Case Report Mycotic Abdominal Aortic Aneurysm Caused by Campylobacter fetus: A Case Report and Literature Review Hideharu Hagiya,1,2 Mitsuaki Matsumoto,3 Hiroshi Furukawa,3 Tomoko Murase,4 and Fumio Otsuka,1 Okayama, Japan
Campylobacter spp. usually cause gastrointestinal infections, but among them, Campylobacter fetus is a well-known organism causing mycotic abdominal aortic aneurysm (MAAA), which requires proper surgical intervention and antibiotic therapy. We report a 65-year-old man who was successfully treated by an in situ operation using a rifampicin (RFP)ebonded J-Graft for C. fetuseinduced MAAA. We performed a review of the English literature on MAAA caused by C. fetus and summarized the results of the cases (28 cases). All but 2 of the patients (92.9%) were men. Blood culture and arterial wall culture were positive in 63% and 73.1% of the cases, respectively. Aneurysm rupture was seen in half of the patients, and approximately half of those patients died. Among the 18 patients who underwent in situ graft replacement, only 1 patient (5.6%) died after surgery. Antibiotic therapy was performed for more than 1 month in most cases, and overall mortality rate was 25.9% (7 of 27 cases, 3 deaths before the operation and 4 deaths after surgery). Although extra-anatomic bypass has been conventionally performed after complete resection of an MAAA, the utility of in situ surgery has generally been recognized. Our review suggests that the in situ operation can be a choice also in cases of C. fetuseassociated MAAA. Furthermore, our case suggested the clinical utility of a newly manufactured prosthetic graft, J-Graft, for such surgical treatment.
Conflicts of Interest: The authors state that there are no conflicts of interests to declare. 1
Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. 2 Emergency Unit and Critical Care Center, Tsuyama Central Hospital, Okayama, Japan. 3 Department of Cardiovascular Surgery, Tsuyama Central Hospital, Okayama, Japan. 4 Microbiology Division, Department of Clinical Laboratory, Tsuyama Central Hospital, Okayama, Japan. Correspondence to: Hideharu Hagiya, MD, PhD, Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kitaku, Okayama 700-8558, Japan; E-mail: [email protected]
Ann Vasc Surg 2014; -: 1–8 http://dx.doi.org/10.1016/j.avsg.2014.06.072 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 18, 2014; manuscript accepted: June 19, 2014; published online: ---.
Mycotic abdominal aortic aneurysm (MAAA), which is formed by destruction of the arterial wall as a result of infection, accounts for approximately 1% of all aortic abdominal aneurysms (AAAs).1 Common sites of MAAA are the abdominal aorta distal to the renal artery and the thoracic aorta.2 The risk factors include arterial injury, preceding infection, immunocompromised state, atherosclerosis, preexisting aneurysm, and aging. Some patients complain of lumbar or back pain, whereas others may present fever of unknown origin or sudden rupture of the aneurysm. The overall mortality rate in patients with MAAA has been reported to be as high as 30%.1,3 The risk of aneurysm rupture has been reported to be as high as 50e80%,1,4,5 and the mortality rate would be more than 70% if it is ruptured.6 The common causative organisms of MAAA include Staphylococcus spp., Salmonella spp., and Streptococcus spp.7 Occasionally, Campylobacter spp. 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Abdominal contrast-enhanced computed tomography (CECT) and gross appearance of J-Graft. (A) A coronal image of the three-dimensional vascular reconstruction, (B) a sagittal image of CECT, (C) Axial images of CECT, and (D) rifampicin (RFP)ebonded J-Graft after anastomosis. Arrow: infected aneurysm, Arrowhead: true lumen.
A saccular-type abdominal aneurysm (40 39 mm) surrounded by a dirty fat sign was found between the inferior mesenteric artery and bifurcation of the common iliac artery (AeC). The patient underwent aortobilateral iliac reconstruction with bifurcated RFP-bonded Dacron graft (J-Graft; D).
are detected as pathogenic organisms of MAAA. Among them, Campylobacter fetus is reported to be the most common pathogen.8 C. fetuseassociated MAAA has rapid progression and a high mortality rate (approximately 30%),9,10 and no survival can be expected without surgical intervention.11,12 Because the number of reported cases is still insufficient, the appropriate strategy for C. fetuseassociated MAAAs is inconclusive. We report a case of MAAA caused by C. fetus, which was successfully treated with replacement of a newly manufactured Japanese woven Dacron graft, J-Graft (Japan Lifeline Co. Ltd, Tokyo, Japan), which was preliminarily bonded with rifampicin (RFP). Furthermore, we discuss the diagnosis and treatment of C. fetuseassociated MAAAs based on a literature review.
episode of diarrhea 2 weeks previously, but the etiology was unknown. There was no history of drinking raw milk or consuming uncooked meat. A urinary examination showed hematuria, and he returned home with the diagnosis of urolithiasis. The next day, he consulted an urologist and was again diagnosed as having urolithiasis although a urinary tract stone was not apparent in plain computed tomography (CT). Later that day, a physician noticed an inflammatory change around his abdominal aorta in the CT, and the patient was called immediately to visit the hospital. On arrival, his body temperature was 38.1 C. He complained of rigor and shivering, but his vital signs were stable. Laboratory examination revealed white blood cells of 10,500/mm3 and C-reactive protein of 13.8 mg/dL. Emergently performed contrast-enhanced CT (CECT) showed a saccular and poorly marginated AAA (40 39 mm; Fig. 1AeC). The aneurysm only involved the infrarenal aorta, and celiac, renal, and mesenteric arteries were confirmed to be patent by CT angiography. Ascites or free abdominal air was not obvious. After drawing 3 sets of blood culture, administration of ceftriaxone (2 g every 24 hr) and ciprofloxacin (CPFX, 300 mg every 12 hr)
CASE REPORT A 65-year-old man without any past medical history presented with a 1-week history of lumbar pain. He had an
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Fig. 2. Histopathologic findings of the resected aneurysm. (A) Hematoxylineeosin staining (magnification 200). (B) Gram staining (magnification 1,000). Microscopic
examination of the arterial wall showed diffuse necrosis and infiltration of neutrophils (A). Gram-negative spindle-form rods were found in purulent tissues (B).
was initiated with a suspicion of MAAA, and the patient was admitted to an intensive care unit. The next morning, the patient complained of abdominal pain, but repeated CECT was negative for any deteriorating findings of the aneurysm. Physical examination and transthoracic echocardiography did not indicate any findings associated with infective endocarditis. That night (day 2), an emergency operation was performed under the diagnosis of impending rupture of the MAAA. The MAAA had tightly adhered to the spine and the retroperitoneum. It was carefully dissected to the bilateral iliac artery region and totally removed after clamping the infrarenal aorta. A 16 8-mm bifurcated Dacron graft (J-Graft) replacement was performed after immersing the graft in a solution of RFP for 30 min in the operating room (Fig. 1D). The greater omentum was dissected between the greater curvature of the stomach and the right gastroepiploic artery (RGEA) from the pylorus ring to the end of the RGEA. Then, the greater omentum was harvested with a harmonic scalpel from the end of the RGEA to the free margin. After boring a hole in the root of the transverse mesocolon, the harvested greater curvature was passed through it and was spread over the graft. It was also fixed to the retroperitoneum with 4e 0 prolene in an interrupted manner. Owing to the highly adhesive nature of the aneurysm, the total operation time and ischemic interval of lower extremities were 7 hr and 25 min and 4 hr and 7 min, respectively. The patient suffered from rhabdomyolysis triggered by ischemiaereperfusion syndrome, and continuous hemodiafiltration was initiated postoperatively. Swelling of his lower extremities was not profound, and fasciotomy was not performed. The patient’s condition including renal function gradually improved, and there was no sign of myonephropathic metabolic syndrome. He was discharged from the intensive care unit 2 weeks after the operation. The resected aneurysm was enlarged with a varicose deformity, and its wall was markedly thickened. Microscopically, fibrosing and hyalinizing changes were observed at the retroperitoneal and periaortic tissues (Fig. 2A). Gram staining of the resected aortic wall
revealed gram-negative spindle-form rods (Fig. 2B), and bacterial culture revealed C. fetus, which was sensitive to ampicillin, imipenem, amikacin, azithromycin, clindamycin, ciprofloxacin, and levofloxacin. Blood cultures remained negative even after 2 weeks (BacT/Alert). Stool culture was also negative for Campylobacter spp. The clinical course after that was relatively uneventful, and the patient was discharged on day 36 without any sequel. Administration of oral CPFX has been continued, and there has been no recurrence for more than 1 year.
DISCUSSION C. fetus is a motile gram-negative rod with a spindle form, which is carried by livestock such as cattle and sheep. While C. jejuni and C. coli cause gastrointestinal symptoms after ingestion, C. fetus frequently causes bacteremia without any digestive manifestations. Actually, unlike C. jejuni or C. coli, most cases of C. fetus infection have been diagnosed from positive results of blood culture; according to a previous summary of 178 Campylobacter bacteremia patients, C. fetus was the most commonly identified species (53% of the patients).13 Elderly, disabled, and immunocompromised people are considered to be at high risk for persistent bacteremia.14 Additionally, C. fetus specifically possesses a surface layer protein that provides resistance to complementdependent bactericidal action or opsonization, and the organism can easily form an extraintestinal infectious focus.15 Thus, C. fetus can cause systemic infections, and patients with lung abscess, urinary infection, meningitis, subdural abscess, arthritis, peritonitis, and cholecystitis have been reported. Furthermore, C. fetus shows a special tropism for the human vascular endothelium via bacteriasurface receptors,16 and the organism therefore has potential to cause endovascular infections.
4 Case Report
Table I. A summary of mycotic aortic abdominal aneurysms caused by Campylobacter fetus Year
Age (years)
Sex
BC
AWC
Ruptured
Operation
Treatment
Outcome (follow-up duration)
References
1
1971
68
M
P
N
Yes
d
1979 1979 1983 1983
63 67 73 54
M M M M
P P P P
N ND P P
Yes Yes Yes No
d d Long term 7 Months
Died, a few hours after operation Died, before operation Died, before operation Alive, 45 months Alive, 2 years
Dolev et al.
2 3 4 5
File et al. Taylor et al. Anolik et al. Marty et al.
6 7
1983 1985
68 56
M F
P N
N P
No No
7 Weeks 1 Week
Alive, 18 months Alive, 3 years
Blabey et al. Righter et al.
8
1985
70
M
P
N
Yes
8 Weeks
Alive, 6 months
Perry et al.
9
1989
59
M
N
P
No
5 Months
Alive, 2 year
Rutherford et al.
10 11 12 13
1989 1990 1991 1993
64 61 84 56
M M F M
P N P ND
P P P P
Yes No Yes Yes
d 2 Weeks d d
Died, after 7 days Alive, 36 months Died, before operation ND
Jacobs et al. Kato et al. Allerberger et al. Grollier et al.
14
1998
45
M
N
P
No
3 Months
Alive, 1 year
Mii et al.
15 16
2007 2008
78 69
M M
N P
P N
No Yes
Life long Long term
Alive, 9 months Alive, 6 months
Tran et al. Cochennec et al.
17
2008
76
M
N
P
Yes
Long term
Alive, 5 months
Cochennec et al.
18
2008
76
M
P
ND
Yes
Long term
Died, after 2 weeks
Cochennec et al.
19
2008
79
M
P
N
No
Long term
Alive, 18 months
Cochennec et al.
20
2010
69
M
P
P
Yes
Replaced with polyester graft (Dacron graft) d d Aneurysm excision, AXBF Replaced with polyester graft (Dacron graft) Aneurysm excision, AXBF Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Aneurysm excision, AXBF Aneurysm excision, AXBF d Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Replaced with polyester graft Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) EVAR (Zenith bifurcated stent graft) Replaced with polyester graft (allograft) Replaced with polyester graft (Dacron graft)
d
Alive, 34 months
Brossier et al.
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Case
No P N M 2013 28
65
ND ND No P P P N N P M M M 2011 2011 2011 25 26 27
76 57 72
No P P M 2010 24
78
No N P M 2010 23
76
No P N M 2010 22
76
Yes P P M 69 2010 21
AWC, arterial wall culture; AXBF, axillobifemoral bypass operation; BC, blood culture; EVAR, endovascular aortic repair; N, negative; ND, not described; P, positive.
Present case Alive, 1 year
Alive Alive Alive, 1 year
Maeda et al. Maeda et al. Noda et al.
Case Report 5
d d More than 4 weeks Long term
Alive, 38 months
Brossier et al.
2014
d
Died, after 15 days
Brossier et al.
-, -
d
Alive, 5 months
Brossier et al.
No.
d
-,
Replaced with polyester graft (Silver graft) Replaced with polyester graft (Dacron graft) EVAR (Zenith bifurcated stent graft) Replaced with polyester graft (allograft) Replaced with polyester graft Replaced with polyester graft Replaced with polyester graft (Dacron graft) Replaced with polyester graft (J-graft)
d
Alive, 28 months
Brossier et al.
Vol.
Gazaigne et al. reported that 24% of C. fetus bacteremia cases were complicated with MAAA.14 It was unknown whether the episode of diarrhea 2 weeks before the onset in this case was related to the occurrence of MAAA. Typical cases of MAAA may present fever and a high inflammatory state accompanied by abdominal pain, back pain, and a pulsatile mass. However, less than half of the cases show typical presentation,4,17 and only about half of MAAA cases show positive results of blood culture.1 As a result, definitive diagnosis of MAAA is challenging. Diagnosis is often made in the later phase of the clinical course, and the patient’s outcome would be worse. Imaging tests, especially CECT, can be of use in such cases. Characteristic findings of MAAA include arterial wall thickening, ectopic gas surrounding the aorta, periaortic edema, rapid progression, and a saccular or lobulated shape of the aneurysm that changes its form within a short time and is complicated with a dirty fat sign.18 Actually, in our patient, we could recall MAAA as a potential diagnosis at the beginning of the clinical course because of typical CT findings with a high inflammatory serum state. We searched for previous cases of C. fetuse associated MAAA in PubMed, and results of 28 cases including our case are summarized in Table I.8,9,11,19e34 The average age of the patients was 68 years (54e84 years). All but 2 of the patients (26 of 28 cases, 92.9%) were men. Of 27 cases, blood culture was positive in 17 cases (63%), and of 26 cases, arterial wall culture was positive in 19 cases (73.1%). Aneurysm rupture was seen in 50% of the cases (13 of 26 cases), and among them, approximately half of the patients (6 of 13 cases) died. For surgical treatment, an axillobifemoral (AXBF) bypass operation was performed in 4 cases, endovascular aortic repair (EVAR) was used in 2 cases, and in situ graft replacement was selected in 19 cases. One of the 4 patients who received an AXBF operation died because of acute myocardial infarction,28 and both of the patients who received EVAR died because of sepsis.9,33 On the other hand, only 1 (5.6%) of the 18 patients who received in situ graft replacement died after surgery. Notably, the patient who received the in situ operation died soon after surgery that was performed as an emergent treatment for aneurysm rupture,19 and thus, the in situ operation itself was not necessarily associated with death. Overall mortality rate of MAAA caused by C. fetus was 25.9% (7 of 27 cases, 3 deaths before the operation and 4 deaths after surgery). For the treatment of MAAA, antibiotic therapy is indispensable but would be inadequate if given alone. At least, identification of the pathogen and
6 Case Report
careful attentions to its susceptibility examination would be required. For example, fluoroquinolones are commonly selected for Campylobacter spp. infection; however, the rate of resistance of Campylobacter spp. to fluoroquinolone has been reported to have increased to as high as 32%.13 Still, the appropriate dose, duration, and regimen of antibiotic therapy for postoperative MAAA have not been established.35 Some authors reported that a period of 4e8 weeks of antibiotic treatment is sufficient,12 whereas others insisted that patients with MAAA should take antibiotics for their whole life.36,37 There is no widely acceptable consensus on this point, and we need to determine the indication case by case. Cases with extensive infection, recurrence, or prosthetic infection may need longer treatment. In our review of C. fetuseassociated MAAA, most cases (13 of 15 cases, 86.7%) received antibiotic therapy for more than 1 month. We have treated our patient with oral CPFX for more than 1 year after the 1-month period of intravenous therapy. Oral antibiotic therapy is planned for life. Surgical intervention for MAAA remains challenging. Extra-anatomic bypass (mostly AXBF operation) was once a standard option for treatment of MAAA; however, the usefulness of in situ graft replacement surgery has recently been recognized. According to Lee et al.,38 who compared the outcomes of 2 modalities in patients with infrarenal MAAA, postoperative vascular-related complications were frequently seen in patients with extraanatomic bypass grafting (P ¼ 0.044), but there was no significant difference in mortality rate (P ¼ 0.333). Because that study was retrospective, small scaled (28 patients in total), and single centered, a well-designed randomized control study is required to make a conclusion regarding the superiority or selection criteria of the 2 methods. The results of our review show good prognosis after in situ graft replacement surgery (survival rate of 94%; 17 of 18 cases). Although the in situ operation may have potential to recurrent infection of prosthetic grafts after surgery, the usefulness of an antibioticbonded graft, especially with an additional omental wrapping, has been reported.39e42 RFP is considered a preferable one because it bonds well with gelatin. The gelatin-bonded RFP would be bonded with prosthetic grafts for a few weeks, and a regional high concentration is considered to be protective for the implanted graft. We used RFP-bonded J-Graft for in situ graft replacement surgery in the present case. J-Graft is a polyester woven graft that is covered with bovine bone-derived gelatin. Launched in 2007, the use
Annals of Vascular Surgery
of J-Graft in Japanese clinical settings has been increasing. So far, however, gelatin-coated conventional grafts have been the standard for RFP bonding, and the safety and superiority of RFP-bonded J-Graft have not been completely determined. To the best of our knowledge, there has been only one clinical report of a successfully treated case of prosthetic graft infection of the ascending aorta by RFP-bonded J-Graft.43 It is thought that J-Graft evokes less hemorrhage and postoperative inflammatory reaction, resulting in less accumulation of perigraft fluids, which can be a source of infection. However, reliable data are still insufficient, and further study is warranted before its wide use. In our case, we selected J-Graft for reconstruction surgery mainly based on the surgeon’s preference. With regard to the amount of RFP, conventional grafts might be better. Structurally, conventional grafts have higher porosity, and therefore, a large amount of gelatin coating is provided both inside and outside the graft, whereas J-Graft is coated with gelatin only inside. Thus, a larger amount of RFP would be applied to conventional grafts, possibly leading to more preventive effect. To secure in situ graft replacement with RFP-bonded J-Graft, omentum wrapping may be needed because RFP would not be bonded on the outside. With this report, we do not recommend or insist that J-Graft should be chosen for the in situ operation, but we want to point out the potential of J-Graft as an alternative choice for reconstruction. The use of EVAR in the management of MAAAs has also been reported recently. As in the present case, MAAAs often adhere to the surrounding tissues, and operation time or ischemic interval of visceral organs and lower extremities can be prolonged, leading to various adverse effects postoperatively. However, EVAR has no relation to such problems because the procedure deals with intravascular affairs. Although small-scaled, a recent study comparing the efficacy of EVAR and conventional surgery for the treatment of MAAAs showed that EVAR treatment appears to be equivalent to surgery.44 Thus, EVAR can generally be an alternative technique for the management of MAAAs. However, according to our review, both of the previously reported patients who received EVAR died,9,33 and the use of EVAR in cases of C. fetuse related MAAA should be carefully considered. In summary, we reported a rare case of C. fetuse associated MAAA with a literature review. Patients with C. fetus bacteremia could be complicated with MAAA, and prompt management including appropriate surgical therapy is essential. In situ graft
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replacement surgery using RFP-bonded J-Graft was safely and successfully performed in our case.
REFERENCES 1. Muller BT, Wegener OR, Grabitz K, et al. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106e13. 2. Miller DV, Oderich GS, Aubry MC, et al. Surgical pathology of infected aneurysms of the descending thoracic and abdominal aorta: clinicopathologic correlations in 29 cases (1976 to 1999). Hum Pathol 2004;35:1112e20. 3. Fichelle JM, Tabet G, Cormier P, et al. Infected infrarenal aortic aneurysms: when is in situ reconstruction safe? J Vasc Surg 1993;17:635e45. 4. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900e8. 5. Alonso M, Caeiro S, Cachaldora J, et al. Infected abdominal aortic aneurysm: in situ replacement with cryopreserved arterial homograft. J Cardiovasc Surg (Torino) 1997;38: 371e5. 6. Blanchard JF. Epidemiology of abdominal aortic aneurysms. Epidemiol Rev 1999;21:207e21. 7. Takano H, Taniguchi K, Kuki S, et al. Mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum: a case report of surgical management and review of the literature. J Vasc Surg 2003;38:847e51. 8. Maeda H, Umezawa H, Goshima M, et al. Primary infected abdominal aortic aneurysm: surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period. Surg Today 2011;41:346e51. 9. Cochennec F, Gazaigne L, Lesprit P, et al. Aortoiliac aneurysms infected by Campylobacter fetus. J Vasc Surg 2008; 48:815e20. 10. Alsac JM, Boura B, Desgranges P, et al. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta: a multicenter analysis of 28 cases. J Vasc Surg 2008;48: 1369e74. 11. Tran JK, de Virgilio C. Management of an abdominal aortic aneurysm infected with Campylobacter fetus: a case report. Ann Vasc Surg 2007;21:137e42. 12. Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40:30e5. 13. Pacanowski J, Lalande V, Lacombe K, et al. Campylobacter bacteremia: clinical features and factors associated with fatal outcome. Clin Infect Dis 2008;47:790e6. 14. Gazaigne L, Legrand P, Renaud B, et al. Campylobacter fetus bloodstream infection: risk factors and clinical features. Eur J Clin Microbiol Infect Dis 2008;27:185e9. 15. Blaser MJ, Smith PF, Repine JE, et al. Pathogenesis of Campylobacter fetus infections. Failure of encapsulated Campylobacter fetus to bind C3b explains serum and phagocytosis resistance. J Clin Invest 1988;81:1434e44. 16. Morrison VA, Lloyd BK, Chia JK, et al. Cardiovascular and bacteremic manifestations of Campylobacter fetus infection: case report and review. Rev Infect Dis 1990;12:387e92. 17. Ting AC, Cheng SW, Ho P, et al. Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta. Am J Surg 2005;189:150e4.
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18. Macedo TA, Stanson AW, Oderich GS, et al. Infected aortic aneurysms: imaging findings. Radiology 2004;231:250e7. 19. Dolev E, Altmann G, Padeh B. Vibrio fetus septicemia. A case report. Isr J Med Sci 1971;7:1188e91. 20. File TM Jr, Barnishan J, Fass RJ. Campylobacter fetus sepsis with mycotic aortic aneurysm. Arch Pathol Lab Med 1979; 103:143e5. 21. Taylor PR, Weinstein WM, Bryner JH. Campylobacter fetus infection in human subjects: association with raw milk. Am J Med 1979;66:779e83. 22. Anolik JR, Mildvan D, Winter JW, et al. Mycotic aortic aneurysm. A complication of Campylobacter fetus septicemia. Arch Intern Med 1983;143:609e10. 23. Marty AT, Webb TA, Stubbs KG, et al. Inflammatory abdominal aortic aneurysm infected by Campylobacter fetus. JAMA 1983;249:1190e2. 24. Blabey RG Jr, Parry MF, Bull SM, et al. Mycotic aneurysm of the abdominal aorta: successful management of Campylobacter fetus aortitis. Conn Med 1983;47:129e30. 25. Righter J, Woods JM. Campylobacter and endovascular lesions. Can J Surg 1985;28:451e2. 26. Perry MO. Infected aortic aneurysms. J Vasc Surg 1985;2: 597e9. 27. Rutherford EJ, Eakins JW, Maxwell JG, et al. Abdominal aortic aneurysm infected with Campylobacter fetus subspecies fetus. J Vasc Surg 1989;10:193e7. 28. Jacobs J, Van Lierde J, Nevelsteen A, et al. Campylobacter fetus subspecies fetus infection of an abdominal aneurysm. Acta Clin Belg 1989;44:123e8. 29. Kato R, Ohta T, Kazui H, et al. Campylobacter fetus infection of abdominal aortic aneurysm. J Cardiovasc Surg (Torino) 1990;31:756e9. 30. Allerberger F, Kasten MJ, Anhalt JP. Campylobacter fetus subspecies fetus infection. Klin Wochenschr 1991;69: 813e6. 31. Grollier G, Burucoa C, Ricco JB, et al. Isolation and immunogenicity of Campylobacter fetus subsp. fetus from an abdominal aortic aneurysm. Eur J Clin Microbiol Infect Dis 1993;12:847e9. 32. Mii S, Tanaka K, Furugaki K, et al. Infected abdominal aortic aneurysm caused by Campylobacter fetus subspecies fetus: report of a case. Surg Today 1998;28:661e4. 33. Brossier J, Lesprit P, Marzelle J, et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience. Eur J Vasc Endovasc Surg 2010; 40:582e8. 34. Noda Y, Sawada K, Yoshida SH, et al. Mycotic abdominal aneurysm caused by campylobacter fetus: a case report for surgical management. Ann Vasc Dis 2011;4:56e9. 35. Tremblay C, Gaudreau C, Lorange M. Epidemiology and antimicrobial susceptibilities of 111 Campylobacter fetus subsp. fetus strains isolated in Quebec, Canada, from 1983 to 2000. J Clin Microbiol 2003;41:463e6. 36. Chan FY, Crawford ES, Coselli JS, et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193e203. 37. Hollier LH, Money SR, Creely B, et al. Direct replacement of mycotic thoracoabdominal aneurysms. J Vasc Surg 1993;18: 477e84. discussion 485. 38. Lee CH, Hsieh HC, Ko PJ, et al. In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms. J Vasc Surg 2011;54:64e70. 39. Uchida N, Katayama A, Tamura K, et al. In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta
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using rifampicin-bonded grafting and omental pedicle grafting. Ann Thorac Surg 2012;93:438e42. 40. Hayes PD, Nasim A, London NJ, et al. In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998). J Vasc Surg 1999;30:92e8. 41. Bandyk DF, Novotney ML, Johnson BL, et al. Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections. J Surg Res 2001;95:44e9. 42. Gupta AK, Bandyk DF, Johnson BL. In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-
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impregnated Dacron grafts: a preliminary case report. J Vasc Surg 1996;24:472e6. 43. Iida Y, Ito T, Kitahara H, et al. A case of in-situ reconstruction with a rifampicin-bonded gelatin-sealed woven dacron graft for prosthetic graft infection with pseudoaneurysms after ascending aortic replacement for type a dissection. Ann Vasc Dis 2014;7:68e71. 44. Kan CD, Lee HL, Luo CY, et al. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm-institute case management with systemic literature comparison. Ann Vasc Surg 2010;24:433e40.
Campylobacter spp. usually cause gastrointestinal infections, but among them, Campylobacter fetus is a well-known organism causing mycotic abdominal aortic aneurysm (MAAA), which requires proper surgical intervention and antibiotic therapy. We report a 65-year-old man who was successfully treated by an in situ operation using a rifampicin (RFP)ebonded J-Graft for C. fetuseinduced MAAA. We performed a review of the English literature on MAAA caused by C. fetus and summarized the results of the cases (28 cases). All but 2 of the patients (92.9%) were men. Blood culture and arterial wall culture were positive in 63% and 73.1% of the cases, respectively. Aneurysm rupture was seen in half of the patients, and approximately half of those patients died. Among the 18 patients who underwent in situ graft replacement, only 1 patient (5.6%) died after surgery. Antibiotic therapy was performed for more than 1 month in most cases, and overall mortality rate was 25.9% (7 of 27 cases, 3 deaths before the operation and 4 deaths after surgery). Although extra-anatomic bypass has been conventionally performed after complete resection of an MAAA, the utility of in situ surgery has generally been recognized. Our review suggests that the in situ operation can be a choice also in cases of C. fetuseassociated MAAA. Furthermore, our case suggested the clinical utility of a newly manufactured prosthetic graft, J-Graft, for such surgical treatment.
Conflicts of Interest: The authors state that there are no conflicts of interests to declare. 1
Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. 2 Emergency Unit and Critical Care Center, Tsuyama Central Hospital, Okayama, Japan. 3 Department of Cardiovascular Surgery, Tsuyama Central Hospital, Okayama, Japan. 4 Microbiology Division, Department of Clinical Laboratory, Tsuyama Central Hospital, Okayama, Japan. Correspondence to: Hideharu Hagiya, MD, PhD, Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kitaku, Okayama 700-8558, Japan; E-mail: [email protected]
Ann Vasc Surg 2014; -: 1–8 http://dx.doi.org/10.1016/j.avsg.2014.06.072 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 18, 2014; manuscript accepted: June 19, 2014; published online: ---.
Mycotic abdominal aortic aneurysm (MAAA), which is formed by destruction of the arterial wall as a result of infection, accounts for approximately 1% of all aortic abdominal aneurysms (AAAs).1 Common sites of MAAA are the abdominal aorta distal to the renal artery and the thoracic aorta.2 The risk factors include arterial injury, preceding infection, immunocompromised state, atherosclerosis, preexisting aneurysm, and aging. Some patients complain of lumbar or back pain, whereas others may present fever of unknown origin or sudden rupture of the aneurysm. The overall mortality rate in patients with MAAA has been reported to be as high as 30%.1,3 The risk of aneurysm rupture has been reported to be as high as 50e80%,1,4,5 and the mortality rate would be more than 70% if it is ruptured.6 The common causative organisms of MAAA include Staphylococcus spp., Salmonella spp., and Streptococcus spp.7 Occasionally, Campylobacter spp. 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Abdominal contrast-enhanced computed tomography (CECT) and gross appearance of J-Graft. (A) A coronal image of the three-dimensional vascular reconstruction, (B) a sagittal image of CECT, (C) Axial images of CECT, and (D) rifampicin (RFP)ebonded J-Graft after anastomosis. Arrow: infected aneurysm, Arrowhead: true lumen.
A saccular-type abdominal aneurysm (40 39 mm) surrounded by a dirty fat sign was found between the inferior mesenteric artery and bifurcation of the common iliac artery (AeC). The patient underwent aortobilateral iliac reconstruction with bifurcated RFP-bonded Dacron graft (J-Graft; D).
are detected as pathogenic organisms of MAAA. Among them, Campylobacter fetus is reported to be the most common pathogen.8 C. fetuseassociated MAAA has rapid progression and a high mortality rate (approximately 30%),9,10 and no survival can be expected without surgical intervention.11,12 Because the number of reported cases is still insufficient, the appropriate strategy for C. fetuseassociated MAAAs is inconclusive. We report a case of MAAA caused by C. fetus, which was successfully treated with replacement of a newly manufactured Japanese woven Dacron graft, J-Graft (Japan Lifeline Co. Ltd, Tokyo, Japan), which was preliminarily bonded with rifampicin (RFP). Furthermore, we discuss the diagnosis and treatment of C. fetuseassociated MAAAs based on a literature review.
episode of diarrhea 2 weeks previously, but the etiology was unknown. There was no history of drinking raw milk or consuming uncooked meat. A urinary examination showed hematuria, and he returned home with the diagnosis of urolithiasis. The next day, he consulted an urologist and was again diagnosed as having urolithiasis although a urinary tract stone was not apparent in plain computed tomography (CT). Later that day, a physician noticed an inflammatory change around his abdominal aorta in the CT, and the patient was called immediately to visit the hospital. On arrival, his body temperature was 38.1 C. He complained of rigor and shivering, but his vital signs were stable. Laboratory examination revealed white blood cells of 10,500/mm3 and C-reactive protein of 13.8 mg/dL. Emergently performed contrast-enhanced CT (CECT) showed a saccular and poorly marginated AAA (40 39 mm; Fig. 1AeC). The aneurysm only involved the infrarenal aorta, and celiac, renal, and mesenteric arteries were confirmed to be patent by CT angiography. Ascites or free abdominal air was not obvious. After drawing 3 sets of blood culture, administration of ceftriaxone (2 g every 24 hr) and ciprofloxacin (CPFX, 300 mg every 12 hr)
CASE REPORT A 65-year-old man without any past medical history presented with a 1-week history of lumbar pain. He had an
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Case Report 3
Fig. 2. Histopathologic findings of the resected aneurysm. (A) Hematoxylineeosin staining (magnification 200). (B) Gram staining (magnification 1,000). Microscopic
examination of the arterial wall showed diffuse necrosis and infiltration of neutrophils (A). Gram-negative spindle-form rods were found in purulent tissues (B).
was initiated with a suspicion of MAAA, and the patient was admitted to an intensive care unit. The next morning, the patient complained of abdominal pain, but repeated CECT was negative for any deteriorating findings of the aneurysm. Physical examination and transthoracic echocardiography did not indicate any findings associated with infective endocarditis. That night (day 2), an emergency operation was performed under the diagnosis of impending rupture of the MAAA. The MAAA had tightly adhered to the spine and the retroperitoneum. It was carefully dissected to the bilateral iliac artery region and totally removed after clamping the infrarenal aorta. A 16 8-mm bifurcated Dacron graft (J-Graft) replacement was performed after immersing the graft in a solution of RFP for 30 min in the operating room (Fig. 1D). The greater omentum was dissected between the greater curvature of the stomach and the right gastroepiploic artery (RGEA) from the pylorus ring to the end of the RGEA. Then, the greater omentum was harvested with a harmonic scalpel from the end of the RGEA to the free margin. After boring a hole in the root of the transverse mesocolon, the harvested greater curvature was passed through it and was spread over the graft. It was also fixed to the retroperitoneum with 4e 0 prolene in an interrupted manner. Owing to the highly adhesive nature of the aneurysm, the total operation time and ischemic interval of lower extremities were 7 hr and 25 min and 4 hr and 7 min, respectively. The patient suffered from rhabdomyolysis triggered by ischemiaereperfusion syndrome, and continuous hemodiafiltration was initiated postoperatively. Swelling of his lower extremities was not profound, and fasciotomy was not performed. The patient’s condition including renal function gradually improved, and there was no sign of myonephropathic metabolic syndrome. He was discharged from the intensive care unit 2 weeks after the operation. The resected aneurysm was enlarged with a varicose deformity, and its wall was markedly thickened. Microscopically, fibrosing and hyalinizing changes were observed at the retroperitoneal and periaortic tissues (Fig. 2A). Gram staining of the resected aortic wall
revealed gram-negative spindle-form rods (Fig. 2B), and bacterial culture revealed C. fetus, which was sensitive to ampicillin, imipenem, amikacin, azithromycin, clindamycin, ciprofloxacin, and levofloxacin. Blood cultures remained negative even after 2 weeks (BacT/Alert). Stool culture was also negative for Campylobacter spp. The clinical course after that was relatively uneventful, and the patient was discharged on day 36 without any sequel. Administration of oral CPFX has been continued, and there has been no recurrence for more than 1 year.
DISCUSSION C. fetus is a motile gram-negative rod with a spindle form, which is carried by livestock such as cattle and sheep. While C. jejuni and C. coli cause gastrointestinal symptoms after ingestion, C. fetus frequently causes bacteremia without any digestive manifestations. Actually, unlike C. jejuni or C. coli, most cases of C. fetus infection have been diagnosed from positive results of blood culture; according to a previous summary of 178 Campylobacter bacteremia patients, C. fetus was the most commonly identified species (53% of the patients).13 Elderly, disabled, and immunocompromised people are considered to be at high risk for persistent bacteremia.14 Additionally, C. fetus specifically possesses a surface layer protein that provides resistance to complementdependent bactericidal action or opsonization, and the organism can easily form an extraintestinal infectious focus.15 Thus, C. fetus can cause systemic infections, and patients with lung abscess, urinary infection, meningitis, subdural abscess, arthritis, peritonitis, and cholecystitis have been reported. Furthermore, C. fetus shows a special tropism for the human vascular endothelium via bacteriasurface receptors,16 and the organism therefore has potential to cause endovascular infections.
4 Case Report
Table I. A summary of mycotic aortic abdominal aneurysms caused by Campylobacter fetus Year
Age (years)
Sex
BC
AWC
Ruptured
Operation
Treatment
Outcome (follow-up duration)
References
1
1971
68
M
P
N
Yes
d
1979 1979 1983 1983
63 67 73 54
M M M M
P P P P
N ND P P
Yes Yes Yes No
d d Long term 7 Months
Died, a few hours after operation Died, before operation Died, before operation Alive, 45 months Alive, 2 years
Dolev et al.
2 3 4 5
File et al. Taylor et al. Anolik et al. Marty et al.
6 7
1983 1985
68 56
M F
P N
N P
No No
7 Weeks 1 Week
Alive, 18 months Alive, 3 years
Blabey et al. Righter et al.
8
1985
70
M
P
N
Yes
8 Weeks
Alive, 6 months
Perry et al.
9
1989
59
M
N
P
No
5 Months
Alive, 2 year
Rutherford et al.
10 11 12 13
1989 1990 1991 1993
64 61 84 56
M M F M
P N P ND
P P P P
Yes No Yes Yes
d 2 Weeks d d
Died, after 7 days Alive, 36 months Died, before operation ND
Jacobs et al. Kato et al. Allerberger et al. Grollier et al.
14
1998
45
M
N
P
No
3 Months
Alive, 1 year
Mii et al.
15 16
2007 2008
78 69
M M
N P
P N
No Yes
Life long Long term
Alive, 9 months Alive, 6 months
Tran et al. Cochennec et al.
17
2008
76
M
N
P
Yes
Long term
Alive, 5 months
Cochennec et al.
18
2008
76
M
P
ND
Yes
Long term
Died, after 2 weeks
Cochennec et al.
19
2008
79
M
P
N
No
Long term
Alive, 18 months
Cochennec et al.
20
2010
69
M
P
P
Yes
Replaced with polyester graft (Dacron graft) d d Aneurysm excision, AXBF Replaced with polyester graft (Dacron graft) Aneurysm excision, AXBF Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Aneurysm excision, AXBF Aneurysm excision, AXBF d Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) Replaced with polyester graft Replaced with polyester graft (Dacron graft) Replaced with polyester graft (Dacron graft) EVAR (Zenith bifurcated stent graft) Replaced with polyester graft (allograft) Replaced with polyester graft (Dacron graft)
d
Alive, 34 months
Brossier et al.
Annals of Vascular Surgery
Case
No P N M 2013 28
65
ND ND No P P P N N P M M M 2011 2011 2011 25 26 27
76 57 72
No P P M 2010 24
78
No N P M 2010 23
76
No P N M 2010 22
76
Yes P P M 69 2010 21
AWC, arterial wall culture; AXBF, axillobifemoral bypass operation; BC, blood culture; EVAR, endovascular aortic repair; N, negative; ND, not described; P, positive.
Present case Alive, 1 year
Alive Alive Alive, 1 year
Maeda et al. Maeda et al. Noda et al.
Case Report 5
d d More than 4 weeks Long term
Alive, 38 months
Brossier et al.
2014
d
Died, after 15 days
Brossier et al.
-, -
d
Alive, 5 months
Brossier et al.
No.
d
-,
Replaced with polyester graft (Silver graft) Replaced with polyester graft (Dacron graft) EVAR (Zenith bifurcated stent graft) Replaced with polyester graft (allograft) Replaced with polyester graft Replaced with polyester graft Replaced with polyester graft (Dacron graft) Replaced with polyester graft (J-graft)
d
Alive, 28 months
Brossier et al.
Vol.
Gazaigne et al. reported that 24% of C. fetus bacteremia cases were complicated with MAAA.14 It was unknown whether the episode of diarrhea 2 weeks before the onset in this case was related to the occurrence of MAAA. Typical cases of MAAA may present fever and a high inflammatory state accompanied by abdominal pain, back pain, and a pulsatile mass. However, less than half of the cases show typical presentation,4,17 and only about half of MAAA cases show positive results of blood culture.1 As a result, definitive diagnosis of MAAA is challenging. Diagnosis is often made in the later phase of the clinical course, and the patient’s outcome would be worse. Imaging tests, especially CECT, can be of use in such cases. Characteristic findings of MAAA include arterial wall thickening, ectopic gas surrounding the aorta, periaortic edema, rapid progression, and a saccular or lobulated shape of the aneurysm that changes its form within a short time and is complicated with a dirty fat sign.18 Actually, in our patient, we could recall MAAA as a potential diagnosis at the beginning of the clinical course because of typical CT findings with a high inflammatory serum state. We searched for previous cases of C. fetuse associated MAAA in PubMed, and results of 28 cases including our case are summarized in Table I.8,9,11,19e34 The average age of the patients was 68 years (54e84 years). All but 2 of the patients (26 of 28 cases, 92.9%) were men. Of 27 cases, blood culture was positive in 17 cases (63%), and of 26 cases, arterial wall culture was positive in 19 cases (73.1%). Aneurysm rupture was seen in 50% of the cases (13 of 26 cases), and among them, approximately half of the patients (6 of 13 cases) died. For surgical treatment, an axillobifemoral (AXBF) bypass operation was performed in 4 cases, endovascular aortic repair (EVAR) was used in 2 cases, and in situ graft replacement was selected in 19 cases. One of the 4 patients who received an AXBF operation died because of acute myocardial infarction,28 and both of the patients who received EVAR died because of sepsis.9,33 On the other hand, only 1 (5.6%) of the 18 patients who received in situ graft replacement died after surgery. Notably, the patient who received the in situ operation died soon after surgery that was performed as an emergent treatment for aneurysm rupture,19 and thus, the in situ operation itself was not necessarily associated with death. Overall mortality rate of MAAA caused by C. fetus was 25.9% (7 of 27 cases, 3 deaths before the operation and 4 deaths after surgery). For the treatment of MAAA, antibiotic therapy is indispensable but would be inadequate if given alone. At least, identification of the pathogen and
6 Case Report
careful attentions to its susceptibility examination would be required. For example, fluoroquinolones are commonly selected for Campylobacter spp. infection; however, the rate of resistance of Campylobacter spp. to fluoroquinolone has been reported to have increased to as high as 32%.13 Still, the appropriate dose, duration, and regimen of antibiotic therapy for postoperative MAAA have not been established.35 Some authors reported that a period of 4e8 weeks of antibiotic treatment is sufficient,12 whereas others insisted that patients with MAAA should take antibiotics for their whole life.36,37 There is no widely acceptable consensus on this point, and we need to determine the indication case by case. Cases with extensive infection, recurrence, or prosthetic infection may need longer treatment. In our review of C. fetuseassociated MAAA, most cases (13 of 15 cases, 86.7%) received antibiotic therapy for more than 1 month. We have treated our patient with oral CPFX for more than 1 year after the 1-month period of intravenous therapy. Oral antibiotic therapy is planned for life. Surgical intervention for MAAA remains challenging. Extra-anatomic bypass (mostly AXBF operation) was once a standard option for treatment of MAAA; however, the usefulness of in situ graft replacement surgery has recently been recognized. According to Lee et al.,38 who compared the outcomes of 2 modalities in patients with infrarenal MAAA, postoperative vascular-related complications were frequently seen in patients with extraanatomic bypass grafting (P ¼ 0.044), but there was no significant difference in mortality rate (P ¼ 0.333). Because that study was retrospective, small scaled (28 patients in total), and single centered, a well-designed randomized control study is required to make a conclusion regarding the superiority or selection criteria of the 2 methods. The results of our review show good prognosis after in situ graft replacement surgery (survival rate of 94%; 17 of 18 cases). Although the in situ operation may have potential to recurrent infection of prosthetic grafts after surgery, the usefulness of an antibioticbonded graft, especially with an additional omental wrapping, has been reported.39e42 RFP is considered a preferable one because it bonds well with gelatin. The gelatin-bonded RFP would be bonded with prosthetic grafts for a few weeks, and a regional high concentration is considered to be protective for the implanted graft. We used RFP-bonded J-Graft for in situ graft replacement surgery in the present case. J-Graft is a polyester woven graft that is covered with bovine bone-derived gelatin. Launched in 2007, the use
Annals of Vascular Surgery
of J-Graft in Japanese clinical settings has been increasing. So far, however, gelatin-coated conventional grafts have been the standard for RFP bonding, and the safety and superiority of RFP-bonded J-Graft have not been completely determined. To the best of our knowledge, there has been only one clinical report of a successfully treated case of prosthetic graft infection of the ascending aorta by RFP-bonded J-Graft.43 It is thought that J-Graft evokes less hemorrhage and postoperative inflammatory reaction, resulting in less accumulation of perigraft fluids, which can be a source of infection. However, reliable data are still insufficient, and further study is warranted before its wide use. In our case, we selected J-Graft for reconstruction surgery mainly based on the surgeon’s preference. With regard to the amount of RFP, conventional grafts might be better. Structurally, conventional grafts have higher porosity, and therefore, a large amount of gelatin coating is provided both inside and outside the graft, whereas J-Graft is coated with gelatin only inside. Thus, a larger amount of RFP would be applied to conventional grafts, possibly leading to more preventive effect. To secure in situ graft replacement with RFP-bonded J-Graft, omentum wrapping may be needed because RFP would not be bonded on the outside. With this report, we do not recommend or insist that J-Graft should be chosen for the in situ operation, but we want to point out the potential of J-Graft as an alternative choice for reconstruction. The use of EVAR in the management of MAAAs has also been reported recently. As in the present case, MAAAs often adhere to the surrounding tissues, and operation time or ischemic interval of visceral organs and lower extremities can be prolonged, leading to various adverse effects postoperatively. However, EVAR has no relation to such problems because the procedure deals with intravascular affairs. Although small-scaled, a recent study comparing the efficacy of EVAR and conventional surgery for the treatment of MAAAs showed that EVAR treatment appears to be equivalent to surgery.44 Thus, EVAR can generally be an alternative technique for the management of MAAAs. However, according to our review, both of the previously reported patients who received EVAR died,9,33 and the use of EVAR in cases of C. fetuse related MAAA should be carefully considered. In summary, we reported a rare case of C. fetuse associated MAAA with a literature review. Patients with C. fetus bacteremia could be complicated with MAAA, and prompt management including appropriate surgical therapy is essential. In situ graft
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replacement surgery using RFP-bonded J-Graft was safely and successfully performed in our case.
REFERENCES 1. Muller BT, Wegener OR, Grabitz K, et al. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106e13. 2. Miller DV, Oderich GS, Aubry MC, et al. Surgical pathology of infected aneurysms of the descending thoracic and abdominal aorta: clinicopathologic correlations in 29 cases (1976 to 1999). Hum Pathol 2004;35:1112e20. 3. Fichelle JM, Tabet G, Cormier P, et al. Infected infrarenal aortic aneurysms: when is in situ reconstruction safe? J Vasc Surg 1993;17:635e45. 4. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900e8. 5. Alonso M, Caeiro S, Cachaldora J, et al. Infected abdominal aortic aneurysm: in situ replacement with cryopreserved arterial homograft. J Cardiovasc Surg (Torino) 1997;38: 371e5. 6. Blanchard JF. Epidemiology of abdominal aortic aneurysms. Epidemiol Rev 1999;21:207e21. 7. Takano H, Taniguchi K, Kuki S, et al. Mycotic aneurysm of the infrarenal abdominal aorta infected by Clostridium septicum: a case report of surgical management and review of the literature. J Vasc Surg 2003;38:847e51. 8. Maeda H, Umezawa H, Goshima M, et al. Primary infected abdominal aortic aneurysm: surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period. Surg Today 2011;41:346e51. 9. Cochennec F, Gazaigne L, Lesprit P, et al. Aortoiliac aneurysms infected by Campylobacter fetus. J Vasc Surg 2008; 48:815e20. 10. Alsac JM, Boura B, Desgranges P, et al. Immediate endovascular repair for acute traumatic injuries of the thoracic aorta: a multicenter analysis of 28 cases. J Vasc Surg 2008;48: 1369e74. 11. Tran JK, de Virgilio C. Management of an abdominal aortic aneurysm infected with Campylobacter fetus: a case report. Ann Vasc Surg 2007;21:137e42. 12. Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40:30e5. 13. Pacanowski J, Lalande V, Lacombe K, et al. Campylobacter bacteremia: clinical features and factors associated with fatal outcome. Clin Infect Dis 2008;47:790e6. 14. Gazaigne L, Legrand P, Renaud B, et al. Campylobacter fetus bloodstream infection: risk factors and clinical features. Eur J Clin Microbiol Infect Dis 2008;27:185e9. 15. Blaser MJ, Smith PF, Repine JE, et al. Pathogenesis of Campylobacter fetus infections. Failure of encapsulated Campylobacter fetus to bind C3b explains serum and phagocytosis resistance. J Clin Invest 1988;81:1434e44. 16. Morrison VA, Lloyd BK, Chia JK, et al. Cardiovascular and bacteremic manifestations of Campylobacter fetus infection: case report and review. Rev Infect Dis 1990;12:387e92. 17. Ting AC, Cheng SW, Ho P, et al. Surgical treatment of infected aneurysms and pseudoaneurysms of the thoracic and abdominal aorta. Am J Surg 2005;189:150e4.
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18. Macedo TA, Stanson AW, Oderich GS, et al. Infected aortic aneurysms: imaging findings. Radiology 2004;231:250e7. 19. Dolev E, Altmann G, Padeh B. Vibrio fetus septicemia. A case report. Isr J Med Sci 1971;7:1188e91. 20. File TM Jr, Barnishan J, Fass RJ. Campylobacter fetus sepsis with mycotic aortic aneurysm. Arch Pathol Lab Med 1979; 103:143e5. 21. Taylor PR, Weinstein WM, Bryner JH. Campylobacter fetus infection in human subjects: association with raw milk. Am J Med 1979;66:779e83. 22. Anolik JR, Mildvan D, Winter JW, et al. Mycotic aortic aneurysm. A complication of Campylobacter fetus septicemia. Arch Intern Med 1983;143:609e10. 23. Marty AT, Webb TA, Stubbs KG, et al. Inflammatory abdominal aortic aneurysm infected by Campylobacter fetus. JAMA 1983;249:1190e2. 24. Blabey RG Jr, Parry MF, Bull SM, et al. Mycotic aneurysm of the abdominal aorta: successful management of Campylobacter fetus aortitis. Conn Med 1983;47:129e30. 25. Righter J, Woods JM. Campylobacter and endovascular lesions. Can J Surg 1985;28:451e2. 26. Perry MO. Infected aortic aneurysms. J Vasc Surg 1985;2: 597e9. 27. Rutherford EJ, Eakins JW, Maxwell JG, et al. Abdominal aortic aneurysm infected with Campylobacter fetus subspecies fetus. J Vasc Surg 1989;10:193e7. 28. Jacobs J, Van Lierde J, Nevelsteen A, et al. Campylobacter fetus subspecies fetus infection of an abdominal aneurysm. Acta Clin Belg 1989;44:123e8. 29. Kato R, Ohta T, Kazui H, et al. Campylobacter fetus infection of abdominal aortic aneurysm. J Cardiovasc Surg (Torino) 1990;31:756e9. 30. Allerberger F, Kasten MJ, Anhalt JP. Campylobacter fetus subspecies fetus infection. Klin Wochenschr 1991;69: 813e6. 31. Grollier G, Burucoa C, Ricco JB, et al. Isolation and immunogenicity of Campylobacter fetus subsp. fetus from an abdominal aortic aneurysm. Eur J Clin Microbiol Infect Dis 1993;12:847e9. 32. Mii S, Tanaka K, Furugaki K, et al. Infected abdominal aortic aneurysm caused by Campylobacter fetus subspecies fetus: report of a case. Surg Today 1998;28:661e4. 33. Brossier J, Lesprit P, Marzelle J, et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience. Eur J Vasc Endovasc Surg 2010; 40:582e8. 34. Noda Y, Sawada K, Yoshida SH, et al. Mycotic abdominal aneurysm caused by campylobacter fetus: a case report for surgical management. Ann Vasc Dis 2011;4:56e9. 35. Tremblay C, Gaudreau C, Lorange M. Epidemiology and antimicrobial susceptibilities of 111 Campylobacter fetus subsp. fetus strains isolated in Quebec, Canada, from 1983 to 2000. J Clin Microbiol 2003;41:463e6. 36. Chan FY, Crawford ES, Coselli JS, et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193e203. 37. Hollier LH, Money SR, Creely B, et al. Direct replacement of mycotic thoracoabdominal aneurysms. J Vasc Surg 1993;18: 477e84. discussion 485. 38. Lee CH, Hsieh HC, Ko PJ, et al. In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms. J Vasc Surg 2011;54:64e70. 39. Uchida N, Katayama A, Tamura K, et al. In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta
8 Case Report
using rifampicin-bonded grafting and omental pedicle grafting. Ann Thorac Surg 2012;93:438e42. 40. Hayes PD, Nasim A, London NJ, et al. In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998). J Vasc Surg 1999;30:92e8. 41. Bandyk DF, Novotney ML, Johnson BL, et al. Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections. J Surg Res 2001;95:44e9. 42. Gupta AK, Bandyk DF, Johnson BL. In situ repair of mycotic abdominal aortic aneurysms with rifampin-bonded gelatin-
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impregnated Dacron grafts: a preliminary case report. J Vasc Surg 1996;24:472e6. 43. Iida Y, Ito T, Kitahara H, et al. A case of in-situ reconstruction with a rifampicin-bonded gelatin-sealed woven dacron graft for prosthetic graft infection with pseudoaneurysms after ascending aortic replacement for type a dissection. Ann Vasc Dis 2014;7:68e71. 44. Kan CD, Lee HL, Luo CY, et al. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm-institute case management with systemic literature comparison. Ann Vasc Surg 2010;24:433e40.
