Mycotic aortic aneurysms. Epidemiology, etiology, diagnostics and treatment

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Arnolda Marija Baškytė1

1 Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania

Abstract

Infected abdominal aortic aneurysms (IAAAs) or mycotic aortic aneurysms (MAAs) is considered to be one of the most rare and critical disease because of its high mortality and morbidity rate. The most typical pathogens, which cause IAAAs are Staphylococcus, Salmonella and Streptococcus species. The clinical presentation of this uncommon condition is fever with unknown cause, abdominal, chest or back pain, shock symptoms, loss of consciousness and pulsatile mass. The main diagnostic criteria are clinical manifestation, laboratory, radiological and intraoperative findings. The management of MAAs can be divided into three categories: antibiotic therapy, surgery and endovascular repair. Open surgery repair is commonly referred as the gold standard in the treatment of MAAs. Based on different literature sources surgical repair can be divided into aneurysm excision and ligation without arterial reconstruction, excision with immediate reconstruction, excision with interval reconstruction or extraanatomic bypass (EAB) and in situ graft placement.

Keywords: mycotic abdominal aortic aneurysm, infected abdominal aortic aneurysm.

Journal of Medical Sciences. November 30, 2020 - Volume 8 | Issue 19. Electronic - ISSN: 2345-0592
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Medical Sciences 2020 Vol. 8 (19), p. 189-197
Mycotic aortic aneurysms. Epidemiology, etiology, diagnostics and
treatment
Arnolda Marija Baškytė
1
1
Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania
Abstract
Infected abdominal aortic aneurysms (IAAAs) or mycotic aortic aneurysms (MAAs) is considered to be
one of the most rare and critical disease because of its high mortality and morbidity rate. The most typical
pathogens, which cause IAAAs are Staphylococcus, Salmonella and Streptococcus species. The clinical
presentation of this uncommon condition is fever with unknown cause, abdominal, chest or back pain,
shock symptoms, loss of consciousness and pulsatile mass. The main diagnostic criteria are clinical
manifestation, laboratory, radiological and intraoperative findings. The management of MAAs can be
divided into three categories: antibiotic therapy, surgery and endovascular repair. Open surgery repair is
commonly referred as the gold standard in the treatment of MAAs. Based on different literature sources
surgical repair can be divided into aneurysm excision and ligation without arterial reconstruction, excision
with immediate reconstruction, excision with interval reconstruction or extraanatomic bypass (EAB) and
in situ graft placement.
Keywords: mycotic abdominal aortic aneurysm, infected abdominal aortic aneurysm.
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190
1. Introduction
Infected abdominal aortic aneurysms (IAAAs)
also known as mycotic abdominal aortic
aneurysms (MAAs) are one of the most difficult
and challenging conditions due to its multifarious
and non – specific symptoms. In some literature
sources it is called microbial arteritis with
aneurysm [1]. Although it is infrequent
pathology, but it’s considered to be critical
disease because of its high mortality and
morbidity rate. IAAA tends to progress rapidly
and rupture unexpectedly, what leads to the
patient’s death. It is believed, that arterial
injuries, antecedent infection, impaired
immunity, atherosclerosis, pre - existing
aneurysms are the main risk factors for MAAs
occurrence [1,2]. However, the most common
pathogenesis mechanism is bacterial infection.
IAAAs may occur cause of direct bacterial
inoculation into the arterial wall after the
vascular injury. Another mechanism of
pathogenesis may be bacteremic seeding of an
existing intimal injury or atherosclerotic plaque.
Extension of a contiguous postoperative
infection can lead to MAAs too. Especially, the
focus of infection can extend after
appendectomy, cholecystectomy, colorectal
surgery, knee or hip replacement surgery [2].
Other reason may be septic emboli, which from
the heart can occlude vessel lumen, what leads to
vascular wall infection and MAA formation. So,
the purpose of this literature review is to
summarize the key data of the infected
abdominal aortic aneurysm and to evaluate the
diagnostic and treatment options for this rare
pathology.
2. Epidemiology
Just 0,7 – 3% of all diagnosed and treated
aneurysms are mycotic [3-5]. The most common
localization of mycotic aneurysms are the aorta
and intracerebral vessels [1]. Some prior
researches suggest that the first most often
localization is intracerebral vessels, the second is
aorta and the third is peripheral blood vessels [6].
The mean age of patients is 67 – 70 years [3,7].
A series of studies have indicated that men are
more likely to be sick with MAAs than women
[8,9].
3. Etiology
The most typical pathogens, which cause IAAA
are Staphylococcus, Salmonella and
Streptococcus species. That’s bacteria with best
affinity for the arterial wall. Staphylococcus
aureus is the most common pathogen in Europe
followed by Salmonella [1-2,10]. However,
Salmonella especially group D species is the
most prevalent microorganism in Asia [9, 11].
Salmonella often affects aneurysms with
atherosclerotic plaques. MAAs infected with this
pathogen are prone to faster progression and have
a higher risk of rupture [1]. Other frequent
species are Campylobacter and Streptococcus
[12]. However, IAAA caused by Streptococcus
pneumoniae was much more frequent in the pre -
antibiotic era, while Streptococcus pyogenes is
extremely rare too [2, 13]. It was reported in
literature that, other uncommon pathogens
include Treponema pallidum,
Mycobacterium spp., Campylobacter Jejuni,
Listeria monocytogenes and others [2, 14-15].
Fungal arterial infections are extremely rare, but
they can cause MAAs too. Fungal IAAA may
occur in patients with immunosuppression,
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diabetes mellitus and disseminated fungal
infection.
These pathogens include Candida, Cryptococcus,
Aspergillus and other species [2]. Table 1 lists
the possible pathogens causing MAA described
in literature.
Table 1. Pathogens causing MAAs
Common pathogens
Rare pathogens
Staphylococcus spp.
Mycobacterium spp.
Salmonella spp.
Campylobacter spp.
Streptococcus spp.*
Clostridium spp.
Klebsiella spp.
Escherichia coli
Pseudomona spp.
Treponema pallidum
Listeria spp.
Candida, Cryptococcus, Aspergillus
*Streptococcus pneumoniae and Streptococcus pyogenes were common before the pre – antibiotic era, but
now are rare.
4. Symptoms and Diagnostics
In the past 17 years, the main diagnostic criteria
were: (1) clinical manifestation; (2) laboratory
findings; (3) radiological findings; (4)
intraoperative findings [16]. The manifestation
of MAAs is always with non – specific and
general symptoms. In almost all cases patients
have fever with unknown cause. Also, clinical
presentation may occur as abdominal, chest or
back pain, shock symptoms, loss of
consciousness and pulsatile mass. Other
manifestations include IAAA rupture, expanding
intraabdominal retroperitoneal hematoma, which
usually cause hypovolemic shock. Infection of
abdominal aorta may produce contiguous
infection of the lumbar or thoracic vertebra, what
leads to osteomyelitis. Acute ischemia of the
lower limb, intraabdominal abscess, compression
of nearby structures may occur too [1].
Laboratory findings include increased
inflammatory findings (C – reactive protein,
leucocytosis), elevated erythrocyte
sedimentation and positive blood culture.
Radiological examination consists of computed
tomography (CT) or magnetic resonance (MR)
imaging. Multifunctional CT angiography
(CTA) remains the first – line diagnostic method,
cause of it’s sensitivity of 92 – 96% and a
specificity of 93 – 100%. Magnetic resonance
angiography (MRA) is an alternative method.
However, it has hypersensitivity to motion
artifact and takes much more time. It has 95 –
100% sensitivity and 82 – 96% specificity.
Invasive aortography can be used for patients to
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whom non – invasive examinations cannot reject
mycotic aneurysm, because it can depict just the
lumen of the artery. Mycotic peripheral arteries
can be imaged by ultrasound, but it's significance
for MAA is not described in the literature [16-
17]. Radiological findings specific to MAAs may
be rapid expansion, saccular or multilobular
appearance, periaortic soft tissue mass and
periaortic gas formation within the aneurysm
thrombus [1,9,19]. Some authors have also
suggested, that molecular diagnostics may be
helpful too, especially in difficult cases. For
example, 16S ribosomal ribonucleic acid (rRNA)
testing determining Streptococcus pneumoniae
[20]. The value of positron emission tomography
(PET) and granulocyte scintigraphy in the
diagnostic of mycotic aortic aneurysms have not
been widely investigated yet, but it is thought
that these methods may help in diagnostics [18-
19]. Though, individual literature sources
describe leukocyte scintigraphy in an attempt to
detect inflammatory processes in the arteries, but
it lacks sensitivity and specificity. The
distribution of sensitivity and specificity of
radiological examination is shown in Table 2.
Table 2. Sensitivity and specificity of radiological examinations
Diagnostic method
Sensitivity
Specificity
CT angiography
92 – 96%
93 – 100%
MR angiography
95 – 100%
82 – 96%
F-FDG PET*
60 – 90%
88 – 100%
* F – fluorodeoxyglucose positron emission tomography
5. Treatment
The management of MAAs can be divided into
three categories: antibiotic therapy, surgery and
endovascular repair. The literature review shows,
that it is recommended to start empirical
treatment with vancomycin and an anti – Gram –
negative antibiotics, such as intravenous
fluoroquinolone, ceftriaxone, and piperacillin-
tazobactam. Antibiotic therapy should be
reviewed after the identification of
microorganism. Unfortunately, no specific
algorithm has been developed to indicate how
long antibiotic therapy should last. It is believed,
that it depends on various factors, such as
immune competence of patient, location of
infection, specific bacteria, fever, hemodynamic
stability and others. However, literature sources
recommend continue treatment at least six or
eight weeks with intravenous and oral antibiotics
[1-2]. Open surgery repair is commonly referred
as the gold standard in the treatment of MAAs.
The aim of this type of treatment is to remove all
infected and necrotic tissue. Also, management
of the occurrence and spread of ischemia. Based
on different literature sources surgical repair can
be divided into aneurysm excision and ligation
without arterial reconstruction, excision with
immediate reconstruction, excision with interval
reconstruction or extraanatomic bypass (EAB)
and in situ graft placement [1,10]. EAB is most
commonly applied to infrarenal aneurysms,
while in situ graft is used for suprarenal MAAs.
EAB is associated with complications such as
aortic stump disruption, amputation, and
reinfection. There are several different in situ
grafts: silver-coated grafts, cryopreserved
arterial allografts, rifampicin-impregnated grafts,
and autogenous vein grafts [10]. Some authors
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have also suggested that open repair with
biological grafts shows better midterm results
cause of its’ no reinfection [21]. Another option
to treat IAAAs is endovascular aneurysm repair
(EVAR). It was reported in literature, that this
treatment method is the most suitable for patients
at high risk of mortality during open surgery.
Also, it can be a great alternative as the primary
method of treatment, then it is needed to wait to
perform open reconstruction. However, EVAR
have a risk of complications such as stent
infection, malposition and endoleak, potential
rupture [1-2,10]. All in all, a recent study by Karl
Sörelius and co - authors concluded, that after
EVAR survival at 30 days, 3 months and 1 year
is actually better than after open surgery. Also,
authors suggest, that there is no difference
between these two treatment methods in survival
at 5 and 10 year period [8]. A large number of
existing studies in the broader literature have
showed almost the same results too [3,22-26].
However, the newest systematic review showed,
that early results after EVAR is better than after
open surgery [27]. The distribution of long – term
survival after open repair or endovascular
treatment in different studies is shown in Table 3
and Table 4.
Table 3. Long – term survival after endovascular treatment
Reference
Study Period
Country
Chung-Dann Kan et al. 2007 [29]
1980 – 2007
Taiwan
Karl Sörelius et al. 2014 [22]
1999 – 2013
International
Karl Sörelius et al. 2016
[8]
1994 – 2014
Sweden
Ming – Yuan Liu et al. 2020 [33]
2001 – 2017
China
Joel S. Corvera et al. 2018 [31]
2006 - 2016
USA
C.-M. Luo et al. 2018
[24]
2009 – 2015
Taiwan
Table 4. Long – term survival after open repair
Reference
Study Period
Country
Karl Sörelius et al. 2016
[8]
1994 – 2014
Sweden
Guy Lesèche et al. 2001 [30]
1992 – 2000
France
Theodosios Bisdas et al. 2010
[32]
2000 – 2008
Germany
Ming – Yuan Liu et al. 2020 [33]
2001 – 2017
China
Ivika Heinola et al. 2018 [21]
2006 – 2016
International
Munetaka Hashimoto et al. 2019
[28]
2010 – 2017
Japan
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6. Prognosis
The diagnosis of mycotic aortic aneurysms is
always life - threatening, as MAAs are associated
with 15–50% mortality [34]. Diagnosis and
delayed treatment may be due to multifarious,
non-specific symptoms, rapid enlargement and
expansion of the aneurysm sac. Up to 24% of
IAAA rupture spontaneously and are associated
with 63% to 100% mortality [10]. Nevertheless,
patients’ with timely diagnosed and treated
MAAs survival for 1 year reaches 71-96%, and 5
years - 41-83%.
7. Conclusions
MAA is one of the most dangerous health
disorders due to its non-specific symptoms,
laboratory tests. Therefore, CT or MR remain the
main diagnostic method. Open repair is
considered to be the gold standard treating
IAAAs. However, new studies and literature
sources suggest that survival after EVAR is the
same as after open surgery. Unfortunately, due to
the rarity of MAA and low statistical significance
it is hard to do basic conclusions in diagnostics
and treatment algorithms, so further studies must
be conducted.
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