Reply to Ugurlucan and Alpagut Endovascular management of a descending thoracic mycotic aneurysm: Mid term follow-up Free

I would like to thank Ugurlucan and Alpagut [1] for their valuable comments regarding the management of thoracic mycotic aneurysms using endovascular technology. Endoluminal stent grafting of the aorta has increasingly been applied to treat various aortic pathologies including mycotic aneurysms. Results of open surgical repair consisting of intensive antibiotic administration, extensive excision and debridement of the infected field associated with extra-anatomic or in situ prosthetic bypass grafting are associated with mortality rates ranging from 5% to 75% [2,3]. Endovascular approach to mycotic aneurysm avoids the extensive excision and debridement of the infected field. The potential benefit of the endovascular approach is thus compared to the obvious risk of recurrence of the infection. We have had experience with the management of two patients with suspected mycotic aneurysms. In both cases an identifiable organism was cultured from the blood stream. Antibiotics must be tailored to the offending organism and preferably blood cultures should be negative before planning to treat such patients with an endoluminal graft. Some authors have suggested presoaking the graft in an antibiotic solution before deploying an endoluminal graft to exclude a suspected mycotic aneurysm. An extended zone proximal and distal to the aortic wall abnormality should be chosen because of the likelihood of more extended arterial lesions. The duration of antibiotic coverage remains controversial. The duration of antibiotic therapy remains debatable as some authors have used a short course of antibiotics ranging from 6 weeks to 6 months with other authors using life-long antibiotics [4,5]. At our institution we are of the belief that antibiotic coverage should be tailored to the patient’s general condition, blood culture results, sedimentation rate, presence or absence of fevers and leucocytosis. Although in our two patients who were treated with a stent graft for a mycotic aneurysm we had recommended life-long antibiotics, the patients stopped their antibiotics after 6 weeks. We continuously follow patients with mycotic aneurysms receiving an endoluminal graft clinically to detect any sign of reinfection and radiologically with serial CT scans to determine regression of the mycotic aneurysm with stabilization of the thoracic aorta.

In conclusion, life-long surveillance is necessary in patients with mycotic aneurysms treated with an endoluminal graft.

References