
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_9
35
36
Fig. 9.1 CTA showing perigraft uid around the graft
and air near the proximal anastomosis
Fig. 9.2 Showing positive uptake of indium (nuclear
scan) in the midline suggestive of developing abscess
9 Secondary Aortoduodenal Fistula Following Abdominal Aortic Aneurysm Repair
Axillobifemoral graft using 8 mm GORE®
INTERING® PTFE (W.L. Gore Newark, DE)
was performed. However, patient died in the
postoperative period from multisystem organ
failure. It is possible that Streptococcus con-
stellatus became seeded into the Dacron graft
following extraction of the tooth abscess, but
this secondary infection could not be
conrmed.
Discussion
Secondary aortoenteric stula is one of the
most dreaded complications of AAA repair and
occurs in 0.5–1.2% of all aortic reconstructions. One of the important considerations in its
management includes hemodynamic status of
the patient and location of the distal anastomosis (distal aorta, iliac or femoral arteries). Status
of aortic neck as determined by CTA will determine if there is an adequate aortic neck for
reconstruction of proximal anastomosis.
Patients with aortoenteric stula usually present 2–3years following infrarenal AAA repair
with GI bleeding, which may manifest initially
as a melena (herald bleed). Initial massive
bleeding is uncommon. Patient may present
with sepsis in up to 50% of patients. The communication between the gastrointestinal tract
and the prosthetic graft can involve the anastomosis (true aortoenteric stula) or the graft
body or the limb (prosthetic-enteric erosion). In
aortoenteric stula the bleeding is from the
aorta, while in the prosthetic-enteric erosion,
bleeding is from the edge of the bowel wall.
Esophagogastroduodenoscopy with attention to
the distal portion of the duodenum is necessary,
though it is extremely uncommon to visualize
the graft material with duodenoscopy.
CTA imaging demonstrates perigraft uid
thickening of the bowel wall with inammation
and fat stranding. Air in the periprosthetic area
and pseudoaneurysm formation may also be
present [1]. In a hemodynamically stable patient,
after conrmation of diagnosis or with a strong
Discussion
37
suspicion of the diagnosis, surgeon may choose
two different management options: (A) staged
or bilateral axillofemoral graft followed by
infected aortic graft excision and (B) excision of
the aortic graft with in-line aortic graft reconstruction with following conduits: (1) femoral
vein, (2) cryopreserved arterial allograft, and (3)
rifampin-soaked Dacron graft. Prior to in-line
replacement, debridement of inamed tissue
around the graft along with coverage of the
proximal anastomosis and the omental pedicel
ap is necessary.
The patient should be on broad spectrum of
antibiotics suitable for polymicrobial nature of
infection. Through a midline incision, supraceliac exposure of the aorta is obtained, and
proximal control is obtained after systemic
heparinization and mannitol infusion is
started. Distal control is obtained at the iliac
or femoral artery level. In relatively more stable patients, a new in-line rifampin-soaked
graft should be prepared before exposing the
site of aortoenteric communication. If bleeding is encountered in the site of fistula, proximal or distal clamps are applied immediately
[2, 3]. As the infrarenal segment of the aorta is
exposed, the proximal clamp is moved from
the supraceliac to the infrarenal location to
reduce the visceral and renal ischemic time [2,
3]. Depending on inflammatory changes in the
aorta below the renal artery, suprarenal clamping may be more appropriate. Proximal perirenal aorta is debrided and proximal anastomosis
is performed. The opening in the bowel wall is
isolated with saline-soaked sponges. Vascular
clamp is moved distal to the proximal anastomosis to check for hemostasis. Debridement
of the remaining periaortic tissues is completed. Complete excision of the infected graft
is performed. Distal anastomosis is performed
to the iliac arteries beyond the previously performed distal anastomosis. The duodenal
defect is debrided and closed by sutures in two
layers [2, 3].
If the infected graft extends distal to the femoral arteries, groin incision performed rst with
exposure of the graft and origins of the supercial artery, the new tunnels in the retroperitoneum
are ideal but in practice may be difcult to
accomplish without risking injury to the iliac
veins and the ureters. Sartorius muscle rotation
aps are created after transecting a muscle at its
origin from the anterior superior iliac spine. This
promotes coverage of the new graft and groin
anastomosis. Wound vac is applied for both groin
incisions [2, 3].
In high-risk patients, bilateral axillofemoral
bypass followed by graft excision is safer. This
approach reduces extent of abdominal portion of
operation and decreases ischemia-reperfusion
injury associated with prolonged pelvic and
lower extremity clamp time [2]. After the performance of bilateral axillofemoral bypass grafts,
the patient undergoes staged excision of the
infected graft, repair of the defect in the duodenum, and closure of the aortic stump up to 3days
later the aortic stump is closed in two layers with
three uninterrupted polypropylene sutures with a
horizontal mattress sutures followed by second
layer of continuous sutures. In most patients, distal anastomosis of the axillofemoral graft is performed to the proximal supercial femoral
arteries. Endovascular repair is also an option as
a bridge to the denite repair in extremely highrisk patients.
Hemodynamically unstable patients can be
taken immediately from the ER to the hybrid
operating room. Percutaneous access under
ultrasound guidance is performed followed by
placement of large sheath in the femoral artery.
Proximal aortic balloon occlusion catheter is
then advanced to obtain proximal control. If
endovascular repair is feasible, this should be
considered as a bridge to denitive repair. If not,
a midline incision is made and a proximal supraceliac control is obtained. If there is a limited
contamination, rifampin-soaked Dacron graft
reconstruction can be performed after debridement. If the patient’s condition is poor, ligation
of the aorta, removal of the graft, and debridement followed by extra-anatomic graft are more
suitable.