Accepted Manuscript Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm Pedro G. Teixeira, MD Eli Thompson, MS Sarah Wartman, MD Karen Woo, MD PII:

S0890-5096(14)00221-0

DOI:

10.1016/j.avsg.2014.03.032

Reference:

AVSG 2001

To appear in:

Annals of Vascular Surgery

Received Date: 13 August 2013 Revised Date:

16 March 2014

Accepted Date: 24 March 2014

Please cite this article as: Teixeira PG, Thompson E, Wartman S, Woo K, Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm, Annals of Vascular Surgery (2014), doi: 10.1016/j.avsg.2014.03.032. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Original Article

Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm.

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Pedro G. Teixeira, MD; Eli Thompson, MS; Sarah Wartman, MD; Karen Woo, MD

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University of Southern California, Los Angeles, California

Running Head: Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm

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Presented at the 31st meeting of the Southern California Vascular Surgery Society, May 2013.

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Please address correspondence to:

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Karen Woo, MD Assistant Professor of Surgery Division of Vascular Surgery

University of Southern California 1520 San Pablo St Suite 4300 Los Angeles, CA 90033 Phone: (323) 442-6835 Fax: (323) 442-5735 email: [email protected] Key Words: Superior mesenteric artery; Visceral arteries aneurysms; Mycotic pseudoaneurysm; Infectious pseudoaneurysm; Endocarditis.

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ABSTRACT

Background: Since William Osler first described mycotic aneurysms in the setting of

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endocarditis in 1885, few pseudoaneurysms (PA) of the superior mesenteric artery (SMA) have been reported in the literature. We report two cases of SMA PA related to infective endocarditis that were managed with open surgery.

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Results: Here we report two cases of SMA pseudoaneurysms treated with different surgical

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techniques. A 59-year-old male with a history of intravenous drug use presented with abdominal pain and was found to have S. viridans endocarditis and an SMA PA. A laparotomy was performed and proximal and distal control of the SMA PA was obtained. After ensuring that Doppler signals were still present in the distal mesentery and the entirety of the bowel was

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viable, the SMA was ligated proximal and distal to the PA. The patient recovered uneventfully. The second case is a 35-year-old female who presented with abdominal pain and was found to have S. gordonii endocarditis and an SMA PA for which the patient was initially observed. After

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several weeks the patient’s condition deteriorated and the patient underwent open ligation of the SMA proximal and distal to the PA with a bypass from the infrarenal abdominal aorta to a

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distal unnamed SMA branch and resection of three feet of ischemic small bowel. The patient continued to have recurrent bowel ischemia over the next several weeks and ultimately expired.

Conclusion: SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and associated morbidity and mortality. Delay in surgical management may increase this risk.

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INTRODUCTION

Infectious pseudoaneurysms of the superior mesenteric artery (SMA) are a rare entity

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that commonly remains asymptomatic until rupture occurs, resulting in elevated mortality. We report two cases of SMA pseudoaneurysms related to infective endocarditis that were managed

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with open surgery.

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Case 1

A 59-year-old male was transferred from an outside hospital with a diagnosis of a superior mesenteric artery pseudoaneurysm. The patient had a history of intravenous drug use and was diagnosed at the outside hospital with endocarditis and an SMA thrombus. He was

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treated with anticoagulation therapy for the SMA thrombus at the outside hospital but a follow up CT scan showed progression to an SMA pseudoaneurysm (Figure 1). CT scan performed

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following transfer confirmed the presence of an SMA pseudoaneurysm measuring 4.5 cm in greatest diameter (Figure 2). The distal SMA appeared to be thrombosed. The patient was

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tolerating a diet without difficulty with no evidence of mesenteric ischemia.

The patient was taken to the operating room where a laparotomy was performed. The SMA was ligated proximal and distal to the pseudoaneurysm. Subsequently, the small bowel was examined and found to be viable in its entirety and pulses were palpable at the mesenteric border. Post-operatively, the patient had an unremarkable recovery and was discharged on post-operative day 7.

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Case 2

A 35-year-old woman presented with worsening abdominal pain. The patient was

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recently discharged from the hospital after an emergent mitral valve replacement for severe mitral regurgitation secondary to mitral endocarditis. The patient had been found to have an SMA thrombus during the previous hospitalization. The patient’s original imaging demonstrated

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a thrombus of the distal SMA (Figure 3). Distally, there was no reconstitution of the main SMA, only unnamed branches. Due to the fact that she had no symptoms of mesenteric ischemia at

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that time, she was discharged from the hospital.

Two weeks later, the patient began to complain of increasing abdominal pain. A follow up CT then demonstrated a large SMA pseudoaneurysm measuring 6 cm by 4 cm in greatest

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diameter (Figures 4). At this point, the patient was taken to the operating room where a laparotomy was performed. The ischemic bowel was resected. The SMA was ligated proximal and distal to the pseudoaneurysm and the wall of the pseudoaneurysm was debrided. The only

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distal target that could be identified on the SMA was a small unnamed SMA branch. Thus, a bypass was performed from the infrarenal aorta to the SMA branch using saphenous vein.

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Although the bypass was confirmed to be patent with a Doppler signal, there were no pulses at the mesenteric border. Post-operatively, the patient intermittently tolerated a diet. Two weeks post-operatively, a CT scan was performed for increasing abdominal pain and demonstrated pneumatosis in the small bowel and cecum. At this time a partial cecectomy was performed. Subsequently, the patient continued to experience abdominal pain and a CT scan demonstrated pneumatosis throughout the small bowel and stomach with

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pneumoperitoneum and portal venous gas (Figure 5). The patient and her family declined further operative management and elected for comfort care and the patient expired.

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DISCUSSION

Splanchnic artery aneurysms are rare, with an estimated prevalence of 0.1% to 2% in the

general population.(1,2) SMA aneurysms represent 6% to 8% of all splanchnic aneurysms.(3,4)

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Although exceedingly rare, with an incidence of 0.01% to 2.6%, SMA pseudoaneurysms are

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clinically relevant because of their high risk of rupture (10-50%) and mortality (22-40%).(5,6) The etiology of SMA pseudoaneurysms includes infection, inflammatory processes (pancreatitis in particular), iatrogenic injury, atherosclerosis, and trauma.(7) Abdominal pain is the most common symptom of visceral pseudoaneurysm, but most cases of visceral pseudoaneurysm

hemorrhage ensues.(8)

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remain undiagnosed due to their paucity of symptoms until rupture occurs and intra-abdominal

Currently, the most sensitive modality for diagnosing SMA pseudoaneurysms is

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mesenteric angiography with or without digital subtraction. Diagnosis of SMA

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pseudoaneurysms can also be made with traditional, noninvasive, imaging techniques such as MRI, CT, and abdominal ultrasound but such tests are considered less sensitive.(7,9) As spiral CT scan technology evolves with added capability of rendering high quality 3-D reconstruction images, CT angiograms have become the imaging modality of choice.(10) When diagnosed, immediate surgical intervention is generally recommended due to the relatively high risk of rupture and post-rupture fatality which can be as high as 75%.(11) These risks are also

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compounded by the possibility of pseudoaneurysmal compression and erosion of adjacent structures resulting in potentially lethal hemorrhages.(6)

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Historically, the treatment of non-mycotic SMA pseudoaneurysms has consisted of open surgery and includes exclusion of the aneurysm with or without mesenteric revascularization depending on the location of the pseudoaneurysm and patient presentation. Ligation without

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reconstruction, as was performed in our first case, is acceptable and commonly performed in emergency situations.(5) Revascularization, however, is recommended for patients who

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present with associated symptoms of angina(12) and in which the there is involvement of the trunk of the SMA due to a high risk of intestinal ischemia if ligation only is performed.(5) With the development of endovascular techniques in the 1980s coil embolization gained popularity as a treatment modality for visceral pseudoaneurysms. This continued until the

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introduction of covered stents in the 1990s and since then both options have been suggested to be safe and have acceptable outcomes when compared to an open approach for non-mycotic visceral pseudoaneurysms.(6,13) Catheter-based techniques as the primary treatment modality

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for visceral artery aneurysms and pseudoaneurysms are especially attractive for high-risk patients and those with anatomically challenging lesions. (14,15) Tulsyan et al achieved an

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overall success rate of 98% for the endovascular treatment of visceral artery aneurysms, with an 8% 30-day mortality.(1) In a recent literature review, embolotherapy was found to be the primary treatment modality treatment for two-thirds of SMA aneurysms and pseudoaneurysms, with a reported success rate of 89%.(6) However, the risk of recanalization and recurrence remains a potential drawback of this technique. (6,14-19)

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An approach utilizing a combination of endoluminal stent grafting and thrombin injection has gained popularity for the management of pseudoaneurysms. (6,20-22) A

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comparison of outcomes between open and endovascular procedures for visceral arteries aneurysms by Sachdev at al found no difference in the rate of complications (33% vs. 26%) or 30-day mortality (4% vs. 3%), but patients treated endovascularly had a shorter

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hospitalization.(13) Sessa et al also found similar morbidity rates for both techniques (12% vs. 18%).(5) The significant rate of procedure-related complications associated with the

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endovascular approach, which can be as high as 22-25%(13,16), may be a contributor to the similar complication rates between the two techniques. Miller et al found a 0.2% mortality rate for patients treated endovascularly compared to 8% for those undergoing open treatment. (6) However, an endovascular approach is still not indicated when the patient is hemodynamically

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unstable, or when vessel tortuosity or anatomy prevent its use. For patients with clinical evidence of possible intestinal ischemia, open surgery is the treatment modality of choice as it permits treatment of the pseudoaneurysm as well as assessment of bowel viability and

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resection of any non-viable bowel.

Ultimately, the majority of data regarding SMA aneurysms relates to true, non-mycotic

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SMA aneurysms. The SMA is the most common location for a visceral mycotic pseudoaneurysm, making up 88% of visceral mycotic pseudoaneurysms. (23) This type of pseudoaneurysm often occurs secondary to an embolic event. Infectious endocarditis is associated with a 30% to 60% incidence of embolic events to major organs (24), and 2.5% to 10% mycotic aneurysms formation(25). Once the embolus occurs, bacteria from the infected embolus seed the vessel wall, causing aneurysmal degeneration resulting in a mycotic aneurysm or pseudoaneurysm of

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the affected vessel. The two cases being reported both exemplify that natural history. The second case emphasizes the importance of early aggressive removal of infected tissue. Silver

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reported the case of a ruptured SMA branch pseudoaneurysm in a patient with Cardiobacterium hominis endocarditis. (8) That patient died despite successful percutaneous embolization, again supporting the role of the open surgical approach in managing this

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problem. As illustrated by both cases, delayed removal of infected material can result in a substantially increased risk of mortality. The principles of infectious endocarditis treatment

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include early empiric antibiotic therapy and consideration of cardiac surgery in cases which progress to heart failure, uncontrolled infection and to prevent embolic events. (26) Cardiac complications of infectious endocarditis requiring surgical management take precedence over

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peripheral pseudoaneurysm and their treatment prioritized.

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Figure Legends Figure 1. Computerized tomography scan digital reconstruction demonstrating SMA pseudoaneurysm (arrows).

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Figure 2. Computerized tomography axial section demonstrating an SMA pseudoaneurysm measuring 4.5 cm in greatest diameter (arrow).

Figure 3. Computerized tomography axial section demonstrating thrombus of the distal SMA

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(arrow), with no identifiable distal reconstitution of the main SMA (arrow head).

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Figure 4. Computerized scan axial section demonstrating a 6x4 cm SMA pseudoaneurysm (arrow).

Figure 5. Computerized scan axial sections demonstrating widespread pneumatosis intestinalis

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(arrow heads).

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