Case description
An 82- year old male was admitted to the hospital with fever and joint pain of the right knee, thumb and left shoulder. Blood, urine and bursa cultures of the thumb and shoulder showed a Staphylococcus aureus bacteremia. Based on these cultures intravenous flucloxacillin was prescribed, six gram/day. His medical history revealed an ischemic cerebral vascular accident, psoriasis vulgaris and corneal transplant for which he used acetylsalicylic acid, dipyridamole and valacyclovir.
After two weeks of intravenous antibiotic treatment a chest X-ray was performed on suspicion of a pneumonia (CRP 180 mg/l, leukocytes 13 x 109/l). The X-ray showed no signs of a pneumonia but, however, widening of the mediastinum. An additional computed tomography angiography scan (CTA scan) showed impending rupture of a mycotic saccular aneurysm of the descending thoracic aorta of 55mm, four centimeters below the left subclavian artery, with compression of the trachea and esophagus (Figure 1).
Therefore, patient was referred to our tertiary referral center. At arrival patient was hemodynamically stable but suffered from dyspnea and a subtle expiratory stridor. There were no signs of dysphagia, hypoxemia or fever. An emergency thoracic endovascular aortic repair (TEVAR) procedure was performed; a Gore©CTAG© 37mm x 10cm was expanded just distal of the left subclavian artery. Completion angiography showed exclusion of the aneurysm without signs of endoleak.
Several hours following the procedure the patient deteriorated, suffering from tachycardia, tachypnea and respiratory failure. A CTA scan was performed, showing progressive compression of the trachea and esophagus. The diameter of the saccular aneurysm was stable (56mm) and a type 1b endoleak, inadequate distal sealing, was suspected (Figure 2). Emergency bronchoscopy showed severe obstruction of the distal tracheal lumen, carina, proximal left and right bronchus. A silicone Dumon© stent (18x14x14mm) was deployed in the trachea. Because of persistent compression an additional fully covered expandable Microtech© nitinol Y stent (16x13x13mm) was placed to allow mechanical ventilation. The aortic stent graft was extended to both ends with a Gore© CTAG© 37mm x 20cm just below the left common carotid artery, overstenting the subclavian artery. Completion angiography showed exclusion of the aneurysm (Figure 3). Although the operation did result in decreased ventilation pressure and even detubation, the patient died four days after surgery because of excess pulmonary secretion and subsequent respiratory insufficiency.