Management of a Mycotic Aneurysm in a Patient with COVID-19: A Case Report

Abstract

The aim of this paper is to share our experience in managing a patient with Klebsiella pneumoniae mycotic abdominal aortic aneurysm who was also infected with COVID-19. A 69-year-old male was transferred to our hospital for the management of an infra-renal mycotic abdominal aortic aneurysm. During his hospital course, the patient contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was intubated due to respiratory distress. Over a short period, his mycotic aneurysm increased in size from 2.5 cm to 3.9 cm. An emergency repair of his expanding aneurysm was achieved using our previously described protocol of coating endovascular stents with rifampin. The patient was managed with a rifampin-coated endovascular stent graft without any major complications. Postoperatively, the patient did not demonstrate any neurological deficits nor any vascular compromise. He remained afebrile during his postoperative course and was extubated sometime thereafter. He was then transferred to the ward for additional monitoring prior to his discharge to a rehab hospital while being on long-term antibiotics. During his hospital stay, he was monitored with serial ultrasounds to ensure the absence of abscess formation, aortic aneurysm growth or graft endoleak. At 6 weeks after stent graft placement, he underwent a CT scan, which showed a patent stent graft, with a residual sac size of 2.5 cm without any evidence of abscess or endoleak. Over a follow-up period of 180 days, the patient remained asymptomatic while remaining on long-term antibiotics. Thus, in patients whose surgical risk is prohibitive, endovascular stent grafts can be used as a bridge to definitive surgical management.

Keywords: COVID-19; Klebsiella pneumoniae; SARS-CoV-2; endoleak; endovascular stents; follow-up studies; mycotic aneurysm; rifampin.

Figure 1

Interim development of an infra-renal mycotic aneurysm measuring 2.5 cm.

Figure 2

(A) Preoperative duplex ultrasound demonstrating rapid expansion of an infra-renal mycotic aortic aneurysm to a maximum diameter of 3.96 cm. (B) Anterior posterior intraoperative angiogram demonstrating a mycotic aneurysm. (C) Final intraoperative angiogram demonstrating a sealed mycotic aneurysm using an endovascular stent graft.

Figure 3

CT scan (A) axial view and (B) coronal view at 6 weeks after endovascular repair, demonstrating a stable sac without any noticeable evidence of mycotic aneurysm progression or endoleak. R = right; L = Left; P = Posterior, AP = Anterior Posterior.

Figure 4

Duplex ultrasound at 6 months after endovascular repair of the mycotic aneurysm, demonstrating a stable sac that had decreased to a size of 2.65 cm.