A multidisciplinary FEVAR and stent graft repair to exclude mycotic aneurysms by interventional radiology and vascular surgery: Case report

Mycotic pseudoaneurysms are rare arterial wall disruptions caused by infectious or inflammatory destruction of the vessel wall. They account for a small percentage, about 0.7%, of all aortic aneurysms. Bacillus Calmette-Guérin (BCG) therapy for nonmuscle invasive bladder cancer has been associated with rare vascular complications, including infectious aortitis and pseudoaneurysm formation. We present a 69-year-old male with a history of intravesical BCG therapy who presented with severe bilateral flank and abdominal pain and was found to have multifocal pararenal aortic and left common iliac pseudoaneurysms with extensive necrotic para-aortic and iliac lymphadenopathy. Given concern for an underlying infection and poor candidacy for open surgery, a multidisciplinary team consisting of vascular surgery and interventional radiology performed complex in situ laser fenestrated endovascular aneurysm repair with preservation of the superior mesenteric and bilateral renal arteries. The procedure successfully excluded the pseudoaneurysms. Although microbiologic confirmation of BCG infection was not obtained, the temporal relationship to prior intravesical BCG therapy and imaging findings raised suspicion for a BCG-associated infectious source. This case highlights the technical feasibility of multidisciplinary endovascular management of complex paravisceral pseudoaneurysms and emphasizes the importance of maintaining a broad differential diagnosis in patients presenting with vascular abnormalities following BCG therapy.