their management remains one of the most challenging clinical problems facing vascular physicians

(1)

Contents

26.1 Introduction . . . . 267

26.2 Surgical Strategy . . . . 267

26.3 Endovascular Strategy . . . . 269

26.4 Conclusion . . . . 271

26.1 Introduction

First described in 1885 by Osler [1], mycotic aneurysms are usually painful, rapidly growing, often ruptured at the time of the procedure and usually with a history of fever, leukocytosis and positive blood cultures. The termmycotic aneurysmis inappropriate as they are related to a secondary abscess secondary to a remote bacterial infection. Although rare, they are frequently associated with a life-threatening condition with significant morbidity and mortality; their management remains one of the most challenging clinical problems facing vascular physicians.

The traditional approach in this setting is surgery with intensive antibiotic administration, extensive excision and debridement of the infected field associated with extra-anatomic or in situ prosthetic bypass grafting.

However, results fromthe literature suggest that optimal results are not achieved with this traditional open-chest treatment, especially in terms of mortality and morbidity.

And as for other high-risk patients, endoluminal treatment appeared to be an attractive alternative with an increasing number of cases reported in the literature; however, its use is still a matter of debate mainly because the lack of debridement which is associated with endovascular repair goes against surgical teaching [2].

In this chapter, we report the published results of the surgical and endoluminal management of thoracic mycotic aneurysms in order to determine the exact place of the endovascular treatment.

26.2 Surgical Strategy

To begin with, two specific points need to be high- lighted:

1. As mycotic aneurysms are unusual, the number of articles specifically related to thoracic localization is low. Moreover, most series contain a small number of patients with limited follow-up.

2. Moreover, in these articles mycotic aneurysm and infected aortic grafts are often mixed.

So as infectious problems facing surgeons are similar, we will also take into account in this discussion series including abdominal mycotic aneurysms or infected aortic grafts.

Fromthe 1960 to the 1980s, with the usual extensive excision and debridement of the infected field, the recommended treatment included ligation of the aorta associated with extra-anatomical bypass graft (from the ascending aorta) [3, 4]. Theoretically, the main advan- tage of extra-anatomical revascularization in a noncon- tamined field is the reduction of the risk of secondary graft infection. The first step of the surgical procedure includes median sternotomy and midline laparotomy, which allow distal revascularization, and is followed in a second step by left thoracotomy for aortic ligation. In some specific cases, axillo-femoral grafting can alternatively be performed, even if retrograde blood supply of the entire abdominal cavity seems in this case generally not reliable.

However, as for the aortic arch, in descending or thoraco-abdominal (paravisceral) aortic localizations, extra-anatomical bypass is in a large majority of cases impossible owing to the proximity of major aortic branches [5] and in situ grafting is unavoidable. At the beginning of the 1990s, with increasing experience and the improvement of thoraco-abdominal surgery results, the first series with in situ revascularization and good results were published [5±8]. Moreover, this technique is potentially associated with a less aggressive surgery

Is There a Place

for Endovascular Treatment

in Thoracic or Thoraco-abdominal Mycotic Aneurysms?

Louis Labrousse, Oliver Pellerin, Doron Carmi, Marc Sapoval

26

(2)

(one step) and better long-termpatency (and obviously avoid aortic stump blowout [6]).

Initially, the prosthetic repair was performed with a Dacron prosthesis [5±8]. But, in order to decrease the risk of recurrence of the infection, and because of good results obtained in cardiac surgery with a homograft valve in the setting of endocarditis, a similar therapeu- tic concept has been introduced by using arterial allografts [9±11]. They have provided superior resistance to infection which could be related to their viability which is associated with a higher antibiotic concentration level and immunocompetent cell density into the wall and the perigraft space [12]. Basically, the aortic homograft is harvested on a brain-dead patient and stored in a tis- sue bank; and during the implantation, the graft is in- serted as a Dacron prosthesis. Although experiences with ªfreshº or ªrefrigeratedº allografts have been associated with early rupture and late aneurismal degeneration [13, 14], the use of cryopreserved homografts and technical modifications have allowed these complications to be dealt with successfully [12±16] and so it appears to be the management of choice. Alternatively, if a homograft is not available, include the use of a graft soaked with rifampicin [17, 19, 20], local application of antibiotic-impregnated fibrin glue or gauze [12, 18, 19]

and in all cases, the reconstruction should be covered with an omental flap if it is technically possible [5]. It is noteworthy that in an in vitro experimental model poly(tetrafluoroethylene)-expanded grafts appeared to be more resistant to infections than Dacron grafts [21];

up to now, clinical data are insufficient to draw conclu- sions.

Lastly, if the lesion is well circumscribed, a simple excision and repair with a patch can be performed (Da- cron, pericardial, arterial allograft or the more recently described venous patch fromthe superficial femoral vein [22]).

The operative survival rates of the main recent series reported in the literature are summarized in Table 26.1.

Overall perioperative mortality was between 5 and 75%.

Note that the series fromCin et al. includes a literature review of mycotic thoraco-abdominal aortic aneurysm from1966 to 1999.

Regarding operative morbidity, and compared with atherosclerotic disease of the thoraco-abdominal aorta, surgeons are facing the same problems, which especially include postoperative respiratory and renal failure and neurological deficit. Moreover, in this specific clinical setting, the morbidity is increased by septic complications and probably reflects the combination of an aggressive surgery with a difficult localization (especially for thoracic and paravisceral localization) in patients with comorbidities such as diabetes, immunocompro- mised state, renal failure, age of more than 70 and pul- monary disease [5, 15±20, 23]. Concerning the high rate of aneurysmal rupture in these patients, the recent review by Cin et al. [20] found similar early results compared with the results fromelective surgery; probably because most of the ruptures were contained and the patients had a stable hemodynamic state.

The midterm and long-term follow-up of these patient depends on the recurrence of the infectious disease. In modern series, recurrence has been reported in 5±15% of patients [5, 8], and is especially related to periaortic extension infection and to aggressive germs like Staphylococcus aureus [5, 8, 17, 23]. There is no consensus on the duration of antibiotic therapy. Usually the recommended length is at least 6 weeks [15, 16], but for some patients a longer length can be recommended [12], or even lifelong prophylactic antibiotherapy [5, 18, 19], especially if Salmonella is involved or if the infection is active at the time of the surgery. Indeed, in some patients the infectious etiology of the aneurysmis determined incidentally fromthe history of the disease with all cultures (blood or aortic wall) negative [17, 24]. And in this situation the risk of recurrence seems obviously lower compared with that for patients with frank purulent effusion or adjacent infected focus (osteomyelitis). Lastly, the classically poor survival rate in patients with aortic infection due to Salmonella was

Table 26.1. Operative results in recent surgical series with thoracic mycotic aneurysms and/or aortic graft infections Number of patients Operative mortality Graft use

Chan et al. [4] 22 14% (3/22) Dacron

Cin et al. [20] 73 (thoraco-abdominal review) Extraanat graft: 66% (2/6) In situ graft: 75%

Emergent repair: 74%

Elective repair: 75%

Dacron + poly(tetrafluoroethylene)

Muller et al. [17] 33 36% Dacron

Oderich et al. [19] 43 21% Dacron

Hsu et al. [18] 19 (9 supra renal) 5% Dacron

Vogt et al. [10] 49 (mycotic and infected graft) 6% Arterial allograft Kieffer et al. [16] 179 (infrarenal aortic infected graft) 20% Arterial allograft

Teebken et al. [15] 42 (39 infected graft) 14% Arterial allograft

(3)

not confirmed by the last series from Hsu et al. [18], with no death among 14 consecutive patients.

Long-termbiological monitoring usually involves measurement of the white cell count, erythrocyte sedi- mentation rate and C-reactive protein level as these are regarded as sensitive indicators for the presence of infection. Our own method as well as that of others [20]

is to stop the antibiotherapy after at least three consecutive months with strictly normal biological monitoring.

To conclude, clinical, biological and imaging follow- up lifelong seems reasonable and should include at least quarterly biological examinations, and an imaging ex- amination yearly. MRI or a computed tomography (CT) scan is usually advocated [16, 19], but one can also use a labeled white blood cell scan with gallium-67 isotope, which seems to distinguish reliably between seroma/he- matoma and adjacent infection, and so excludes recurrence of the infection [25].

26.3 Endovascular Strategy

The development of the endovascular treatment of thoracic aneurysm, which has shown, since the middle of the 1990s, good results even in challenging situations [26], explains that the endoluminal technique appears to be very attractive in this clinical setting. Moreover, results of open-chest surgical series (Table 26.1) are not yet satisfactory in term of morbidity and mortality.

Lastly, these series are fromteams known to be ªlead- ersº in the thoracic surgery field. In other places, these patients are basically either contraindicated for surgery, or results are not good enough to be published.

The main problem facing the endovascular approach is that extensive excision and debridement of the infected field, which are part of the surgical strategy, are impossible to perform. So, the potential benefit due to this minimally invasive approach has to be compared with the obvious higher risk of recurrence of the infection. However, there are an increasing number of cases

Table 26.2.Results of endovascular stent-graft placement for thoracic mycotic aneurysms Number

of patients Organism Follow-up

Semba et al. [27] 3 Proteus mirabilis

Clostridium septicum Unknown

25 months died (NR*) 24 months alive

4 months alive

Madhavan et al. [28] 1 Staphylococcus 12 months alive

Kinney et al. [29] 1 Escherichia coli 10 months died (NR*)

Kråmer et al. [30] 4 Escherichia coli

Staphylococcus epidermitis Staphylococcus aureus Staphylococcus aureus

34 months alive 3 months alive 12 months alive 7 months alive

Lepore et al. [31] 3 Staphylococcus aureus Alive. Follow-up <3years

Ishida et al. [32] 1 Staphylococcus aureus 2 days died (R**)

Stanley et al. [33] 4 Streptococcus

Staphylococcus aureus Enterococcus

Streptococcus pneumoniae

12 months alive 15 months alive 10 months alive

1 month died (R**)

Bell et al. [34] 1 Staphylococcus aureus 15 months alive

Lamme et al. [35] 2 Clostridium/Salmonella 27 months alive

Stoica et al. [36] 1 Salmonella 24 months alive

Krohg-Sorensen et al. [37] 3 Staphylococcus aureus Streptococcus empyema Streptococcus

15 months alive 18 months alive 11 days died (NR)

Ting et al. [38] 1 Salmonella 12 months alive

Nishimoto et al. [39] 1 Salmonella 12 months alive

Kotzampassakis et al. [40] 1 Salmonella 6 months alive

Jones et al. [2] 9 Salmonella (n=2)

Strptococcus pneumoniae Unknown (n=6)

2 deaths (R) at 5 and 62 months

Total 36 4 deaths (R)

2 deaths (NR)

Follow-up: 11 months (1±62) NR death not related to the aneurysmor to the endoprosthesis, R death related to failed endovascular treatment

(4)

and small series reported in the literature [2, 27±39]

with encouraging results (Table 26.2). All of the patients involved were usually contraindicated for classic open- chest surgery; with a very short life expectancy.

The first issue to be raised here is that of imaging.

Because secondary infection of the arterial wall can arise anywhere it is recommended to perform a thoraco-abdomino-pelvic angio CT scan. This technique is now possible with recent multidetector row CT in a single contrast bolus and in single breath hold. Triphasic CT should be used because late enhancement of the arterial wall will help to diagnose inflammatory or in-

fected aortic wall, as well as end-organ damage in the case of infective embolism. Jones et al. [2] reported on one early death related to a misdiagnosed remote false aneurysm. Magnetic resonance angiography can be used, but caution should be applied when interpreting images because calcifications are not visualized and spatial resolution is less optimal; thus, the relation to side branches can be misinterpreted.

Care should also be taken to carefully assess the ac- cess site at preoperative or perioperative angiography because these patients can have narrow and calcified native arteries, and complications during endograft de- livery can be of concern.

The bacteria involved are similar to those found in surgical series. Even tuberculosis aneurysms have been reported to be successfully treated by an endovascular approach [41]. Figures 26.1 and 26.2 show a similar ex- ample of a tuberculosis thoracic mycotic aneurysm treated with a Talent (Medtronic, Minneapolis, USA) endoprosthesis.

The mortality rate of the patients in the reported cases is inferior to surgical rates. Note that the two ªun- related to the endovascular treatmentº deaths were due to cardiac disease. And even if there is bias in the fact that usually only successful procedures are reported, the same bias exists in surgical results. In terms of morbidity, and as for the other endovascular indications, stent- grafts avoid full heparinization, aortic cross clamping, distal ischemia and the use of a shunt. All these aspects lead to a theoretically less aggressive surgery with ear- lier extubation, better perioperative hemodynamic state with less organ(s) failure and neurological complications [31]. However renal failure [28, 33], ischemic coli- tis [28, 33] and paraplegia [28] have been reported. The deployment of the device is without any specific aspect, although a perioperative rupture [2], a migration [33]

and a malpositioning with a type I endoleak [2] have been described.

Fig. 26.1.Preoperative angiogramof a tuberculosis mycotic an- eurysmof the descending aorta (68-year-old patient hospita- lized for hemoptysis)

Fig. 26.2.Postoperative computed tomography scan with perfect exclusion of the tuberculosis aneurysm

(5)

Owing to the usually limited or sacciform aspect of mycotic aneurysms, the endovascular approach can be useful in paravisceral localization; and to deal with vis- ceral perfusion, fenestrated stents [28, 29, 33, 41] are advocated.

Lastly, as for surgery, different types of devices are recommended. Some authors use homemade devices with Z Gianturco stents covered by an autologous arterial wall [28], but the simplest and theoretically most efficient method seems to use a commercial device with a Rifampicin- or vancomycin-soaked graft [33] (the antibiotherapy is injected perioperatively into the deliv- ery system). Different devices have been used successfully, including the Talent and the Aneurx (Medtronic), the Cook thoracic and the TAG excluder (Gore). The fabric is either polyester or polytetrafluoroethylene (PTFE) and the metal is nitinol or surgical stainless steel. The possible higher resistance of PTFE to infection has been suggested but the available literature reported here is not sufficient to advocate one device over the other [42].

The stent-graft should be selected for availability, size and conformability to the lesion to be covered.

Covering at least 2 cmabove and below the arterial wall disruption should be advocated. In fact, enough secur- ity margins should be reserved because the likelihood of a more extended arterial lesion is always high in this setting.

The main limitation of this literature review is the limited follow-up with a mean delay around 1 year. At that time, it is obviously too early to say that patients are cured; even if in some cases imaging controls have shown reduction of the aneurysmsac size [34, 39]. The

issue of the duration of systemic antibiotherapy is un- clear. On one hand, it is recognized that even if mycotic aneurysms are an infectious disease, when debridement tissues are cultured 25% of themdo not show any bacterial growth [2]. Moreover, negative blood cultures are frequent at the time of treatment. In the literature the largest series comprising nine patients is of interest regarding this issue. Antibiotherapy was not used at all in two cases and relatively short treatment was adminis- tered for the rest (up to 6 weeks) with no evidence of reinfection. In most series treatment for 6-months was performed [33, 36, 38, 40, 41]. In our opinion prolonged antibiotherapy seems reasonable but could be tailored to the general condition of the patient and to the results of blood cultures.

It is also very important to follow these patients lifelong. We suggest a protocol combining an annual angio CT scan and a lateral and postero-anterior chest radio- graph to verify the position and integrity of the stent- graft. Strict long-termbiological monitoring is also needed as a function of the patient condition.

26.4 Conclusion

Owing mainly to the rarity of the condition, this literature review is unable to conclude froma scientific point of view on the exact place of endovascular treatment for thoracic mycotic aneurysms.

However, endovascular treatment appears to be associated with morbidity and mortality rates similar to or below those of open surgery [43]. Associated with an

Fig. 26.3.Proposed medical strategy for treatment of thoracic mycotic aneurysms

(6)

aggressive and long-termantibiotherapy, it seems reasonable to conclude that in the case of good anatomical conditions, midterm control of the disease is possible.

So, a theoretical strategy can be proposed (Fig. 26.3) with three situations for the endovascular treatment:

destination therapy, final therapy or bridge for surgery.

If patients are not eligible for open-chest surgery (usually because of comorbidities), the endovascular approach is the only way to palliate rupture and death.

For other patients, the endovascular option might be proposed either as a bridge in the case of temporary surgical contraindication or as a first ªlow-riskº surgical step with following strict monitoring. In this last case, the efficiency and the availability of long-termoral antibiotherapy and anatomical criteria (especially the landing zone) might be two of the main criteria of se- lection.

As surgical and radiologist teams are waiting for more data to optimize the strategy for treatment of thoracic mycotic aneurysms, an international registry seems necessary to confirmthe long-termresults of the endovascular treatment [42]. Because this review has shown at least equivalence if not superiority of the endovascular approach, we propose treating all anatomi- cally suitable patients using stent-grafts and performing close and prolonged follow-up while in the meantime all consecutive patients could be entered in this registry.

It is thus likely that enough data could be obtained to support or contraindicate this strategy.

References

1. Osler W. The Gulstonian lectures on malignant endocarditis. Br Med J 1885; 1:467.

2. Jones KG, Bell RE, Sabharwal T, Aukett M, Reidy JF, Tay- lor PR. Treatment of mycotic aortic aneurysms with endoluminal grafts. Eur J Vasc Endovasc Surg 2005; 29:139±

3. Yeager RA, Moneta GL, Taylor MM Jr, at al. Improving144.

survival and limb salvage in patients with aortic graft infection. AmJ Surg 1990; 159:446±449.

4. Reilly LM, Stoney RJ, Goldstone J, et al. Improved management of aortic graft infection: the influence of opera- tion sequence and staging. J Vasc Surg 1987; 5:421±431.

5. Chan FY, Crawford ES, Coselli JS, et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989; 47:193±203.

6. Robinson JA, Johansen K. Aortic sepsis: is there a role for in situ graft reconstruction? J Vasc Surg 1991; 13:677±682.

7. Pasic M, Carrel T, von Segesser L, Turina M. In situ repair of mycotic aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1993; 105:321±326.

8. Hollier LH, Money SR, Creely B, Bower TC, Kazmier FJ.

Direct replacement of mycotic thoracoabdominal aneurysms. J Vasc Surg 1993; 18:477±484.

9. Kieffer E, Bahnini A, Koskas F, Ruotolo C, Le Blevec D, Plissonnier D. In situ allograft replacement of infected infrarenal aortic prosthetic grafts: results in forty-three patients. J Vasc Surg 1993; 17:349±355.

10. Vogt PR, von Segesser LK, Goffin Y, Pasic M, Turina MI.

Cryopreserved arterial homografts for in situ reconstruc-

tion of mycotic aneurysms and prosthetic graft infection.

Eur J Cardiothorac Surg 1995; 9:502±506.

11. Knosalla C, Weng Y, Yankah AC, Hofmeister J, Hetzer R.

Using aortic allograft material to treat mycotic aneurysms of the thoracic aorta. Ann Thorac Surg 1996; 61:1146±

1152.

12. Vogt PR, Brunner-LaRocca HP, Lachat M, Ruef C, Turina MI. Technical details with the use of cryopreserved arterial allografts for aortic infection: influence on early and midterm mortality. J Vasc Surg 2002; 35:80±86.

13. Kieffer E, Plissonnier D, Bahnini A, Koskas F. Abdominal aortic graft excision and in situ allograft replacement. In:

Calligaro KD, Veith FJ, editors. Management of infected arterial grafts. Quality Medical Publishing, St. Louis 1994.

p. 82±94.

14. Lehalle B, Gschier C, Fiv G, Stoltz JF. Early rupture and degeneration of cryopreserved arterial allografts. J Vasc Surg 1997; 25:751±752.

15. Teebken OE, Pichlmaier MA, Brand S, Haverich A. Cryo- preserved arterial allografts for in situ reconstruction of infected arterial vessels. Eur J Vasc Endovasc Surg 2004;

27:597±602.

16. Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F, Bah- nini A. Allograft replacement for infrarenal aortic graft infection: early and late results in 179 patients. J Vasc Surg 2004; 39:1009±1017.

17. Muller BT, Wegener OR, Grabitz K, Pillny M, Thomas L, Sandmann W. 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;

33:106±113.

18. Hsu RB, Tsay YG, Wang SS, Chu SH. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. J Vasc Surg 2002; 36:746±750.

19. Oderich GS, Panneton JM, Bower TC, Cherry KJ Jr, Row- land CM, Noel AA, Hallett JW Jr, Gloviczki P. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;

34:900±908.

20. Cin CS, Arena GO, Fiture AO, Clase CM, Doobay B. Rup- tured mycotic thoracoabdominal aortic aneurysms: a report of three cases and a systematic review. J Vasc Surg 2001; 33:861±867.

21. Rosenman JE, Kempczinski RF, Berlatzky Y, Pearce WH, Ramalanjaona GR, Bjornson HS. Bacterial adherence to endothelial-seeded polytetrafluoroethylene grafts. Surgery 1985; 98:816±823.

22. Tambyraja AL, Wyatt MG, Clarke MJ, Chalmers RT. Auto- logous deep vein reconstruction of infected thoracoabdominal aortic patch graft. J Vasc Surg 2003; 38:852±854.

23. Chiba Y, Muraoka R, Ihaya A, Kimura T, Morioka K, Nara M, et al. Surgical treatment of infected thoracic and abdominal aneurysms. Cardiovasc Surg 1996; 62:35±39.

24. Malouf JF, Chandrasekaran K, Orzulak TA. Mycotic aneurysms of the thoracic aorta: a diagnostic challenge. Am J Med 2003; 15:489±496.

25. Ben-HaimS, Seabold JE, Hawes DR, Rooholamini SA.

Leukocyte scintigraphy in the diagnosis of mycotic aneurysm. J Nucl Med 1992; 33:1486±1493.

26. Lee JT, White RA. Current status of thoracic aortic endograft repair. Surg Clin North Am2004; 84:1295±1318, vi±vii 27. Semba CP, Sakai T, Slonim SM, Razavi MK, Kee ST, Jor- gensen MJ, Hagberg RC, Lee GK, Mitchell RS, Miller DC, Dake MD. Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1998; 9(1 Pt 1):33±40.

28. Madhavan P, McDonnell CO, Dowd MO, Sultan SA, Doyle M, Colgan MP, McEniff N, Molloy M, Moore DJ, Shanik GD. Suprarenal mycotic aneurysm exclusion using a stent

(7)

with a partial autologous covering. J Endovasc Ther 2000;

7:404±409.

29. Kinney EV, Kaebnick HW, Mitchell RA, Jung MT. Repair of mycotic paravisceral aneurysm with a fenestrated stent-graft. J Endovasc Ther 2000; 7:192±197.

30. Kramer S, Pamler R, Seifarth H, Brambs HJ, Sunder-Plass- mann L, Gorich J. Endovascular grafting of traumatic aortic aneurysms in contaminated fields. J Endovasc Ther 2001; 8:262±267.

31. Lepore V, Lonn L, Delle M, Bugge M, Jeppsson A, Kjell- man U, Radberg G, Risberg B. Endograft therapy for diseases of the descending thoracic aorta: results in 43 high- risk patients. J Endovasc Ther 2002; 9:829±837.

32. Ishida M, Kato N, Hirano T, Shimono T, Yasuda F, Tanaka K, Yada I, Takeda K. Limitations of endovascular treatment with stent-grafts for active mycotic thoracic aortic aneurysm. Cardiovasc Intervent Radiol 2002; 25:216±218.

33. Stanley BM, Semmens JB, Lawrence-Brown MM, Denton M, Grosser D. Endoluminal repair of mycotic thoracic aneurysms. J Endovasc Ther 2003; 10:511±515.

34. Bell RE, Taylor PR, Aukett M, Evans GH, Reidy JF. Suc- cessful endoluminal repair of an infected thoracic pseu- doaneurysmcaused by methicillin-resistant Staphylococ- cus aureus. J Endovasc Ther 2003; 10:29±32.

35. Lamme B, de Jonge IC, Reekers JA, de Mol BA, Balm R.

Endovascular treatment of thoracic aortic pathology: fea- sibility and mid-term results. Eur J Vasc Endovasc Surg 2003; 25:532±539.

36. Stoica L, Chocron S, Falcoz PE, Etievent JP. Endovascular stent grafting for contained rupture of the descending thoracic aorta. Eur J Cardiothorac Surg 2003; 23:1068±

1070.

37. Krohg-Sorensen K, Hafsahl G, Fosse E, Geiran OR. Ac- ceptable short-termresults after endovascular repair of diseases of the thoracic aorta in high risk patients. Eur J Cardiothorac Surg 2003; 24:379±387.

38. Ting AC, Cheng SW, Ho P, Poon JT. Endovascular repair for multiple Salmonella mycotic aneurysms of the thoracic aorta presenting with Cardiovocal syndrome. Eur J Cardiothorac Surg 2004; 26:221±224.

39. Nishimoto M, Hasegawa S, Asada K, Tsunemi K, Sasaki S.

Stent-graft placement for mycotic aneurysm of the thoracic aorta: report of a case. Circ J 2004; 68:88±90.

40. Kotzampassakis N, Delanaye P, Masy F, Creemers E. Endo- vascular stent-graft for thoracic aorta aneurysmcaused by Salmonella. Eur J Cardiothorac Surg 2004; 26:225±227.

41. Liu WC, Kwak BK, KimKN, KimSY, Woo JJ, Chung DJ, Hong JH, KimHS, Lee CJ, ShimHJ. Tuberculous aneu- rysmof the abdominal aorta: endovascular repair using stent grafts in two cases. Korean J Radiol 2000; 1:215±218.

42. Bergamini TM, Bandyk DF, Govostis D, Kaebnick HW, Towne JB. Infection of vascular prostheses caused by bacterial biofilms. J Vasc Surg 1988; 7:21±30.

43. Smith JJ, Taylor PR. Endovascular treatment of mycotic aneurysms of the thoracic and abdominal aorta: the need for level 1 evidence. Eur J Endovasc Surg 2004; 27:569±

570.