ObjectivesThe aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes. MethodsA systematic literature review was performed ...using the search terms mycotic and infected aortic aneurysms in the MEDLINE and ScienceDirect databases, published between January 2000 and September 2018. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinised regarding surgical technique, aortic segment involved, pre- and post-operative antibiotic regimens, survival and infection related complications (IRCs), and factors associated with adverse or favourable outcomes. ResultsTwenty-eight studies, with a total of 963 patients, were included. All publications were observational, retrospective studies. Patient and study heterogeneity, along with missing data, precluded meta-analyses. Overall treatment consisted of open surgical repair (OSR; n = 556 58%), endovascular aortic repair (EVAR; n = 373 39%), and medical treatment alone ( n = 34 3%). OSR was the dominant surgical technique prior to 2010, shifting to EVAR thereafter. For MAAs located in the abdominal aorta, EVAR was associated with better short term survival than OSR. Antibiotic treatment for more than six months post-operatively was associated with better survival, but there was no consensus on the length of treatment. MAAs were complicated by IRCs in 21%, irrespective of surgical technique, of which 46%–70% were fatal. The most consistently reported factors associated with adverse outcomes were increasing age, rupture, suprarenal abdominal aneurysm location, and non- Salmonella positive culture. ConclusionsWith few exceptions, the literature mainly consists of small, retrospective single centre studies. Standardised reporting is needed to increase comparability of studies. EVAR appears to be associated with superior short term survival without late disadvantages, compared with OSR. This suggests that EVAR can be an acceptable alternative to OSR. However, MAA treatment should always be tailor made and planned individually, and general recommendations are in vain. IRCs pose a significant threat to patients after MAA repair and require further investigation.
Purpose of review
Infective native aortic aneurysms (INAAs) are challenging and complex with both bacteraemia and an aneurysm prone to rupture. They are fatal unless recognized and treated promptly. ...The rarity of the disease makes it unfamiliar to most physicians, which might delay both diagnosis and treatment.
The present review aims to outline the recently published diagnostic algorithm of INAAs, the main characteristics of the disease and present an overview of contemporary treatment strategies.
Recent findings
New terminology, definition, diagnostic algorithm and reporting standards have recently been proposed for INAAs. Current evidence concerning the treatment of INAAs is founded on retrospective register-based multicentre studies and small single-centre studies. Recent findings encourage the use of endovascular aortic repair (EVAR) for surgical treatment of INAAs. Although EVAR, as a surgical approach, does not drain the infection, the postoperative infection-related complication rates (IRCs) are similar to the ones reported after open surgical repair (OSR) with aortic prosthetic reconstruction and extensive debridement. IRCs carry over 50% risk of being fatal. Postoperative mortality after EVAR remains considerably lower supporting the use of method for aged and comorbid group of patients. Biological grafts have the benefit of being more resistant to reinfection. OSR with biological reconstruction is a promising surgical approach for patients fit for open surgery; however, data are scarce and long-term follow-up is lacking.
Summary
The treatment of INAAs should be guided by experienced multidisciplinary team and tailored individually based on patients’ condition and centres’ experience. An international consensus document is warranted to enable further research on this disease.
HIV‐associated infective native aortic aneurysms Jönsson, Adam; Ljungquist, Oskar; Sörelius, Karl
APMIS : acta pathologica, microbiologica et immunologica Scandinavica,
January 2023, 2023-01-00, 20230101, 2023, Letnik:
131, Številka:
1
Journal Article
Recenzirano
HIV‐associated infective native aortic aneurysms (INAA) constitute a subcategory of the disease INAA. This is a very rare group of patients. The aim of this systematic literature review was to ...compile a description of patient characteristics with HIV‐associated INAA. A systematic literature review was performed using the search terms HIV and aortic aneurysm in Ovid MEDLINE and Embase databases, on articles published between 1981 and 2022. Using the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) statement, articles were scrutinized according to a predefined protocol including age, sex, comorbidities, microbiological pathogens, CD4‐count, HIV/AIDS state, aortic segment involved, treatment and outcome. Thirty‐three studies, all case reports with a total of 39 patients, were included. The median age was 48 years (range 27–79), most were male n = 35 (90%), and the median follow‐up was n = 6 months (range 0–63). Cardiovascular comorbidity was present in n = 1 (3%), median CD4‐count was 216 (range 6–1236), and n = 12 (31%) had AIDS. The most common microbiological pathogens were Treponema pallidum, n = 12 (31%), Salmonella spp. n = 10 (26%), Mycobacterium species n = 5 (12%) and Staphylococcal spp. n = 5 (13%). The HIV‐associated INAAs were localized in the abdominal aorta n = 32 (82%), in the thoracic aorta n = 5 (13%) and in the thoraco‐abdominal aorta n = 2 (5%). Open surgery was performed in n = 23 (59%) patients, endovascular aortic repair n = 6 (15%), and n = 7 (18%) did not receive surgery. Infection‐related complications were reported in n = 2 (7%) patients, both with postoperative development of fatal sepsis. Patients with HIV‐associated INAAs were younger, had lower rate of cardiovascular comorbidity, demonstrated low CD4 counts as a measure of immunosuppression, and demonstrated diverse microbiological pathogens compared with other INAAs. Treponema pallidum and Mycobacterium spp. were common pathogens, which are very rare microbiological pathogens in other INAAs.
BACKGROUND:No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes ...after OR and EVAR for MAAA in a population-based cohort.
METHODS:All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score–weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time.
RESULTS:We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%–92%), at 1 year 79% (72%–86%), and at 5 years 59% (50%–68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994–2000 0%, 2001–2007 58%, 2008–2014 60%). Open repair was performed in 62 patients (47%)aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%)standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P<0.001), with a similar trend present at 1 year (73% versus 84%, P=0.054). A propensity score–weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P=0.771), infection-related complications (18% versus 24%, P=0.439), or reoperation (21% versus 24%, P=0.650).
CONCLUSION:This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations.
Objective:
There is striking paucity in consensus on the terminology, definition, and diagnostic criteria of mycotic aortic aneurysms. This literature study aims to elucidate this scientific ...omission, discuss its consequences, and present a proposition for reporting items on this disease.
Methods:
A systematic literature review on PubMed and Medline using mycotic and infected aortic aneurysms between 1850 and 2017 was performed. Articles were assessed according to a protocol regarding terminology, definition, and diagnostic criteria. Case series with less than 5 patients were excluded.
Results:
A total of 49 articles were included. The most prevalent term was mycotic aortic aneurysm but there was no widely accepted definition. Most modern publications used a diagnostic workup based on a combination on clinical presentation, laboratory results, imaging findings, and intraoperative findings. How these protean variables should be balanced was unclear. A proposition of reporting items was framed and consisted of definition of disease used, basis of diagnostic workup, exclusion criteria, patient characteristics, laboratory and imaging findings, aneurysm anatomy, details on treatment, pre/postoperative antibiotic treatment, and details on follow-up.
Conclusions:
This article emphasizes the need to standardize definition, terminology, and diagnostic criteria for mycotic aortic aneurysms and proposes reporting items enhancing comparability between studies.
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