Treatment of Aortic Septic Aneurysm with Predominant Bowing to the Right
Urgent surgical or endovascular intervention is required for aortic septic aneurysm treatment, with TEVAR being the preferred approach when anatomically suitable, followed by long-term antibiotic therapy. 1, 2
Diagnostic Approach
- Imaging: CT with contrast is the gold standard diagnostic tool
- Include non-contrast phase to detect intramural hematoma
- Follow with contrast phase to identify leaks indicating rupture
- Imaging should cover entire aorta, iliac and femoral arteries 1
- Blood cultures: Essential before starting antibiotics to identify causative organism 2
Treatment Algorithm
1. Initial Stabilization
- Control blood pressure and heart rate
- Pain management
- Broad-spectrum antibiotics immediately after blood cultures 2
2. Definitive Treatment
Endovascular repair (TEVAR) is preferred over open surgery when anatomically suitable 1
Open surgical repair when:
3. Antibiotic Therapy
- Initial phase: 4-6 weeks of parenteral antimicrobial therapy post-operatively 2
- Extended phase: Additional 3-6 months of oral antimicrobial therapy 2
- Long-term suppression: Consider lifelong suppressive antibiotics, especially with:
- Retained endovascular devices
- Difficult organisms (MRSA, Pseudomonas, multidrug-resistant)
- Extensive perigraft infection 2
Special Considerations
Timing of Intervention
- Symptomatic patients: Urgent treatment regardless of aneurysm diameter due to high risk of rupture 1
- Contained rupture: Immediate intervention due to risk of free rupture and death 1
Surgical Technique
- Careful debridement of all infected tissue is essential 3
- In situ reconstruction is feasible in many cases, particularly for thoracoabdominal aortic segment 3
- Consider omental wrapping of the graft for abdominal repairs 4
Post-Procedure Monitoring
- Regular monitoring of inflammatory markers (ESR, CRP)
- Periodic imaging surveillance
- Clinical assessment for signs of recurrent infection 2
Outcomes and Prognosis
- In-hospital mortality ranges from 13-36%, significantly higher when aneurysm has already ruptured 3, 5
- Controlling sepsis before intervention significantly improves outcomes 5
- Long-term survival is possible with appropriate surgical intervention and antibiotic therapy 4
Pitfalls to Avoid
- Delaying diagnosis and treatment - mortality approaches 100% in untreated cases 2
- Inadequate debridement of infected tissue 3
- Premature discontinuation of antibiotics 2
- Failure to monitor for development of additional aneurysms at other sites 6
- Using fluoroquinolones in patients with aortic aneurysms due to potential risks 2
The management of aortic septic aneurysms requires a team-based approach involving vascular surgery, infectious disease, cardiology, and critical care specialists to optimize outcomes and reduce mortality.