Eur J Cardiothorac Surg 2004;26:221-224
© 2004 Elsevier Science NL
Endovascular repair for multiple Salmonella mycotic aneurysms of the thoracic aorta presenting with Cardiovocal syndrome
Albert C.W. Ting*,
Stephen W.K. Cheng,
Pei Ho,
Jensen T.C. Poon
Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam, Hong Kong China
Received 11 January 2004;
received in revised form 8 March 2004;
accepted 9 March 2004.
* Corresponding author. Tel.: +852-28-554962; fax: +852-28-554961
e-mail: acwting{at}graduate.hku.hk
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Abstract
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Salmonella mycotic thoracic aortic aneurysm is a rare but life-threatening condition. We report a 59-year-old man with two Salmonella mycotic thoracic aortic aneurysms, presented with fever and chills associated with hoarseness due to left vocal cord palsy (Cardiovocal syndrome). Successful endovascular repair was performed using two Talent thoracic stent-graft devices deployed separately to cover the two mycotic aneurysms. Subsequent computed tomography at 12 months after the operation confirmed exclusion of the two pseudoaneurysms with no endoleak. With potent antibiotics and careful surveillance program, endovascular repair is a possible alternative to conventional open surgery in the management of mycotic thoracic aortic aneurysms, especially in high-risk patients.
Key Words: Endovascular stent-graft • Infected aneurysms • Thoracic aorta
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1. Introduction
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Salmonella mycotic thoracic aortic aneurysm is a rare but life-threatening condition, with less than 40 cases reported in the literature [1,2]. The standard management includes potent antibiotics, adequate debridement and revascularization via an in situ or extra-anatomic route. Despite the advance in surgical techniques and intensive care, the mortality and morbidity associated with Salmonella mycotic thoracic aortic aneurysm remain high [2].
Endovascular repair has been developed as a less invasive therapy for various aortic diseases since its introduction by Parodi [3] for the management of abdominal aortic aneurysm. We report a patient with multiple Salmonella mycotic thoracic aortic aneurysms presenting with hoarseness (Cardiovocal syndrome), successfully treated by endovascular repair.
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2. Case report
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A 59-year-old man with multiple medical problems including a history of myocardial infarction with previous coronary angioplasty and stenting was admitted to another hospital with fever and chills for 2 weeks. He developed hoarseness while staying in hospital and was found to have left vocal cord palsy. Subsequent blood culture showed Salmonella enteritidis. He was given Ceftriaxone intravenously. Computed tomography showed a mycotic thoracic aortic aneurysms just distal to the aortic arch and another at the lower thoracic aorta 4 cm above the coeliac axis (Fig. 1(a) and (b)) . In view of his medical problems, open surgery was judged to be of high risk and he was transferred to our Vascular unit for consideration of endovascular repair.
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Fig. 1. Computed tomography showing two Salmonella mycotic aneurysms over (a) the proximal descending thoracic aorta just distal to the aortic arch and (b) the distal descending thoracic aorta. Computed tomography taken 12 months after operation showing complete exclusion of the Salmonella mycotic aneurysms over (c) the proximal descending thoracic aorta and (d) the distal descending thoracic aorta.
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The patient was hemodynamically stable upon transferal with a hemoglobin level of 10.9 g/dl, white cell count of 7.3x109 l–1 and a creatinine level of 128 µmol/l. The erythrocyte sedimentation rate and the C-reactive protein level were elevated to 132 mm/h and 2.2 mg/dl, respectively (reference range being <10 mm/h and <0.76 mg/dl, respectively). Operation was arranged with 4 weeks' intravenous antibiotics administered and repeated negative blood cultures ascertained. The procedure was performed in the operating room with the patient put under general anesthesia, using image guidance with a mobile C-arm fluoroscopy (Philips BV29, Philips Medical System, The Netherlands). A right oblique groin incision was made for access of the common femoral artery. The left axillary artery was exposed for direct insertion of a proximal angiographic control catheter. Systemic heparin 3500 units was administered intraarterially. Two Talent thoracic stent-graft devices (Medtronic, Sunrise, Fla.) were introduced via a transverse arteriotomy over the right common femoral artery and deployed separately to cover the two mycotic thoracic aortic aneurysms. A 100 mm long straight stent-graft with a diameter of 32 mm covered the proximal descending thoracic aortic lesion, while another 113 mm long tapering stent-graft with a diameter of 30 mm proximally and 26 mm distally was deployed to cover the distal thoracic aortic lesion. Intraoperative aortogram confirms satisfactory positioning of the endografts with complete sealing of the pseudoaneurysm sacs. The left subclavian artery and the coeliac axis remained patent. Postoperative chest X-rays are shown in Fig. 2(a) and (b)
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Fig. 2. Chest X-ray showing the two Talent stent-grafts (a) anteroposterior view (b) left lateral view.
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The operation lasted 2 h and 45 min with a blood loss of 250 ml. The patient was stable throughout the operation and was extubated and sent to the Intensive Care Unit for close monitoring, where he stayed for 3 days. He was discharged home with no complications 19 days after the operation. Intravenous Ceftriaxone had been administered for 5 weeks, and was followed by Levofloxacin maintenance. He was followed up regularly with interval computed tomographies and plain X-rays every 6 month to detect any endoleak, device migration or infection. Latest computed tomography at 12 months after the operation confirmed exclusion of the two pseudoaneurysms with no endoleak (Fig. 1(c) and (d)). Life-long Levofloxacin was continued. He remained well 13 months after the operation with no evidence of infection, although the left vocal cord palsy and hoarseness persisted. His latest white cell count was 9.2x109 l–1 and the erythrocyte sedimentation rate as well as the C-reactive protein level decreased to 21 mm/h and <0.35 mg/dl, respectively.
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3. Discussion
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The mortality and morbidity associated with Salmonella aortitis is significant as a result of the frequent delay in diagnosis and subsequent rupture. In a review by Oskoui [2], more than half of the patients with Salmonella aortitis presented with aortic rupture, with an overall mortality rate of 41% in those treated surgically. With the non-specific signs and symptoms and the inaccessibility to physical examination, early diagnosis of Salmonella mycotic thoracic aortic aneurysm is difficult. In our patient, hoarseness developed as a result of left recurrent laryngeal nerve palsy secondary to stretching by the mycotic proximal descending thoracic aortic aneurysm. This is also known as Cardiovocal syndrome, or Ortner's syndrome.
Hoarseness serves as an important sign prompting the investigation of the thoracic aorta, especially in a patient with underlying Salmonella infection. Because of the significant risk of endothelial infection in older patients with Salmonella bacteremia, patients older than 50 years, who had blood culture positive for Salmonella along with fever, back pain, abdominal pain or chest pain should have an extensive work up for Salmonella aortitis and mycotic aneurysm [2].
The risk of operative treatment for mycotic thoracic aortic aneurysm is high because of the need for thoracotomy, proximal aortic cross-clamping, and possibly extra-corporeal bypass. As shown by Moneta [4], the operative mortality is much higher in patients with mycotic aneurysms involving the suprarenal or thoracic aorta as compared to infrarenal involvement (43 vs. 10%). This is especially relevant in our patient who has significant medical comorbidities.
As the total aortic cross-clamping time and the extent of aortic repair are the important determinants for spinal cord ischemia [5], open surgery in this patient who may require replacement of extensive segments of the thoracic aorta would incur considerable risk of postoperative paraplegia. With the absence of aortic cross-clamping, endovascular repair has a theoretical benefit of minimizing the ischemic injury to the spinal cord and hence decreased risk of paraplegia [6].
Endovascular repair has been popular in the management of abdominal aortic aneurysms since its introduction in 1991 [3]. Its application has also been extended to various thoracic aortic pathologies including aneurysm [7], trauma [8] and dissection [9]. Its use in mycotic aneurysms is controversial because of the concern of stent-graft infection. However, even with open repair, in situ reconstruction is often unavoidable and the safety and durability of in situ reconstruction in the presence of aortic sepsis have been described [10].
With potent antibiotics and careful surveillance program, endovascular repair is a possible alternative to conventional open surgery in the management of mycotic thoracic aortic aneurysms, especially in high risk patients. Long-term durability, however, needs further study and longer follow-up to define.
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References
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- Parodi J.C., Palmaz J.C., Barone H.D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499.[CrossRef][Medline]
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Abstract
1. Introduction
