Karl Sörelius

Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study

Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection. # CLINICAL PERSPECTIVE {#article-title-32}Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection.

Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction

OBJECTIVES Open abdomen (OA) treatment is sometimes necessary after surgery for aortic aneurysm (AA), to prevent or treat abdominal compartment syndrome (ACS). A multicentre study evaluating vacuum-assisted wound closure (100-150 mmHg) and mesh-mediated fascial traction (VAWCM) was performed. METHODS All patients treated with OA after AA repair (2006-2009) were prospectively registered at four centres; those treated <5 days were excluded. All surviving patients underwent a 1-year follow-up, including computed tomography (CT) examination. RESULTS Among 1041 patients treated with open or endovascular repair of AA, 28 (2.9%) had OA treatment with VAWCM; another two had VAWCM after hybrid operations for thoraco-abdominal AA. Eighteen (60%) were operated on for rupture and 12 (40%) electively. Eight had suprarenal or thoraco-abdominal aneurysms. Eight (27%) died within 30 days, none due to OA-related complications. Four died before abdominal closure; primary delayed fascial closure was achieved in all survivors. One-year mortality was 50%. Ten (33%) had bowel ischaemia requiring bowel resection. Late potential OA-related infectious complications occurred in five (17%), all of whom first developed intestinal ischaemia: entero-atmospheric fistulae (two), graft infections (two), aorto-enteric fistula (one). One year follow-up with clinical evaluation and CT showed no signs of graft infection. Incisional hernias occurred in 9 of 15 patients (60%); only three were symptomatic. CONCLUSION VAWCM provided high fascial closure rate after AA repair and long-term OA treatment. Infectious complications occur after intestinal ischaemia and prolonged OA treatment, and are often fatal. The poor prognosis among patients needing OA after AA surgery may be improved by using VAWCM, permitting earlier closure.

Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair

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.

Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction

PurposeTo report incisional hernia (IH) incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM).MethodsFive-year follow-up of patients included in a prospective study 2006–2009. The protocol included physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire.ResultsFifty-five (12 women, 43 men; median age 70 years) of 111 included patients were alive. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 %. One-third of the IHs was repaired. At 5-year follow-up 59 % of IHs were clinically detectable. AW symptoms were equivalent in patients with (15/23) and without (11/21) IH (p = 0.541). SF-36 scores were lower than population mean for component scores and all subscales except bodily pain. Patients with major co-morbidity had lower physical component score [31.6 (95 %, CI 25.6–37.4)] compared to those without [48.9 (95 %, CI 46.2–51.4)]. Major co-morbidity was not associated with IH (p = 0.56), AW symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW symptoms had similar SF-36 results compared to those without, whereas patients with a stoma had >5 point lower mean scores for general health, social function and physical component score compared to those without.ConclusionsVAWCM treatment results in high incidence of IH. However, at five years, there was no detectable difference in abdominal wall complaints and QoL in patients with IH compared to those without. Lower QoL appeared mainly to be associated with the presence of major co-morbidity.

Hybrid treatment of a post-EVAR aortoenteric fistula

This report presents a case of secondary aortoenteric fistula after endovascular aortic repair in a fragile patient: The fistula developed due to aneurysm shrinkage and remodeling of the stent graft, resulting in a kink eroding through the aneurysm wall into the duodenum. The aortoenteric fistula was successfully treated with a hybrid procedure with endovascular aortic repair, followed by open enteroraphy and omental flap coverage of the stent graft and local antibiotic irrigation. Despite the presence of the stent graft in a previously infected field, the patient has recovered from the acute event with no septic recurrence or hemorrhage during four years of follow-up.

Endovascular treatment of mycotic aortic aneurysms : a paradigm shift

Treatment of mycotic aortic aneurysms (MAAs) composes a particularly difficult challenge. Open repair has been considered the gold standard, despite lack of evidence supporting its superiority compared with the emerging alternative endovascular aortic repair (EVAR). This review discusses the pros and cons of EVAR for MAAs by dissecting the three largest publications on MAAs, and concludes that there has been a paradigm shift in treatment of MAAs for the benefit of EVAR.

Open Repair of Mycotic Abdominal Aortic Aneurysms With Biological Grafts: An International Multicenter Study

Background The treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm. Methods and Results All patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30‐ and 90‐day survival, treatment‐related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty‐six patients (46 males) with median age of 69 years (range 35–85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In‐situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube‐grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow‐up of 26 months (range 3 weeks–172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty‐day survival was 95% (n=53) and 90‐day survival was 91% (n=51). Treatment‐related mortality was 9% (n=5). Kaplan–Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%–94%) and at 5 years was 71% (52%–89%). Conclusions Mycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

Challenging Current Conservative Management of Uncomplicated Acute Type B Aortic Dissections

Introduction Despite weak evidence, current treatment guidelines for uncomplicated acute type B aortic dissection (uATBAD) consistently recommend intensive and rapid lowering of systolic blood pressure and heart rate. Report The case of a 62 year old man with uATBAD, who was treated according to guidelines, is presented. Owing to an unknown chronic occlusion of the left carotid artery combined with intensive hypotensive treatment, the patient developed a cerebral infarct. Discussion The case illustrates a severe complication of the widely accepted management of uATBAD. This case, along with scrutiny of guidelines and the evidence behind these guidelines, provoke questions regarding the rationale of current conservative management, and whether it should be challenged with alternative strategies employing a more cautious blood pressure regimen. It also highlights the importance of evaluating the vessels of the supra-aortic trunk when determining the extent of the dissection.

On the Diagnosis of Mycotic Aortic Aneurysms

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.

Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: An International Multicentre Study

OBJECTIVES Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation. METHODS This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate. RESULTS Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation. CONCLUSIONS VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.