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.