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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 22-24

Endovascular treatment of the superficial femoral artery aneurysm infected by typhoid Salmonella


1 Department of Vascular Surgery, Affiliated Hospital of Jining Medical University, Jining 272029, China
2 Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining 272029, China

Date of Submission05-Jan-2021
Date of Decision03-Feb-2021
Date of Acceptance04-Feb-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Song Jin
Department of Vascular Surgery, Affiliated Hospital of Jining Medical University, No. 89, Guhuai Road, Jining 272029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT-D-21-00003

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  Abstract 


Salmonella aortitis accounts for approximately 40% of all infectious aortitis. Superficial femoral artery aneurysm infected by Salmonella typhi has rarely been reported. The study reported a 71-year-old Chinese woman with a previous history of nephrotic syndrome and long-term oral hormone therapy, who was admitted to the hospital with a gradually increasing pulsatile mass in the right thigh and pain. After admission, computed tomography angiography revealed rupture and bleeding of an aneurysm in the middle and lower segment of the right superficial femoral artery (SFA). The aneurysm of the SFA was satisfactorily isolated by the covered stent. The bacterial culture of the secretion from the punctured mass showed the S. typhi infection. Based on the results of the drug sensitivity test, the patient received anti-infective treatment for 4 weeks. The patient recovered well after 1-year follow-up.

Keywords: Covered stent, Salmonella typhi, superficial femoral artery aneurysm


How to cite this article:
Sun Z, Li X, Tang L, Jin S. Endovascular treatment of the superficial femoral artery aneurysm infected by typhoid Salmonella. Vasc Invest Ther 2021;4:22-4

How to cite this URL:
Sun Z, Li X, Tang L, Jin S. Endovascular treatment of the superficial femoral artery aneurysm infected by typhoid Salmonella. Vasc Invest Ther [serial online] 2021 [cited 2021 Jul 27];4:22-4. Available from: https://www.vitonline.org/text.asp?2021/4/1/22/309887




  Introduction Top


The most common clinical manifestation of Salmonella infection is gastroenteritis, which is self-limiting, and about 5% can develop into bacteremia. The incidence of extraintestinal focal infection (EFI) is 40% in bacteremia. EFI can infect intravascular tissues, bone, brain, meninges, lungs, or abdominal organs. Intravascular infection is a life-threatening parenteral complication.[1] Salmonella aortitis accounts for approximately 40% of all infectious aortitis.[2] Salmonella infection occurs less frequently in the superficial femoral artery (SFA). Here, we reported a rare case of the SFA aneurysm (SFAA) infected by Salmonella typhi and discussed the course of the treatment.


  Case Report Top


A 71-year-old Chinese woman was admitted to the hospital with a gradually increasing pulsatile mass in the right thigh and pain. She had a history of nephrotic syndrome, hypertension, cerebral infarction, coronary heart disease, and arrhythmia and had taken oral hormones for a long time. On physical examination, she was afebrile and her right lower extremity was swollen. A pulsating mass with a diameter of 5 cm could be touched in the middle and lower part of the right thigh. The mass was tough and tender [Figure 1]a. The posterior tibial artery pulsation was weak and the dorsal foot artery was not palpable.
Figure 1: (a) Picture of lower extremities at admission. (b) Picture of lower extremities before discharge

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Blood routine revealed elevated levels of white cell count (13.90 × 109/L), neutrophil percentage (87%), and C-reactive protein (CRP, 37 mg/L). Preoperative hemoglobin level decreased compared to admission (from 101 g/L to 91 g/L), with no hemodynamic instability. Liver function showed albumin was 22.1 g/L. Renal function showed creatinine was 138.0 μmol/L and urea was 15.80 mmol/L. Urine routine showed protein, occult blood, and glucose were all 3+.

Computed tomography angiography suggested the penetrating ulcer at the T10 level of the thoracic aorta [Figure 2]a and rupture of an aneurysm in the middle and lower segment of the right SFA [Figure 2]b.
Figure 2: (a) Preoperative aortic computed tomography angiography indicated penetrating ulcer at T10 of thoracic aorta (red thin arrow). (b) Preoperative computed tomography angiography of the lower extremity arteries showing ruptured aneurysm of the right superficial femoral artery (red thick arrow)

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Due to the patient's age and suffering from nephrotic syndrome and other diseases, the risk of surgery under general anesthesia for a ruptured aneurysm was very high. Therefore, we chose to place a covered stent under local anesthesia to isolate the aneurysm. We first retrogradely punctured the left common femoral artery and placed a short 6F introducer (Terumo). After using 5F cobra catheter (Cordis) with a 0.035-inch radifocus hydrophilic guide wire (Terumo) to enter the right common femoral artery, we replaced a 45 cm 7F flexor introducer (Cook). Digital subtraction angiography (DSA) showed the partial rupture of the aneurysm in the middle and lower segments of the right SFA [Figure 3]a. After carefully sending the guide wire to the popliteal artery, we implanted a 5 mm × 100 mm covered stent (Gore Viabahn) to cover the lesion [Figure 3]b and inflated it with a 5 mm × 100 mm balloon (Bard Rival). The final angiography showed that the aneurysm disappeared. SFA and its distal artery were unobstructed, and there was no spillage of the contrast medium [Figure 3]c and [Figure 3]d. The patient's pain was significantly relieved after the operation. We punctured the mass with a fine needle, extracted the yellow-white liquid mixed with a tiny amount of blood, and sent it to the bacterial culture. The culture result showed that Salmonella typhi which was sensitive to ceftriaxone and sulfamethoxazole. According to the results of the drug sensitivity test, the patient was continued on ceftriaxone (2 g once daily intravenously for 4 weeks). The patient did not complain of swelling and pain in the right lower limb [Figure 1]b, and laboratory tests indicated that blood routine and CRP were normal before discharge. After 1-year follow-up, the color Doppler ultrasound showed that the femoral artery stent was unobstructed and the thoracic aortic dissection was stable.
Figure 3: (a) Digital subtraction angiography showing the partial rupture of the right superficial femoral artery aneurysm. (b) The 0.035-inch guide wire and covered stent (Gore Viabahn) were in place. (c) Digital subtraction angiography showing the aneurysm disappeared and superficial femoral artery was unobstructed. (d) Digital subtraction angiography showing the distal artery of superficial femoral artery was unobstructed

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  Discussion Top


In 1885, Olser first described the bacterial aneurysm.[3] Before the widespread use of antibiotics, syphilis, tuberculosis, and bacterial endocarditis were common reasons of bacterial aneurysms. With the spread of antibiotics, bacterial aneurysms have gradually decreased. At present, the main cause is Staphylococcus aureus, followed by Salmonella.[4] The normal aortic intima is highly resistant to infection, and the main risk factor for infectious aortitis is atherosclerosis. Salmonella has a strong affinity for large blood vessels and easily attaches to damaged arteriosclerotic plaques.[5] Salmonella aortitis accounts for approximately 40% of all infectious aortitis.[2] Middle-aged and elderly male patients with hypertension, diabetes, hyperlipidemia, and atherosclerosis are susceptible to this disease.[6] This patient was an elderly woman with nephrotic syndrome, hypertension, cerebral infarction, coronary heart disease, and severe atherosclerosis. The above high-risk factors promoted the colonization of bacteria. Both SFAA and thoracic aortic penetrating ulcers in this patient should be related to S. typhi.

Femoral aneurysms have a low incidence and remain the second most frequent site in peripheral aneurysms. A common cause is atherosclerosis.[7] Common clinical manifestations include pulsatile mass, pain, lower limb swelling caused by femoral vein compression, rupture, thrombosis, and ischemia due to distal embolization.[8] Published data suggest that SFAA is more prone to rupture than complications such as ischemia. Pulcini's retrospective report on 43 patients showed that the rupture rate was 30%–46%, and the incidence of thromboembolism was 12%–46%.[9] The main clinical manifestation of this patient we reported was rupture and bleeding of SFAA.

Treatment of bacterial aneurysms caused by Salmonella should include antibiotic treatment and surgery. Except for patients who need emergency surgery, it is recommended to give adequate anti-infective treatment to reduce the risk of intraoperative infection and recurrence of postoperative infection. Preoperative anti-infective treatment was performed for 1–4 months, and sensitive antibiotics were administered intravenously for at least 6 weeks after surgery.[10] The mortality rate of nonsurgical patients amounts to 70%–90%.[11] Due to the high risk of aneurysm rupture and the high mortality rate of bacterial aneurysms, surgical treatment should be performed as soon as possible. Literature review shows that surgical treatment of bacterial aneurysms includes in situ reconstruction, extra-anatomical bypass, and endovascular treatment. Open surgery is superior to endovascular treatment in terms of removing infected lesions and reducing postoperative recurrence. Owing to the rapid increase in the diameter of bacterial aneurysms, covered stents are beneficial for patients who cannot tolerate open surgery.[11] Kan et al. retrospectively analyzed that the 30-day survival rate of patients with bacterial aneurysms treated by endovascular abdominal aortic aneurysm repair (EVAR) was 90% and the 2-year survival rate was 82%. However, persistent infections occurred in 23% of patients after surgery and their 1-year survival rate was about 39%. The increased risk of recurrent infections limits its application.[12] Preoperative examination of the patient showed an increase in inflammatory indicators such as white blood cells and CRP, but she had no clinical manifestations such as chills and fever. The patient's aneurysm ruptured and bleeding at the time of admission, which required emergency surgery. However, due to the advanced age and many complications, she could not tolerate open surgery under general anesthesia. A 5 mm × 100 mm covered stent (Gore Viabahn) was implanted to isolate the aneurysm under local infiltration anesthesia. Ceftriaxone was given anti-infective treatment for 4 weeks according to the results of drug sensitivity test. During the follow-up period of 2 months to 1 year after operation, there were no signs of recurrence. However, the next step still needs to be followed closely to prevent recurrence of the infection.

The SFAA infected by S. typhi is rare. For elderly patients with many complications, the short-term effect of covered stent combined with effective anti-infective treatment is safe and effective, but long-term follow-up and large amount of case data are needed to focus on long-term effects.

Declaration of patient consent

The authors certify that they have obtained the patient consent form. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

PhD Research Foundation of Affiliated Hospital of Jining Medical University (Project ID: 2020-BS-012).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salzberger LA, Cavuoti D, Barnard J. Fatal Salmonella aortitis with mycotic aneurysm rupture. Am J Forensic Med Pathol 2002;23:382-5.  Back to cited text no. 1
    
2.
Cohen PS, O'Brien TF, Schoenbaum SC, Medeiros AA. The risk of endothelial infection in adults with Salmonella bacteremia. Ann Intern Med 1978;89:931-2.  Back to cited text no. 2
    
3.
Teixeira PG, Thompson E, Wartman S, Woo K. Infective endocarditis associated superior mesenteric artery pseudoaneurysm. Ann Vasc Surg 2014;28:1563.  Back to cited text no. 3
    
4.
Pirvu A, Bouchet C, Garibotti FM, Haupert S, Sessa C. Mycotic aneurysm of the internal carotid artery. Ann Vasc Surg 2013;27:826-30.  Back to cited text no. 4
    
5.
Hakim S, Davila F, Amin M, Hader I, Cappell MS. Infectious aortitis: A life-threatening endovascular complication of nontyphoidal salmonella bacteremia. Case Rep Med 2018;2018:1-5.  Back to cited text no. 5
    
6.
Guo Y, Bai Y, Yang C, Wang P, Gu L. Mycotic aneurysm due to Salmonella species: Clinical experiences and review of the literature. Braz J Med Biol Res 2018;51:e6864.  Back to cited text no. 6
    
7.
Farinon AM, Rulli F, Muzi M. Ruptured aneurysm of the superficial femoral artery. Panminerva Med 1995;37:155-8.  Back to cited text no. 7
    
8.
Dawson J, Fitridge R. Update on aneurysm disease: Current insights and controversies: Peripheral aneurysms: When to intervene-Is rupture really a danger? Prog Cardiovasc Dis 2013;56:26-35.  Back to cited text no. 8
    
9.
Pulcini G, Cimaschi D, Vinco A, De Cesare V, Chiametti G, Cervi GC. Rupture of voluminous atherosclerotic superficial femoral artery aneurysm. Chir Ital 2005;57:661-7.  Back to cited text no. 9
    
10.
Schoevaerdts D, Hanon F, Vanpee D, Swine C, Glupczynski Y, Vander Borght T, et al. Prolonged survival of an elderly woman with Salmonella dublin aortitis and conservative treatment. J Am Geriatr Soc 2003;51:1326-8.  Back to cited text no. 10
    
11.
Knouse MC, Madeira RG, Celani VJ. Pseudomonas aeruginosa causing a right carotid artery mycotic aneurysm after a dental extraction procedure. Mayo Clin Proc 2002;77:1125-30.  Back to cited text no. 11
    
12.
Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review. J Vasc Surg 2007;46:906-12.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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