Glenda F. Medina · bypass to left renal artery with 10 mm Dacron graft with delayed closure for...
Transcript of Glenda F. Medina · bypass to left renal artery with 10 mm Dacron graft with delayed closure for...
Infected aortic aneurysm
Glenda F. Medina
Department of Cardiothoracic and Vascular Surgery McGovern Medical School The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute
MSN, RN, ACNP-BC
Infected (Mycotic) aneurysm Aneurysmal degeneration of the arterial wall
secondary to infection. A serious clinical condition that is associated
with significant morbidity and mortality
Case Study CC: Abdominal Pain, Nausea HPI: 68 yo female with PMHX of Hep C and HTN who presented to urgent care clinic for abdominal pain and nausea for 1 month. Abdominal US demonstrated small abdominal aortic aneurysm and was discharged. Her PCP referred to GI services, and EGD was performed with findings of gastritis. The patient was further planned for colonoscopy. However, abdominal pain increased and she presented to ED with the following findings: VS: HR 100 BPM, BP 169/92, RR 11, O2 SAT 98% RA, TEMP 97.2 F LABS: K 2.8, CR 0.9, BUN 6, ALT 55, AST 124, LIPASE 133, LACTIC ACIC 1.3, WBC 12.4, HBG 11.0, UA Negative CT A/P w contrast: 4.1cm saccular abdominal aneurysmal without evidence rapture or dissection. Correlate clinically for aortitis
Case CT image
Case Study 10 days after initial presentation to ED patient returned to facility with complains of persistent severe abdominal, nausea, tarry stools and loss of appetite VS: HR 121 BPM, BP 196/103, RR 20, O2 SAT 98% RA, TEMP 97.0 F LABS: K 2.9, CR 0.73, BUN 7, ALT 51, AST 133, LACTIC ACID 1.4, WBC 18.7, HGB 12.1, UA Negative, INR 1.37 CTA C/A/P: contained rupture of a juxtarenal abdominal aortic aneurysm, poor perfusion to right kidney
Case CT image
Case CT image
Case Study CVS evaluation : mycotic thoracoabdominal aortic aneurysm Recommendation: emergent repair HD#1 Emergency repair of thoracoabdominal aortic aneurysm using 26 mm Dacron tube graft and bypass to left renal artery with 10 mm Dacron graft with delayed closure for second look HD#3 Exploration of left chest and retroperitoneum with omental mobilization and covering of woven Dacron graft with formal closure of chest and abdomen Surgical tissue culture : Streptococcus pneumoniae BC Negative x 2 ABX: Ceftriaxone 2gm IV Q24 HRS, x 2 months Discharged to LTAC
Etiology Direct bacterial inoculation Bacteremic seeding Contiguous/antecedent infection Endocarditis/septic emboli Impaired immunity
Microbiology Only 50-75% of cases are noted with positive
blood cultures Most common bacteria found:
Staphylococcus spp and Salmonella spp Fungal infections are rare and seen mostly on
immunosuppressed population
Clinical Manifestations
Acute Phase Chest/abdomen/back
pain Fever Malaise Weight loss N/V
Late Phase Pulsatile or enlarging mass GI Bleeding HF Acute or chronic
mesenteric ischemia Dysphagia/hoarseness Hemoptysis
Imaging CTA MRI/MRA TEE PET CT US
Medical Management Antibiotic therapy
Blood and fungal cultures prior to any antibiotic infusion
Vancomycin, Ceftriaxone, Zosyn ID consult 6 weeks of IV ABX Possible need for life long suppressive oral
antibiotic therapy
Surgical Management
Open Surgical repair Pt with low or tolerable
comorbidities Cryopreserved homograft Prosthetic grafts Antibiotic beads Omentum flap
Endovascular repair Pt with high comorbidities Pt with high mortality rates Location of aneurysm Increased risk of
persistent/recurrent infections
Take home points
History and physical exam Blood test can be normal Diagnostic imaging CTA Saccular aneurysm
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