Discussion
Thoracic mycotic aneurysm has a high risk of rupture, and the mortality rate during medical treatment is about 60% (1). Open surgical repair can eliminate infected tissue and enable effective drainage. Despite this advantage, however, open surgical repair has a mortality rate of 12% to 36% (1, 2), and would be much higher in cases of preoperative rupture causing hypovolemic shock. TEVAR has therefore been used to overcome high surgical mortality. Most reported cases, however, were ‘impending rupture’ or ‘contained rupture’ (3-5) but not true rupture causing massive hemothorax and hypovolemic shock. In the present case, the patient and his family refused invasive procedures, resulting in aortic rupture causing abrupt hypovolemic shock. Therefore, the clinical course of thoracic mycotic aneurysm could be observed.
Concerns about TEVAR in mycotic aneurysms remain because it does not enable complete resection of the infected tissue. Hirano et al. reported the use of a combination of TEVAR and VATS for debridement with good result (3). They performed VATS to resect and drain the infected aneurysm 2 weeks after TEVAR. In the present case, however, VATS was performed immediately after TEVAR because the mycotic aneurysm had already ruptured. Therefore we didn’t need to perform further abscess drainage procedure.
In conclusion, TEVAR combined with VATS may be a viable option, especially in cases of ruptured mycotic aneurysm causing massive hemothorax and hypovolemic shock.
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