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Purpose: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms., Materials and Methods: The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed., Results: Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak., Conclusion: EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms., Clinical Impact: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Fungal endocarditis following transcatheter aortic valve implantation (TAVI) is a rare and serious complication of this procedure. We describe a case of a 75-year-old patient who developed fungal endocarditis caused by Candida albicans, complicated by an aortic pseudoaneurysm., (© 2024. The Author(s).)

Burkholderia pseudomallei is a Gram-negative bacterium found predominantly in tropical and subtropical regions. A 49-year-old individual with type 2 diabetes in Hainan, China, with a 4-month history of intermittent fever and 20 days of chest-back pain was diagnosed with aortic pseudoaneurysm through a computerized tomography scan. Burkholderia pseudomallei was identified through bacteriological examination of the patient's blood. The patient received supportive care, with management of hyperthermia, heart rate, blood pressure, and blood glucose levels. Intravenous meropenem and oral sulfamethoxazole were administered for anti-infection treatment. Within 10 days, the patient's temperature normalized, vital signs stabilized, chest pain subsided, and blood cultures cleared. This case highlights the potential severity of B. pseudomallei infections, underscoring the critical role of appropriate antibiotics, supportive care, and long-term follow-up in ensuring comprehensive management and preventing further transmission.

Competing Interests: None.

Aspergillus -induced mycotic aneurysm is difficult to treat and often has poor outcomes with severe symptom progression. Early diagnosis is also difficult, and blood and cerebrospinal fluid tests often fail to reveal any findings. A 74-year-old man presented with recurrent nosebleeds in addition to symptoms of left optic neuritis. Contrast-enhanced computed tomography scan revealed a left internal carotid artery pseudoaneurysm protruding into the left Onodi cells, which was identified as the origin of bleeding. Endovascular left internal carotid artery occlusion was performed. One month postoperatively, external ophthalmoplegia and disorientation occurred. Although antibiotic treatment was continued for 1 month, consciousness loss and haematemesis occurred, and a new contralateral right internal carotid artery pseudoaneurysm ruptured, which resulted in death. At autopsy, Aspergillus infection centred on the skull base was pathologically found, although the sinus mucosal surface was normal. This case suggested a mycotic infection secondary to optic neuritis resulted in a left infectious pseudoaneurysm that spreads to the skull base and formed an aneurysm on the contralateral side 4 months thereafter. Therefore, the possibility that features of the Onodi cells contributed to the spread of inflammation inside and outside the skull and were involved in the formation of aneurysms inside and outside the dura mater was considered for the first time.

Metastatic infections can complicate catheter-related blood stream infections (CRBSI) in dialysis dependent patients. However, an infected/septic aneurysm involving the aorta or its branches as a direct complication of CRBSI without an underlying infective endocarditis is not reported so far in the literature. We report a 43-year female, who presented with CRBSI 2 weeks following a tunneled dialysis catheter (TDC) insertion. Due to the lack of defervescence after 72 h of antibiotics given as per the culture sensitivity reports, the TDC was removed. Blood cultures grew Pseudomonas aeruginosa . After a catheter free interval of 4 days, a TDC was reinserted, an antibiotic course was completed, and she was discharged in stable condition. Five days later, she presented with acute abdominal pain and fever. A tender, firm, and pulsatile mass was noted in the hypogastrium with a bruit. Contrast-enhanced CT revealed a pseudoaneurysm of the aorta, and left common iliac artery at the site of origin. She was started on IV antibiotics and planned for an endovascular prosthesis but had a sudden collapse during her hospital stay due to a ruptured aneurysm. CRBSI due to certain pathogens such as Pseudomonas might require prolonged and dual antibiotic therapy to prevent fulminant complications., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We aimed to analyze the feasibility of endovascular treatment for brucellosis-related aorta-iliac artery pseudoaneurysm. We did a statistical analysis that among the 11 cases, the thoracic aorta was involved in 3 cases, the abdominal aorta was involved in 6 cases, and the iliac artery was involved in 2 cases. Five patients had a history of contact with cattle and sheep, 3 had a history of drinking raw milk, 10 patients had a fever before the operation, and 11 patients had positive serum agglutination test. Blood culture was positive in 2 patients. All patients were given anti-brucellosis treatment immediately after diagnosis. One died of aortic rupture 5 days after emergency endovascular gastrointestinal bleeding. Endovascular-covered stent implantation and active anti-brucellosis therapy were used to treat 10 patients. The follow-up period was 8 years without aortic complications or death for all patients. We think early diagnosis and a combination of anti-brucellosis drugs and endovascular therapy may be the first choice for treating the pseudoaneurysm caused by Brucella., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: An infected popliteal pseudoaneurysm has never been described in the pediatric population. Physicians need to be aware of its presentation and management, in order to diagnose and treat this medical condition adequately., Methods: We describe the case of a 14-year-old boy who developed myositis and cellulitis centered at the popliteal fossa after playing basketball. A treatment of intravenous cefazolin was started. 5 days later, he experienced a knee pain flare-up, which turned out to be a popliteal pyomyositis with a pseudoaneurysm of the popliteal artery. A saphenous vein graft bypass of the popliteal artery and an excision of the popliteal pseudoaneurysm were performed. Intravenous cefazolin was continued for 6 weeks and prophylactic acetylsalicylic acid for 6 months., Results and Conclusion: This case highlighted the importance of repeating radiologic investigations if a patient suffering from soft tissue infection has persistent pain after several days of appropriate antibiotics. A popliteal pseudoaneurysm can be diagnosed with ultrasound imaging and treated with a popliteal-popliteal bypass. Our patient needed a catheter-guided dilation of the anastomosis at the vein graft 6 months post-surgery, and then evolved favorably and went back to playing basketball 6 months post-dilation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Aspergillus spp. is an uncommon and life-threatening cause of transplantrenal artery pseudoaneurysm after kidney transplantation., Case: We report the case of a 62-year-old woman who underwent kidney transplantation 10 months before and presented a 7-cm asymptomatic transplant renal artery pseudoaneurysm. Transplanted kidney and pseudoaneurysm were surgically removed in emergency. Renal graft, urine, and pseudoaneurysm cultures grew Aspergillus flavus. She recovered after 12 months of antifungal therapy., Literature Review: To date 14 cases of Aspergillus spp. renal arteritis after kidney transplantation have been published, including 50% Aspergillus flavus arteritis. Vast majority were diagnosed within 90 days after transplantation (73%). Despite allograft nephrectomy and antifungal therapy, mortality rate was high (33%)., (© 2023 Wiley Periodicals LLC.)

Background: Arterial bypass tunneling via the obturator foramen (OFB) can be performed to circumvent groin infections during lower extremity revascularization. The objective of this study is to report safety and efficacy outcomes of OFB in the setting of infected femoral pseudoaneurysms and infected prosthetic femoral bypass grafts., Methods: A multihospital, single-entity healthcare system retrospective review was conducted for all patients who underwent OFB between January 2014 through June 2020. Any patient >18 years of age who underwent OFB in the setting of groin infection with a minimum of 30 days follow-up was included in the trial. Demographic, operative, and clinical characteristics of patients were gathered during chart review. Statistical analysis was performed using Microsoft Excel and R studio., Results: Seventeen patients underwent OFB during the defined time-period. Demographic data are presented in the first table (Demographic Characteristics). Mean American Society of Anesthesiologists score was 3.25. Mean estimated blood loss was 500 mL. Mean operative time was 307 min. Mean follow-up time was 8.5 months (range 0-35 months). In total, 41.2% patients underwent fluoroscopic-guided tunneling, and, when compared to blind tunneling, showed no difference in intraoperative complications or operative time (P value 0.3). In total, 52.9% of patients required ICU admission resulting in a mean number of 0.8 ICU days. The overall mean length of stay was 16.8 days. Two major amputations were reported during follow-up. Patient mortality within 30 days was 0%. Primary patency within 30 days was 100%. Intravenous drug use was not associated with an increased number of subsequent groin wound procedures (P value 0.3). Intravenous drug use was not associated with concomitant methicillin-resistant Staphylococcus aureus infection (P value 0.3)., Conclusion: OFB is a safe and effective surgical option in patients who are unable to undergo anatomic tunneling during lower extremity bypass. OFB is associated with favorable rates of primary patency and amputation-free survival at midterm follow-up., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Primary aortoduodenal fistula is a rare, life-threatening pathology that is difficult to diagnose and manage. We present the case of a 64-year-old male with a primary aortoduodenal fistula. Our patient initially underwent an endovascular aneurysm repair at an outside institution before being transferred to our tertiary care center, where he ultimately had definitive management with an extra-anatomic bypass, aortic ligation, duodenal resection with primary anastomosis, and gastrojejunostomy tube placement. His surgical cultures grew Candida albicans, and he was discharged with a 6-week course of intravenous antibiotics with subsequent antibiotic suppression for 1 year. He died 14 months postoperatively from tongue squamous cell carcinoma. We also review the current literature regarding epidemiology, pathology, diagnostics, management, and case reports from 2015 to present. Overall, timely diagnosis and treatment is imperative for reducing mortality from primary aortoduodenal fistula, and although formal consensus is lacking regarding most clinical aspects, an increasing number of case reports has helped describe options for management., Competing Interests: Declaration of Competing Interest There are no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: A substantial proportion of infective endocarditis (IE) cases are complicated by local invasion. The purpose of this study was to identify patient and disease characteristics associated with local invasion in surgically treated IE patients., Methods: This was a nested case-control study. All episodes of IE for patients admitted to Cleveland Clinic from 1 January 2013 to 30 June 2016 were identified from the Cleveland Clinic IE Registry. Patients ≥18 years of age who underwent surgery for IE were included. Among these, cases were those with local invasion, controls were those without. Local invasion, defined as periannular extension, paravalvular abscess, intracardiac fistula or pseudoaneurysm, was ascertained from the surgical operative note. Associations of selected factors with local invasion were examined in a multivariable logistic regression model., Results: Among 511 patients who met inclusion criteria, 215 had local invasion. Mean age was 56 years; 369 were male. Overall 345 (68%) had aortic valve, 228 (45%) mitral valve, and 66 (13%) tricuspid or pulmonic valve involvement. Aortic valve involvement (OR 6.23, 95% CI 3.55-11.44), bioprosthetic valve (OR 3.88, 95% CI 2.36-6.44), significant paravalvular leak (OR 3.80, 95% CI 1.60-9.89), new atrioventricular nodal block (OR 3.77, 95% CI 1.87-7.90), infection with streptococci other than viridans group streptococci (OR 7.54, 95% CI 2.42-24.87) and presence of central nervous system emboli (OR 1.85, 95% CI 1.13-3.04) were associated with local invasion., Discussion: Intracardiac and microorganism factors, but not comorbid conditions, are associated with local invasion in IE., (Copyright © 2020 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Objective: Vascular surgical groin wound infection (VS-GWI) has multiple causes and frequently is manifested as a limb- or life-threatening problem, resulting in significant morbidity and mortality. For patients undergoing operative extirpation, in situ repair, extra-anatomic bypass, or ligation can be used; however, limited data exist describing comparative results of the different operative choices or conduit subtypes. Therefore, we sought to describe our experience with management of VS-GWI and to detail outcomes of the different strategies., Methods: Patients (2003-2017) undergoing surgical treatment of VS-GWI (Szilagyi grade III) secondary to primary infectious arteritis or infected pseudoaneurysm after percutaneous intervention as well as previous prosthetic graft placement were reviewed. The primary end point was major adverse limb events (MALEs; major amputation, graft occlusion, or unplanned reintervention). Secondary end points included 30-day mortality, wound healing, amputation-free survival (AFS), and all-cause mortality. Cox proportional hazards modeling was used to determine relative risk of end points; Kaplan-Meier methodology was employed to estimate freedom from outcomes., Results: There were 149 patients (age, 65 ± 11 years; body mass index, 27 ± 6 kg/m 2 ; 70% male; 32% diabetes) identified, of whom 120 (81%) had unilateral and 29 (19%) had bilateral VS-GWI. Indications included infected prosthetic bypass (88% [n = 131]; infrainguinal, 107; suprainguinal, 24) and primary infectious femoral artery complications (12% [n = 18]). A majority underwent single-stage operations (87% [n = 129]). In situ reconstruction occurred in 87% (n = 129); 9% (n = 13) underwent ligation, and 6% (n = 7) received extra-anatomic revascularization. Autogenous conduit was used most commonly (68% [n = 101/149]; 88% single stage), of which 81% (n = 80) were femoral vein. The remaining patients received cadaveric (15% [n = 23]; 87% single stage) or prosthetic (8% [n=12]; 67% single stage) grafts. Adjunctive myocutaneous flap was used in 37% (n = 54). Length of stay was 19 ± 15 days and 30-day mortality was 7% (n = 10), with no difference between conduit repair types. All femoral wounds healed (mean follow-up, 17 ± 11 months); however, 33% (n = 49) underwent reoperation (unplanned graft reintervention, 33%; graft occlusion, 16%; wound débridement, 15%; major amputation, 11%). Reinfection occurred in 17% (n = 27), with no difference between groups. MALE rate was 22% (n = 33; most were arterial reinterventions, 19%), with no difference in single-stage vs multistage, in situ vs extra-anatomic, or autogenous vs nonautogenous conduit strategies Predictors of MALE included younger age (hazard ratio [HR], 1.6 per decade; 95% confidence interval [CI], 1.1-2.5; P = .02) and lower body mass index (<25 kg/m 2 ; HR, 1.6 per BMI category; 95% CI, 1.1-2.5; P = .02). Overall, 1- and 3-year freedom from MALE, AFS, and survival were as follows: MALE, 74% ± 5% and 63% ± 6%; AFS, 68% ± 4% and 58% ± 5%; survival, 78% ± 3% and 70% ± 4%. Autogenous conduit use was associated with better survival (HR, 0.5; 95% CI, 0.3-0.8; 1-year: 83% ± 4% vs nonautogenous, 78% ± 4%; 3-year: 68% ± 8% vs 53% ± 9%; log-rank, P = .006)., Conclusions: An individualized approach to operative strategy and conduit choice leads to comparable outcomes in this challenging group of patients. VS-GWI can be safely managed with in situ, autogenous reconstruction in a majority of patients with acceptable mortality, excellent wound healing rates, and improved overall survival. However, a significant proportion of patients experience reinfection and MALEs, the preponderance of which are arterial reintervention, mandating need for close follow-up and graft surveillance., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study is to assess the incidence, clinical manifestations, management, and prognosis of graft infection after bypass surgery with prosthetic conduit for infectious femoral artery pseudoaneurysms (IFAPs) in patients with a history of intravenous drug use (IVDU)., Methods: A single-center retrospective chart review of IVDU presenting with graft infections after previously being treated with extra-anatomic prosthetic conduit bypass surgery for IFAPs between 2009 and 2019 was performed. Relevant clinical data and patient demographics were collected and analyzed. All patients underwent procedures consisting of graft removal with analysis of operative details and complications., Results: Of all 122 patients who underwent IFAP resection with extra-anatomic prosthetic bypass, the incidence of graft infection was 38.5% (47 patients, 48 grafts) with an average age of 35.7 ± 7.3 years. The average interval between bypass surgery and infectious symptoms was 9.2 ± 2.5 months and average time from bypass to graft removal was 13.6 ± 3.4 months. The most common presentation was repeated or unhealable chronic ulcers with sinus formation or purulence either within the bypass area or along the graft conduit route (43, 89.6%). Occlusion of the infected bypass graft occurred in nearly all cases (46, 95.8%). Severe hemorrhage occurred in only 1 case (2.1%). After graft removal, the stumps were ligated in the majority of patients (33, 68.8%) with 15 patients (31.2%) not amenable to ligation due to a difficult dissection. The average time of operation was 35.4 ± 8.7 min with an average blood loss of 35.8 ± 6.7 mL. There were no significant complications such as infection reoccurrence, severe limb ischemia, amputation, or death observed postoperatively., Conclusions: Patients who receive bypass surgery with prosthetic conduit for IFAPs carry a high incidence of graft infection and subsequent occlusion. However, the presenting symptoms are generally mild, and the incidence of fatal complications is rare. This study suggests that a safe treatment option consists of direct graft removal without reconstruction. Additionally, the procedure proved to be relatively convenient and straightforward, which provides further support toward the strategy of treating IFAPs in IVDUs with pseudoaneurysm resection and prosthetic conduit bypass surgery., (Copyright © 2020. Published by Elsevier Inc.)

Competing Interests: Competing interests: None declared.

Pseudoaneurysm of the aorta is a rare and high-risk complication of native aortic valve endocarditis and can develop following cardiac surgery for aortic valve and root disease. If left untreated, there is a significant risk of aortic wall rupture and fatality. Given the high risk of mortality associated with traditional open surgical repair of aortic pseudoaneurysms, endovascular approach is a potentially favourable alternative. We describe a unique case of a young woman with a large and complex paraprosthetic pseudoaneurysm with multiple communicating fistulae which was successfully percutaneously treated with two occluder devices. In this technically challenging case, a minor but unique procedural complication is also illustrated., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients., Methods: A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality., Results: During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%., Conclusions: The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: We aimed to study variables affecting limb outcome following ligation of infected femoral pseudoaneurysms in intravenous drug abusers (IVDA)in the emergency setting and to propose an algorithm for management., Design: Prospective study., Methods: We studied short-term outcomes of 26 IVDA presenting with infected femoral pseudoaneurysms who underwent arterial ligation, hematoma evacuation, and debridement. Long-term results pertaining to limb functionality were unfeasible, as all patients were lost to follow-up. We aimed to study the potential predictors that might impact limb outcome in the emergency setting, namely: 1) mode of presentation (impending versus ruptured), 2) site of arterial ligation (above versus below inguinal ligament), 3) presence or absence of pedal Doppler flow post-ligation, and 4) ankle brachial pressure index (ABI) pre- and post-ligation., Results: Arterial ligation without revascularization was done in 19 (73.1%) of our patients, requiring no further intervention for limb salvage during their hospital stay. Four patients (15.4%) required iliopopliteal bypass, and 3 patients (11.5%) required major amputations (2 hip disarticulations and one above-knee amputation). In total, 23 limbs (88.5%) were salvaged. Proximal arterial ligation was done below the inguinal ligament (common femoral artery) in 21 patients (80.8%), while in the remaining 5 patients (19.2%), higher ligation was done above the inguinal ligament (external iliac artery). All 19 patients who were compensated had pedal Doppler flow post-ligation, and 18 of them had arterial ligation done below the inguinal ligament. The mean preoperative ABI (±SD) was 0.87 ± 0.34, and the mean postoperative ABI (±SD) was 0.37 ± 0.27. The mean change in ABI (±SD) was 0.50 ± 0.32., Conclusions: Arterial ligation with local debridement alone is a safe procedure and would have salvaged 73.1% of limbs in this study. However, implementing a selective approach for post-ligation revascularization and our proposed algorithm increased limb salvage rate to 88.5%. The detection of pedal Doppler flow after ligation can stratify patients in whom urgent revascularization might not be required for limb salvage. Additionally, all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Vascular graft infection with anastomotic dehiscence requires immediate surgical intervention to preserve life and limb. We present our experience of using the Omniflow® II biosynthetic vascular prosthesis (LeMaitre Vascular) in the emergency repair of vascular graft dehiscence at the femoral anastomosis., Methods: A retrospective review of consecutive patients presenting with femoral anastomotic dehiscence in a single centre was conducted. All patients were revascularized using an in situ Omniflow II graft. Patient demographics, affected graft type, microbiology, and antibiotic regimes were documented. Primary outcome measures were limb salvage, patency rates, and mortality., Results: Five patients presented with acute femoral false aneurysm and four of five with significant hemorrhage. Infected grafts included one aortobifemoral, two femoral crossover, one axillobifemoral, and one infrainguinal reversed vein graft. All were revascularized with an in situ Omniflow II graft following the excision of the infected graft material. The median followup was 50 months. Limb salvage was achieved in 8 of 9 threatened limbs, and none required further intervention for re-infection. One graft occluded at 5 months. Two of five patients died during followup (one at 12 months, one at 50 months)., Conclusions: Omniflow II provides a useful "off-the-shelf" conduit for the urgent revascularization of infected femoral dehiscence., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In the workup of a pediatric patient with pericarditis we found evidence of a pseudo-aneurysm of the left ventricle, which is a rare complication of purulent pericarditis., Case Presentation: We present a case of a six-year-old girl who was diagnosed with pericarditis and a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart. She was successfully treated with antibiotics and cardio-thoracic surgery. We found 23 published cases (21 with follow-up) of infectious pseudo-aneurysm of the heart, of which 19 underwent surgery, 5 had fatal outcome, and 2 who refused surgery survived. The majority of cases were associated with Staphylococcus aureus. The exact mechanisms of this rare complication remain unknown., Conclusions: A pseudo-aneurysm of the left ventricle is a rare and not well understood complication of a purulent pericarditis most commonly caused by Staphylococcus aureus infection. Because of risk of rupture, surgical intervention is advised.

Competing Interests: Competing interests: None declared.

We report a case of Pseudomonas monteilii and Acinetobacter nosocomialis endocarditis with a fatal outcome in a patient with a recent history of prosthetic aortic valve replacement. Transesophageal echocardiography and computed tomography confirmed the presence of vegetation on the prosthetic valve and aortic pseudoaneurism with an aortic root abscess. Valve cultures yielded P.monteilii and A.nosocomialis. The patient underwent surgery and received antibiotics, but his condition deteriorated and he died 44days after surgery. To our knowledge, this is the first case of P.monteilii and A.nosocomialis endocarditis reported in the literature. These organisms have been described as environmental contaminants; however, they must be considered potential pathogens, particularly in patients with prosthetic valves., (Copyright © 2019 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: The aim of this study was to evaluate outcomes after in situ reconstruction using biological grafts in infected groin pseudoaneurysms in drug abusers., Methods: This was a single centre retrospective analysis of all patients undergoing in situ reconstruction with biological vascular grafts for infected groin pseudoaneurysms in drug abusers from 2000 to 2017. Outcome measures included wound healing problems, re-infection, graft patency, lower limb amputation, and mortality., Results: Twenty-two patients (14 male) with a median age of 39 years (range 27-49) were identified. Fifteen patients (68%) underwent urgent in situ reconstruction with a xenograft, five patients (23%) with a homograft, and two patients (9%) with an autologous vein. There were no in hospital deaths, in hospital re-infections, or early major limb amputations. Four (18%) patients developed wound healing complications requiring re-operation. During a median follow up of 56 months (range 13-180 months), six patients (27%) developed re-infection requiring complete graft replacement with a new biological graft. Thereafter, three (14%) had re-re-infection. Seven patients (32%) had graft occlusions: two were treated endovascularly, two underwent re-operation, and three were treated conservatively. Two patients (9%) had patent grafts but significant stenosis: one had successful angioplasty and another one was left untreated. One patient required above knee amputation, resulting in an overall major amputation rate of 4%. Estimated primary patency was 87% after one year and 40% after five years. Six patients (27%) died during follow up from non-vascular causes., Conclusions: In situ reconstruction using biological grafts of infected groin pseudoaneurysms in drug abusers can be achieved with no peri-operative graft related complications, although rates of wound complications may be high. In the longer term, a significant number of patients develop re-infection, graft occlusion, or stenosis, although the amputation rate remains low. The management of this demanding group of patients remains a major challenge., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Infected pseudoaneurysms are a vascular emergency, necessitating urgent surgical management. Owing to the infected field, a synthetic graft may be inappropriate in patients for whom autografting is impossible. Ligation of the artery is the usual management, often leading to amputation. We report a case of cadaveric allografting of the common femoral artery in a patient with a traumatic, infected pseudoaneurysm, who was taking immunosuppressive therapy for a liver transplant. The patient was followed up with ultrasound at 12 months and was found to have a significant graft stenosis, which was treated successfully with angioplasty. At 18 months, the patient remained well. This case describes the successful implantation of a cadaveric allograft into a patient with an infected pseudoaneurysm, negating the for need primary ligation.

Background: For patients with end-stage renal disease, a good vascular access is essential for chronic haemodialysis. Surgically created access arteriovenous fistula for haemodialysis is associated with multiple complications, and ruptured pseudoaneurysm being the most life threatening and dreaded of all. The management of this complication warrants emergency procedure, although timely diagnosis and arteriovenous fistula salvage has been emphasised. In this study, we describe the surgical technique and outcomes of ligation of the proximal arteriovenous fistula as a plausible alternative and life-saving procedure., Method and Results: This is a retrospective study performed between January 2011 and December 2016. A total of 588 native arteriovenous fistula-related surgeries were performed, of which 18 patients (3.06%) developed delayed complication of infected pseudoaneurysm and rupture. All presented to the emergency care with life-threatening bleeding. We describe the surgical technique as a life-saving measure to this fatal complication., Conclusion: Proximal arteriovenous fistula has higher incidence of aneurysmal complications than distal ones. Ligation of the brachial artery which was a 'grey zone' of unpredictable prognosis has yielded good results and can be safely performed in desperate situations with low complication rates.

Objectives: The aim of the study was to compare the usefulness of cardiac CT to transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnosis of infective endocarditis (IE) and perivalvular complications using surgical inspection as the gold standard., Material and Methods: Fifty-three consecutive patients (42 men, mean age 58.3 ± 12.5) with IE requiring surgical procedures were enrolled in the study. All patients underwent preoperative TTE, TEE, and CT. The presence of vegetations, perivalvular abscess/pseudoaneurysm, leaflet perforation, inflammatory infiltration, and prosthesis dehiscence was assessed., Results: We analyzed 71 affected valves (58 native, 13 prosthetic). Intraoperative assessment revealed 11 abscesses/pseudoaneurysms. Sensitivity and specificity of echocardiography (TTE + TEE) and CT were 63%, 90% and 81%, 90%, respectively. The combination of CT and echocardiography allowed diagnosing all abscesses/pseudoaneurysms. Inflammatory infiltration was found intraoperatively in 15 patients. Sensitivity and specificity of TEE and CT were 53%, 94% and 46%, 100%, respectively. Intraoperative assessment revealed leaflet perforation in 16 patients. Sensitivity and specificity of TEE and CT were 75%, 79% and 43%, 89%. The sensitivity of the combination of TTE + TEE + CT was 81%. Perivalvular leakage was found in eight patients with a prosthetic valve. Sensitivity and specificity of echocardiography and CT were 100%, 100% and 88%, 100%, respectively. TEE showed higher sensitivity (97%) than CT (89%) in the diagnosis of vegetations., Conclusions: The combination of TTE, TEE, and CT increased the sensitivity for the detection of valvular and perivalvular complications of IE., Key Points: • CT is a useful modality in the diagnosis of IE and its local complications in addition to echocardiography. • For the detection of abscesses and pseudoaneurysms, CT is superior to echocardiography. Combining these two modalities can increase the sensitivity of diagnosing abscess/pseudoaneurysm up to 100%. • Adding CT to TEE increases the sensitivity for detection of inflammatory infiltrate. CT is not superior to echocardiography in diagnosing vegetations, valvular leaflet perforations, and perivalvular leaks, but it can be a useful tool when echocardiography is indeterminate.

Background: Arterial ligation has been described in the literature as a safe and effective procedure with a relatively low number of patients requiring major amputations., Methods: We performed a retrospective analysis of a prospectively held database of all patients who underwent arterial ligation for infected femoral pseudoaneurysms due to chronic intravenous drug abuse from January 2012 to March 2018. Information recorded for each patient included age, gender, blood investigations, microbiologic results, diagnostic modality, operative details, outcome of surgery, postoperative complications, and follow-up., Results: There were 25 patients identified, with 2 of them undergoing bilateral ligations. It was more common in men (4:1), and the mean age at presentation was 39.7 years (standard deviation 8.2 y). Nine patients underwent major limb amputation for severe limb ischemia (7 transfemoral amputations and two 53 hip disarticulation). Average hospital stay was 24 days, and there was no mortality. We found a trend with a higher level of arterial ligation, leading to a higher rate of amputation., Conclusions: Our study is the first to show that there is a trend toward a higher risk of amputation with a higher level of ligation in this cohort of patients, and therefore, we suggest avoidance of external iliac artery ligation even at the most distal part just under the ligament, leaving the circumflex iliac vessel in circuit. Arterial ligation also carries a higher risk of major amputation than previously reported., (Copyright © 2019 Elsevier Inc. All rights reserved.)

An 11-year-old boy presented with Staphylococcus aureus infective endarteritis and mycotic pseudoaneurysms within the context of a previously undiagnosed aortic coarctation. He had an urgent resection of the pseudoaneurysm and coarctation repair. Nuances to his initial diagnosis and key learning points related to the complication of pseudoaneurysm are discussed., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Infectious pseudoaneurysm of the intracavernous carotid artery is rare, often caused by sphenoid sinusitis or transsphenoidal surgery. Management of intracranial infectious aneurysms (IIAs) remains a controversial topic lacking randomized controlled trials to guide clinical decision making., Case Description: For this case, we used an antibiotic to treat the patient in the initial stage. Because IIAs enlarge rapidly, endovascular treatment was performed in the emergency department., Conclusions: Unfortunately, the patient died because the IIA recurred and ruptured. Therefore we speculated that stent-assisted coil placement for the treatment of ruptured infectious pseudoaneurysms of the internal carotid artery may not be safe., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Mycotic pseudoaneurysms usually arise from an infectious arteritis or mycotic aneurysms secondary to weakening and destruction of the arterial wall resulting in a contained rupture. We report a case of a mycotic pseudoaneurysm affecting the aortic isthmus of the thoracic aorta which is an extremely rare infection. To our knowledge no case report of mycotic pseudoaneurysm of the aortic isthmus secondary to salmonella infection has thus far been described. The specific case we present is also unique in that it posed a diagnostic imaging dilemma where the initial imaging revealed a periaortic mass which could not be accurately characterized and only on subsequent imaging reveal itself to be a thrombosed mycotic pseudoaneurysm. We hope that our case report highlights to the medical community the high degree of suspicion one should have regarding pseudoaneurysms when dealing with a complex mass intimately related to a vascular structure., (Copyright Journal of Radiology Case Reports.)

Introduction: The increase in the incidence of tuberculosis in developing countries has resulted in increased reporting on more related complications. We report the successful management of an intraoperative spontaneous rupture of a tuberculous pseudo aneurysm associated with spinal tuberculosis., Methodology: We report the case of a 66 years old woman diagnosed with spinal tuberculosis of the T3/T4 vertebrae. During an anterior approach surgical reconstruction for the degenerative vertebrae, massive hemorrhage was observed after the removal of a portion of the prevertebral fascia of the affected vertebrae. This led to the exploration of the hilar fascia for the possibility of hilar hemorrhage, and when no hemorrhage was observed, aneurysm rupture was suspected. A portion of the hilar fascia was then sutured to the prevertebral fascia and the hemorrhage was partially controlled., Results: On the 32nd month post-operative follow-up, the symptoms of chest and back pain had disappeared and the tuberculous lesion eradicated., Conclusion: Presently, there are few reports on the successful treatment of intraoperative spontaneous rupture of tuberculous pseudoaneurysms. We therefore report on the successful management of such a case., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2019 Haijun Tang, Yun Liu, Abu Moro, Zengming Xiao, Xinli Zhan.)

Nontuberculous mycobacteria cause severe pulmonary, vascular graft, and bloodstream infections after cardiac surgery. Patient prognosis remains poor because of delays in diagnosis and treatment. Complicated aortic root infections caused by nontuberculous mycobacteria have been mostly fatal. We describe a case of a 50-year-old man who developed an invasive Mycobacterium chimaera infection with an aortic root pseudoaneurysm after a Bentall-de Bono procedure for a Stanford type A aortic dissection., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)