Letter to the Editor
The endovascular treatment reduces the inflammatory activity in the infected aortic wall
La exclusión endovascular reduce la actividad inflamatoria de la pared aórtica infectada
José Antonio González-Fajardo
, Marina Ansuátegui-Vicente, Sergio Revuelta-Suero
Corresponding author
Servicio de Angiología y Cirugía Vascular, Hospital Universitario, 12-Octubre, Madrid, Spain
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In the absence of intervention, it has a poor prognosis, with a mortality that exceeds 55%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Standard management of this condition includes antibiotic and surgical treatment, with a high rate of morbidity and mortality associated with open surgery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report 2 clinical cases showing resolution of the inflammatory component of the thoracic aorta through wallgraft stent and long-term maintenance of specific antibiotic treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One case was a 64-year-old diabetic woman, immunosuppressed, with pancytopenia secondary to follicular lymphoma treated with autologous hematopoietic stem cell transplantation and chemotherapy, who developed a septic <span class="elsevierStyleItalic">shock</span>. Blood cultures in the Intensive Care Unit were positive for <span class="elsevierStyleItalic">Campylobacter jejuni.</span> A transoesophageal echocardiography to rule out endocarditis revealed intimal thickening in the descending thoracic aorta. A FDG PET-CT showed strong positive uptake in the thoracic aortic wall. An angio-CT scan after 15 days showed the progression and evolution of the lesions to aortic ulcers. After 35 days of continuous antibiotic treatment with meropenem and gentamicin, an aortic stent graft implant was carried out in the injured area (Zenith Alpha™ Thoracic ZTA 32 × 32 × 150 mm; Cook Medical, Inc., Bloomington, IN, USA) and antibiotic treatment with amoxicillin-clavulanic acid (1,000/125 mg every 12 h) was maintained indefinitely, according to the recommendations of the hospital's Infectious Diseases Department. The subsequent clinical course was satisfactory and the follow-up at 18 months showed a FDG PET-CT without metabolic activity in the aortic wall.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The second case corresponded to a 74-year-old man with a fever of unknown origin and a persistent <span class="elsevierStyleItalic">Coxiella burnetii</span> infection (phase-<span class="elsevierStyleSmallCaps">i</span> serology: IgG 1/1,024, phase-<span class="elsevierStyleSmallCaps">ii</span>: IgG 1/8,192), who underwent a transoesophageal echocardiogram to rule out endocarditis, showing a severe atheromatosis of the descending thoracic aorta, with periaortic thickening at the abdominothoracic confluence. Antibiotic treatment with doxycycline was initiated (100 mg/12 h) and hydroxychloroquine (200 mg/8 h). A FDG PET-CT showed intense pathological metabolic activity in the wall of the aorta. A follow-up CT angiography revealed an aortic ulcer in the descending thoracic aorta, which was treated with an endovascular repair of the injured area (Valiant ® Captivia stent graft 30 × 30 × 150 mm; Medtronic, Inc., Minneapolis, MN, USA). After the stent graft implantation, the acute phase reactants returned to normal and the phase <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span> IgG titres decreased significantly (1/512 and 1/2,048, respectively). Subsequent clinical progression was favourable, the patient remained afebrile with normal inflammatory parameters and radiological findings. The FDG PET-CT was negative at the 24-month follow-up control, then hydroxychloroquine was discontinued, and doxycycline was maintained up to 30 months.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Infectious aortitis is a rare entity, typically located on the atherosclerotic arterial wall.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is quite serious since it can degenerate into aortic ulcer, fungal aneurysm, dissection, rupture and/or recurrent bacteraemia with possible septic embolisms.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The optimal management of infectious aortitis remains unknown and controversial. Since drug therapy alone has a disease persistence and a mortality rate greater than 90%, a combined treatment is recommended: drug therapy and surgery.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the use of endovascular procedures (stenting) on a contaminated arterial bed is debatable, these techniques have gained general acceptance and proliferation, given their lower morbidity.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Besides the bacteria involved, what makes our cases unique is the observation that endovascular repair with stenting and maintained antibiotic association is safe and effective by contributing to the disappearance of the inflammatory and infectious component of the aortic wall. However, these patients must undergo a lifelong surveillance protocol to monitor for recurrent infection.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Fajardo JA, Ansuátegui-Vicente M, Revuelta-Suero S, La exclusión endovascular reduce la actividad inflamatoria de la pared aórtica infectada. Med Clin (Barc). 2021;156:256.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infected aneurysm of the thoracic aorta" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.B. Hsu" 1 => "F.Y. 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Gornik" 1 => "M.A. Creager" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.107.760686" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2008" "volumen" => "117" "paginaInicial" => "3039" "paginaFinal" => "3051" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18541754" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.D. Kan" 1 => "H.L. Lee" 2 => "Y.J. Yang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jvs.2007.07.025" "Revista" => array:6 [ "tituloSerie" => "J Vasc Surg." "fecha" => "2007" "volumen" => "46" "paginaInicial" => "906" "paginaFinal" => "912" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17905558" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015600000005/v1_202103120836/S2387020621000450/v1_202103120836/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015600000005/v1_202103120836/S2387020621000450/v1_202103120836/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621000450?idApp=UINPBA00004N" ]
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