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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No conflicts of interest.