Brucellosis is one of the most widespread bacterial zoonoses on the planet, yet its cardiovascular complications are uncommon, affecting roughly one to three percent of infected patients. When the bacterium does reach the arteries, however, the consequences can be devastating. Infectious aortic aneurysm, the most feared vascular manifestation of the disease, progresses rapidly and carries a reported mortality of about 21 to 22 percent. Traditionally, the standard of care has been open surgical replacement of the infected aortic segment combined with long-term antibiotic therapy. That approach, though effective in the right hands, imposes enormous surgical trauma and high complication rates, particularly in elderly patients with multiple comorbidities. As endovascular techniques have matured, minimally invasive stent-graft repair has increasingly been applied to infectious aneurysms, offering faster hemorrhage control but leaving the underlying infection unresolved.

The three cases were managed consecutively at a Chinese institution between 2022 and 2023 under a structured multidisciplinary team protocol that brought together vascular surgeons, infectious disease specialists, interventional radiologists, and cardiothoracic surgeons. Infectious disease physicians directed serological testing and anti-Brucella drug therapy, while the surgical and interventional specialists jointly reviewed computed tomography angiography images to judge whether repeat endovascular intervention was anatomically feasible. The team collectively weighed open versus endovascular repair for each patient, factoring in hemodynamic stability, comorbid disease, and the extent of infection. This collaborative model has recently been emphasized in the literature as essential for managing complex aortic endograft infections, where no single specialty can adequately address both the mechanical and microbiological dimensions of the disease.

The first patient, a 73-year-old man, presented with three months of progressively worsening coughing up of blood, which began six months after elective TEVAR for a thoracic aortic aneurysm at another hospital. Bronchial artery embolization, coil embolization, and left subclavian artery stenting at prior institutions had failed to stop the bleeding, because none of these measures addressed the primary aortic defect, a persistent endoleak communicating with a massive pseudoaneurysm measuring 12.1 by 15.7 centimeters. A history of short-term residence in a pastoral area prompted specific infectious disease testing, and serology confirmed active Brucella infection, with a positive Rose Bengal test, strongly positive serum agglutination, and detectable Brucella IgG and IgM antibodies. Given his prohibitive anesthesia risk, surgeons deployed a covered stent to seal the pseudoaneurysm orifice, used a chimney technique to reconstruct the left common carotid artery, placed a branched endograft component to preserve flow to the left subclavian artery, and coil-embolized the residual aneurysm cavity to accelerate thrombosis and prevent rupture during the long antibiotic course ahead.

One month later, that same patient was readmitted with fever. Chest imaging revealed mediastinal emphysema, and CT-guided drainage of the mediastinum yielded foul-smelling brownish fluid from which Escherichia coli was cultured. The team chose percutaneous rather than surgical drainage after weighing his advanced age, recent repeat endovascular intervention, and the danger that open exploration of an infected field containing a stent-graft could cause graft disruption or catastrophic hemorrhage. Although his temperature normalized after drainage, the patient died suddenly four days later, most likely from overwhelming infection. His course illustrates a sobering reality: even when the primary aortic lesion is technically excluded, the combination of a prosthetic implant, a polymicrobial superinfection, and a frail elderly host can prove fatal.

The second patient, a 69-year-old man with chest pain and fever ten months after TEVAR elsewhere, initially showed no abnormalities on aortic CT angiography, but serology again confirmed brucellosis. After starting standard anti-Brucella antibiotics his symptoms improved, yet on the fourth day of treatment he vomited approximately 1,500 milliliters of blood and went into hemorrhagic shock. Emergency repeat imaging revealed a pseudoaneurysm of the aortic arch, and gastroscopy confirmed an aorto-esophageal fistula with active bleeding. Open surgery was deemed contraindicated because shock made single-lung ventilation and aortic cross-clamping intolerable, and the heavily infected tissue would have required extensive debridement with extreme risk of bacteremic spread and graft reinfection. Instead, the team performed emergency endovascular exclusion, extending the stent-graft landing zone to Zone 0, reconstructing the brachiocephalic trunk with a chimney stent, and restoring the left carotid and subclavian arteries using in-situ fenestration, in which fenestrations are created in the graft with a needle and reinforced with covered stents. He nevertheless died of recurrent hematemesis roughly two months later.

The third patient, a 59-year-old man with hypertension, hepatitis B, and a history of colon cancer, arrived with three days of hemoptysis seven months after elective TEVAR for a pseudoaneurysm at an outside hospital. Early postoperative imaging had shown a well-positioned stent-graft, but contrast-enhanced CT now revealed a new pseudoaneurysm distal to the graft accompanied by a mediastinal hematoma. His history of cattle and sheep exposure led to serological testing that showed the strongest agglutination reaction of the series, plus positive Brucella antibodies. Notably, he had been diagnosed with brucellosis a year earlier and completed six months of therapy, yet still harbored active infection, suggesting either relapse or persistent disease. After his family declined open surgery, clinicians implanted a new covered stent distal to the original graft to exclude the lesion, then continued standardized antimicrobial therapy. At twelve months of follow-up he remains well, with no recurrence of bleeding, and is monitored with quarterly clinical and serological assessments plus annual aortic CTA.

The authors classified all three patients as having definite aortic graft infection under the MAGIC criteria, the case definition developed by the Management of Aortic Graft Infection Collaboration. The first two cases met major clinical criteria, an aorto-bronchial fistula and an aorto-esophageal fistula respectively, while the third met the major radiological criterion of a new perigraft pseudoaneurysm, and all were supported by positive serology. The rapid progression to pseudoaneurysm and fistula within six to ten months of TEVAR, combined with uniformly positive Brucella tests, led the team to conclude that the original aortic pathology was most likely an unrecognized mycotic aneurysm rather than a routine degenerative lesion, with the implanted stent-graft serving as a nidus for bacterial adherence and biofilm formation that amplified local inflammation.

The therapeutic dilemma at the heart of the series is that endovascular repair saves lives in the moment but cannot by itself eradicate infection. Since the first report of TEVAR for a brucella-related aortic aneurysm in 2007, subsequent experience, including a 2011 case of emergency endovascular repair of a Brucella-induced aortic rupture, has supported the model of stent-grafting combined with prolonged antibiotics, with existing data showing roughly 55 percent five-year survival for that strategy. Aorto-esophageal fistula remains the most lethal TEVAR complication; about 45 percent of patients display the classic Chiari triad of chest pain, sentinel hemorrhage, and massive hematemesis, and conservative management alone carries mortality approaching 100 percent within days. All three patients in the series received the WHO-recommended combination of rifampicin and doxycycline at standard doses for extended courses.

The authors acknowledge the limitations of a retrospective three-case series, and they recommend adding 18F-FDG-PET/CT to surveillance protocols, since CTA is insensitive to low-grade graft infection while PET/CT excels at detecting residual metabolic activity around an implant. Still, the central message is unambiguous and urgent: in brucellosis-endemic regions, clinicians must maintain a high index of suspicion for the bacterium whenever patients develop unexplained fever, bleeding, or pain after aortic stent-grafting, because early diagnosis and multidisciplinary management are what separate the survivor in this series from the two patients who did not live.

Subject of Research: Brucella-associated aortic graft infection and pseudoaneurysm complications after thoracic endovascular aortic repair

Article Title: Case Report: Brucella-associated complications following thoracic endovascular aortic repair: a case series of three patients

Article References: Jing, L., Li, L., Zhou, D., Chen, W., Wang, Y., Han, L., Wang, C., Shu, X., Li, L., & Tan, Y. (2026). Case Report: Brucella-associated complications following thoracic endovascular aortic repair: a case series of three patients. Frontiers in Cardiovascular Medicine, 13, Article 1885416. https://doi.org/10.3389/fcvm.2026.1885416

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1885416

Keywords: brucellosis, TEVAR, aortic pseudoaneurysm, aorto-esophageal fistula, vascular graft infection, endovascular repair, Brucella, aortic aneurysm, antimicrobial therapy, MAGIC criteria, cardiovascular surgery, zoonotic infection