Aortic Septic Aneurysm Treatment

Diagnosis and Imaging

• The European Heart Journal recommends CT with contrast as the gold standard diagnostic tool, including non-contrast phase to detect intramural hematoma and contrast phase to identify leaks indicating rupture, covering the entire aorta, iliac, and femoral arteries 1

Treatment Approach

• 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, as suggested by the European Heart Journal 1, 2
• Endovascular repair (TEVAR) is recommended over open surgery when anatomically suitable, with a 30-day mortality of 17-19% for TEVAR vs 25-33% for open repair, and a composite outcome of death, stroke, or permanent paraplegia of 22% for TEVAR vs 36% for open repair, according to the European Heart Journal 1

Patient Management

• Urgent treatment is recommended for symptomatic patients regardless of aneurysm diameter due to high risk of rupture, as stated by the European Heart Journal 1
• Immediate intervention is suggested for contained rupture due to risk of free rupture and death, according to the European Heart Journal 1
• A two-phase treatment strategy is recommended, consisting of an initial phase with 4-6 weeks of parenteral antimicrobial therapy postoperatively, and an extended phase with additional 3-6 months of oral antimicrobial therapy, with lifelong suppressive therapy considered in high-risk patients, as recommended by the American Heart Association 3
• Surgical intervention remains the first-line treatment for infected aortic aneurysms when feasible, as antimicrobial therapy alone has a reported mortality rate of 60-100%, according to the American Heart Association 3
• Lifelong suppressive therapy should be considered in patients with retained endovascular devices, infections with difficult organisms (such as MRSA, Pseudomonas, and multidrug-resistant organisms), and extensive perigraft infection, due to the high risk of recurrent infection and associated morbidity/mortality, as recommended by the American Heart Association and the American College of Cardiology 3
• Patients on long-term suppressive therapy should undergo regular monitoring of inflammatory markers, periodic imaging surveillance, and clinical assessment for signs of recurrent infection, with the choice of suppressive antibiotic based on culture results and susceptibility testing, as recommended by the American Heart Association 3
• Regular imaging surveillance is essential alongside antibiotic therapy, with duplex ultrasound surveillance recommended for abdominal aortic aneurysms, and CT or MRI necessary when ultrasound is inadequate, according to the European Heart Journal 2
• A team-based approach is essential for managing infected aortic aneurysms, involving experts in vascular diseases/surgery, cardiology, interventional radiology, critical care, infectious diseases, and microbiology, as recommended by the American Heart Association 3
• Base selection of antimicrobial therapy on identification and susceptibilities of the specific microorganism, and bactericidal therapy should be administered when possible, as recommended by the American Heart Association 3
• Infection rates with endovascular abdominal repair are approximately 1%, while TEVAR (thoracic endovascular aortic repair) has higher rates up to 5%, according to the American Heart Association 3

Antimicrobial Therapy