- Email: [email protected]
Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm
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.
ACCEPTED MANUSCRIPT
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Original Article
Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm.
SC
Pedro G. Teixeira, MD; Eli Thompson, MS; Sarah Wartman, MD; Karen Woo, MD
M AN U
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.
EP
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
RI PT
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.
SC
Results: Here we report two cases of SMA pseudoaneurysms treated with different surgical
M AN U
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
EP
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.
2
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INTRODUCTION
Infectious pseudoaneurysms of the superior mesenteric artery (SMA) are a rare entity
RI PT
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
SC
with open surgery.
M AN U
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
TE D
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
EP
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
AC C
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.
3
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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
SC
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
M AN U
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
EP
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
4
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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)
SC
Although exceedingly rare, with an incidence of 0.01% to 2.6%, SMA pseudoaneurysms are
M AN U
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)
TE D
remain undiagnosed due to their paucity of symptoms until rupture occurs and intra-abdominal
Currently, the most sensitive modality for diagnosing SMA pseudoaneurysms is
EP
mesenteric angiography with or without digital subtraction. Diagnosis of SMA
AC C
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
5
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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
SC
reconstruction, as was performed in our first case, is acceptable and commonly performed in emergency situations.(5) Revascularization, however, is recommended for patients who
M AN U
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
EP
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
AC C
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)
6
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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
RI PT
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
SC
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
M AN U
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
EP
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.
REFERENCES
Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2007 Feb;45(2):276–83– discussion283.
2.
Hossain A, Reis ED, Dave SP, et al. Visceral artery aneurysms: experience in a tertiary-care center. Am Surg. 2001 May;67(5):432–7.
3.
Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am. 1997 Apr;77(2):425–42.
4.
Friedman SG, Pogo GJ, Moccio CG. Mycotic aneurysm of the superior mesenteric artery. J Vasc Surg. 1987 Jul;6(1):87–90.
5.
Sessa C, Tinelli G, Porcu P, et al. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg. 2004 Nov;18(6):695– 703.
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1.
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Miller MT, Comerota AJ, DiSalle R, et al. Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review. J Vasc Surg. 2007 Feb;45(2):381–6.
7.
Burli P, Winterbottom AP, Cousins C, et al. Imaging appearances and endovascular management of uncommon pseudoaneurysms. Clin Radiol. 2008 Nov;63(11):1254–64.
8.
Silver SE. Ruptured mycotic aneurysm of the superior mesenteric artery that was due to cardiobacterium endocarditis. Clin Infect Dis. 1999 Dec;29(6):1573–4.
9.
Carmeci C, McClenathan J. Visceral artery aneurysms as seen in a community hospital. Am J Surg. 2000 Jun;179(6):486–9.
10.
Dasari BVM, Mullan M, Lau L, et al. A 6.5-cm pseudoaneurysm of the superior mesenteric artery managed by primary surgical repair. Vascular. 2013 Mar 14;21(1):39–42.
11.
Pasha SF, Gloviczki P, Stanson AW, et al. Splanchnic Artery Aneurysms. Mayo Clinic Proceedings. 2007 Apr;82(4):472–9.
12.
Díaz E, Lozano FS, González S, et al. Open and endovascular treatment for pseudoaneurysms of the superior mesenteric artery. Ann Vasc Surg. 2010 Jul;24(5):690.e9–12.
13.
Sachdev U, Baril DT, Ellozy SH, et al. Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg. 2006 Oct;44(4):718–24.
14.
Carr SC, Mahvi DM, Hoch JR, et al. Visceral artery aneurysm rupture. J Vasc Surg. 2001 Apr;33(4):806–11.
15.
Gabelmann A, Görich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther. 2002;9(1):38–47.
16.
Saltzberg SS, Maldonado TS, Lamparello PJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg. 2005 Jul;19(4):507–15.
17.
Salam TA, Lumsden AB, Martin LG, et al. Nonoperative management of visceral aneurysmsand pseudoaneurysms. Am J Surg. 1992 Sep;164(3):215–9.
18.
Onohara T, Okadome K, Mii S, et al. Rupture of embolised coeliac artery pseudoaneurysm into the stomach: Is coil embolisation an effective treatment for coeliac anastomotic pseudoaneurysm? Eur J Vasc Surg. 1992 May;6(3):330–2.
19.
Boudghène F, L'Herminé C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol. 1993 Jul;4(4):551–8.
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6.
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Wallace MJ, Choi E, McRae S, et al. Superior mesenteric artery pseudoaneurysm following pancreaticoduodenectomy: management by endovascular stent-graft placement and transluminal thrombin injection. Cardiovasc Intervent Radiol. 2007 May;30(3):518–22.
21.
Juszkat R, Krasiński Z, Wykrętowicz M, et al. Transarterial thrombin injection secured with an embolic protection device as a treatment for a superior mesenteric artery pseudoaneurysm. Cardiovasc Intervent Radiol. 2011 Feb;34(1):198–201.
22.
Szopiński P, Ciostek P, Pleban E, et al. Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement. Cardiovasc Intervent Radiol. 2005 Jul;28(4):509–14.
23.
Brown SL, Busuttil RW, Baker JD, et al. Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg. 1984 Jul;1(4):541–7.
24.
Weinstein L. Life-threatening complications of infective endocarditis and their management. Arch Intern Med. 1986 May;146(5):953–7.
25.
Werner K, Tarasoutchi F, Lunardi W. Mycotic aneurysm of the celiac trunk and superior mesenteric artery in a case of infective endocarditis. J Cardiovasc Surg (Torino). 1991;32(3):380–3.
26.
Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–2413.
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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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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.
ACCEPTED MANUSCRIPT
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Original Article
Infective Endocarditis Associated Superior Mesenteric Artery Pseudoaneurysm.
SC
Pedro G. Teixeira, MD; Eli Thompson, MS; Sarah Wartman, MD; Karen Woo, MD
M AN U
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.
EP
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.
1
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ABSTRACT
Background: Since William Osler first described mycotic aneurysms in the setting of
RI PT
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.
SC
Results: Here we report two cases of SMA pseudoaneurysms treated with different surgical
M AN U
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
TE D
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
EP
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
AC C
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.
2
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INTRODUCTION
Infectious pseudoaneurysms of the superior mesenteric artery (SMA) are a rare entity
RI PT
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
SC
with open surgery.
M AN U
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
TE D
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
EP
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
AC C
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.
3
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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
SC
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
M AN U
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
TE D
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
EP
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.
AC C
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
4
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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)
SC
Although exceedingly rare, with an incidence of 0.01% to 2.6%, SMA pseudoaneurysms are
M AN U
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)
TE D
remain undiagnosed due to their paucity of symptoms until rupture occurs and intra-abdominal
Currently, the most sensitive modality for diagnosing SMA pseudoaneurysms is
EP
mesenteric angiography with or without digital subtraction. Diagnosis of SMA
AC C
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
5
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compounded by the possibility of pseudoaneurysmal compression and erosion of adjacent structures resulting in potentially lethal hemorrhages.(6)
RI PT
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
SC
reconstruction, as was performed in our first case, is acceptable and commonly performed in emergency situations.(5) Revascularization, however, is recommended for patients who
M AN U
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
TE D
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
EP
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
AC C
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)
6
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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
RI PT
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
SC
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
M AN U
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
TE D
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
EP
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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