- Email: [email protected]
Mycotic aneurysm of the superior mesenteric artery
Mycotic
Aneurysm
of the Superior
Mesen teric Artery J. FILIPE ALVARES, M.D., VICTOR PARSONNET,M.D., ANDDONALDK. BRIEF, M.D., Newark, New Jersey
From the Newark Beth Israel Hospital, Jersey.
Newark,
tered and have assumed greater importance because they can be successfully treated. DeBakey and Cooley performed the first successful resection in 1953 [4]. Since then five more have been successfully treated by West [5], Katz and Jacobson [6], Horton [7], and Buchman and Martin [8], and Poblacion, McKenty and Campbell [9] have reported a patient operated on by Isaac and Farr. A seventh case is now described. (Table I.)
New
LTHO~GHANEURYSMSinvolving the superior mesenteric artery are rare, mycotic aneurysms occur in that artery with relatively frequency. Lewis and Schrager recorded a series of ninety-two mycotic aneurysms in sixty-five patients and found twenty-five located in the superior mesenteric artery [I]. Stengel and Wolferth recorded a series of 264 mycotic aneurysms in 217 patients ; 38 of these aneurysms involved the inferior mesenteric artery and its branches [Z]. In Scott’s analysis of 115 abdominal aneurysms at the Johns Hopkins Hospital, there were twenty-one mycotic aneurysms, five involving the superior mesenteric artery [3]. Since bacterial endocarditis was formerly a highly fatal disease, mycotic aneurysms were largely of academic interest; but with the successful treatment of endocarditis with antibiotics, they are now more frequently encoun-
A
CASE REPORT A thirty-six year old Negro male patient was admitted to the Vascular Service of Newark Beth Israel Hospital on October 26, 1964 with a tender abdominal mass and a history of frequent episodes of obstipation, relieved by enema. In three months his weight fell from 189 to 104 pounds. He had been previously hospitalized in July 1964 with fever, cough, paralysis of the right side of the face and upper extremity, and paresis of the right leg. He denied having previously had hypertension, measles, diphtheria, or rheumatic heart disease. A blood culture showed nonhemolytic Staphylococcus
TABLE SUCCESSFULLY
I
TREATED
PATIENTS
Year
Cause
Treatment
DeBakey and Cooley [4]
1953
Bacterial endocarditis
West [5]
Katz and Jacobson [6]
1954 1957
Unspecified Bacterial endocarditis
Horton [7]
1959
Bacterial endocarditis
Buchman and Martin [8]
1962
Bacterial endocarditis
Poblacion, McKenty, and Campbell [9] Alvares, Parsonnet, and Brief (present case)
1964 1964
Bacterial endocarditis Bacterial
Resection of the aneurysm and inferior mesenteric vein Restorative aneurysmorrhaphy Resection of aneurysm and nonviable small intestine Resection of aneurysm and right hemicolectomy Resection of aneurysm, vein, and nonviable ileum in 18 to 24 hours Ligation Obliterative endoaneurysmorrhaphy
Case
Vol. 111, February
1966
237
Alvares, Parsonnet, and Brief
FIG. 1. A and B, photograph and diagram of translumbar aortogram revealing abrupt cut-off of superior mesenteric artery due to the aneurysmal mass, and the rich collateral flow through the Arch of Riolan. The aneurysm itself was not visualized on the early films because of slow filling due to extensive thrombosis and poor run-off.
albus. He was discharged with the diagnosis of subacute bacterial endocarditis, mitral insufliciency, and cerebral embolism with hemiparesis. On September 9, 1964 the patient was admitted to the Medical Service of the Newark Beth Israel Hospital in congestive cardiac failure. Blood cultures on September 10, 1964 revealed Staphylococcus aureus and Bacillus aerogenes; he was treated with digitalis, diuretics, and large doses of penicillin and Benemid.@ The patient was an alert, cooperative, emaciated Negro man with long thin extremities suggesting archnodactyly, but with no other stigmas of Marfan’s syndrome. The heart was enlarged with the point of maximal impulse in the sixth intercostal space; there was a precordial systolic thrill, a grade 4 holosystolic murmur loudest at the apex, and a soft first sound and a loud second sound of the mitral valve. Blood pressure was 100/60 mm. Hg in the right arm; the lungs were clear. The patient’s abdomen was moderately distended; there was a tender mass measuring about 8 cm. in diameter with expansile pulsation palpated below the left costal border which could be moved about 4 cm. to the right and left. A soft systolic bruit could be heard on auscultation. The liver was palpable two fingerbreadths below the costal margin. The left radial, femoral, popliteal, and pedal pulses were not palpable, apparently being occluded by previous systemic embolization. The neurologic examination was noncontributory. Laboratory examination revealed hemoglobin of 9.5 gm. per cent, hematocrit 37 per cent, white blood cell count 10,800 per cu. mm., and sedimentation rate 27. Blood cultures revealed no abnormalities. Blood urea nitrogen was 18, chloride 95.5, sodium
135.5, potassium 4, carbon dioxide 28, and blood sugar 88. The electrocardiogram showed left atria1 hypertrophy with nonspecific ST-T changes and abnormal P waves. X-ray films of the chest revealed minimal cardiomegaly, mild pulmonary congestion, and a compression deformity of the mid-dorsal vertebra. Abdominal films disclosed a soft tissue mass extending 6 cm. to the left of the lumbar spine, and measuring about 12 cm. in diameter. A gastrointestinal series and intravenous pyelogram were noncontributory. A translumbar aortogram revealed an abrupt cut-off of the superior mesenteric artery near its origin, suggesting an aneurysm. (Fig. 1.) At operation on November 4, 1964 about 180 cc. of yellow fluid were found in the peritoneal cavity. The mass, which was expansile, pulsatile, and edematous, was situated at the root of the mesentery of the small bowel, adherent to the transverse mesocolon, and it occupied the mesentery of the first portion of the jejunum; it was 12 cm. in diameter. (Fig. 2.) An attempt was made to encircle the neck of the aneurysm in the inframesocolic portion. This was not feasible due to adherence of the mass to the superior mesenteric vein. The gastrocolic ligament was opened and the superior mesenteric artery was encircled with an umbilical tape below the middle colic and inferior pancreaticoduodenal branches as it crossed the third portion of the duodenum. While the artery was occluded with a tourniquet, further dissection of the aneurysmal sac was undertaken. Multiple tributaries from the mesenteric vein were densely adherent to the posterior wall and it was thought that sacrificing these would impair
Mycotic
Aneurysm
of Superior
hiZestenteric
Artery
Frc:. :! l’lwto:rapil of aneurysm with ascending and transwrse col~m toward the left and small intestine toxvard the right. The aneurysm, with the peritoneal surface partiali>- btripped off, projects form-ard from the
mescntery.
the viability oi the jejunum. Therefore, the aneurysma1 sac was opened through an incision on its anterior wall. the clot evacuated, and the proximal opening of the superior mesenteric artery closed with a No. 5-O Mersilenes suture. (Fig. 3.) The anterior wall of the aneurysm was resected, leaving the posterior portion in place. No retrograde bleeding was encountered from distal arteries which apparently were thrombosed. The anterior leaf of the mesentery and redundant wall were closed with No. 3-O chromic sutures. No change in color was noted in the small intestine or colon. The encircling tapes were removed and the peritoneal cavity was closed in layers. The patient received 500 cc. of whole blood during the operation, and withstood the procedure well. The postoperative course was complicated by transient hemiparesis of the right side, presumably embolic in nature. He was discharged as fully recovered on Sovember 23, 1964. Since that time the patient has undergone cardiac catheterization and a diagnosis of mitral and tricuspid insufficiency was made. In addition, chromosome studies for Marfan’s syndrome ha\-e given negative results. In May 1965 the patient underwent a successful operation for Starr valve replacement of his mitral valve. COMMENTS
summarizes reports of the patients treated successfully. Stevenson in 1895 was apparently the first to attack surgically a mycotic aneurysm of the superior mesenteric artery. He introduced two yards of fine steel wire into the sac through a cannula [IO]. The patient died of hemorrhage twenty-seven hours later. In 1898 Reed reported an operation performed by Finney in which a galvanic current was used to induce Table
I
Vol. 111, February 1966
FIG. 3. Diagrammatic rcpreaentatiou of tllc aneurysm and operative pl-ocedurc; a segment of transverw co11m has been omitted for illustrative purposes. A, c,;.cr-all view oi anatomic arrangement; a tape encircles tlte superior mesrutcric artery below the pancreas. R aneurysm opened, thrombi evacuated, and orifice of the superior mesentcric artery sutured. C, closure of peritoneum and residual aneurysmal wall.
thrombosis ; the patient died twenty days postoperatively [11]. Stern reported on the first patient on whom extirpation of the aneurysm was performed in 1908; this patient died of hemorrhage after reoperation for recurrence [12]. In 1923 Kolin reported on a patient in whom the stem of the aneurysm was ligated. The latter was removed in toto, sacrificing the inferior mesenteric vein. However, the patient died seventeen hours later of cardiac failure
P31. The type of procedure will depend on the findings at surgery. The method reported herein successfully obliterated the aneurysm and was performed in a short time with minimal blood loss. SUMM.~RY
A case of mycotic aneurysm of the superior mesenteric artery secondary to bacterial endocarditis is reported. This was the seventh
Alvares, known successful resection of the superior mesenteric
an aneurysm
Parsonnet,
and Brief
of
artery.
8.
REFERENCES
1. LEWIS, D. and SCHRAGER, V. L. Embolomycotic aneurysms. J.A .M.A., 53: 1808, 1909. 2. STENGEL, A. and WOLFERTH, C. C. Mycotic (bacterial) aneurysms of intravascular origin. Arch. Int. Med., 31: 527, 1923. 3. SCOTT, V. Abdominal aneurysms: report of 96 cases. Am. J. Syph., 28: 682, 1944. 4. DEBAKEY, M. D. and COOLEY, D. A. Successfully resection of mycotic aneurysms of superior mesenteric artery: case report and review of literature. Am. Surgeon, 19: 202, 1953. 5. WEST, J. P. Bneurysm of the superior mesenteric artery ; successfully treated by restorative aneurysmorrhaphy. Ann. Surg., 140: 882, 1954. 6. KATZ, B. and JACOBSON, L. Aneurysm of superior mesenteric artery successfully treated. Surgery, 41: 613, 1957. 7. HORTON, R. E. Ruptured mycotic aneurysm of
9.
10.
11.
12.
13.
superior mesenteric artery. Brit. J. Surg., 46: 541, 1959. BUCHMAN, R. J. and MARTIN, G. W. Management of mycotic aneurysm of the superior mesenteric artery. Ann. Surg., 155: 620, 1962. POBLACION, D., MCKENTY, J., and CAMPBELL, M. Mycotic aneurysm of the superior mesenteric artery complicating S.B.E. : successful resection. Canad. M. A. J., 90: 744, 1964. STEVENSON, W. F. Case of abdominal aneurysm treated by laparotomy and introduction of wire into sac with death. Lance& 1: 22, 1895. REED, M. D. Aneurysms in the Johns Hopkins hospital; all cases treated in the surgical service from the opening of the hospital to January, 1922. Arch. Surg., 12: 1, 1926. STERN, K. Operation eines Aneurysma embolomycoticum einer Mesenterealarterie. Be&. k&z. Chir., 57: 315, 1908. KOLIN, L. Zir Kenntinis der Anatomic, Klinik and Therapie des -4neurysma der Arteriae mesentericae superioris. Arch. klin. Chir., 123: 684, 1923.
American Journal of Surgery
Aneurysm
of the Superior
Mesen teric Artery J. FILIPE ALVARES, M.D., VICTOR PARSONNET,M.D., ANDDONALDK. BRIEF, M.D., Newark, New Jersey
From the Newark Beth Israel Hospital, Jersey.
Newark,
tered and have assumed greater importance because they can be successfully treated. DeBakey and Cooley performed the first successful resection in 1953 [4]. Since then five more have been successfully treated by West [5], Katz and Jacobson [6], Horton [7], and Buchman and Martin [8], and Poblacion, McKenty and Campbell [9] have reported a patient operated on by Isaac and Farr. A seventh case is now described. (Table I.)
New
LTHO~GHANEURYSMSinvolving the superior mesenteric artery are rare, mycotic aneurysms occur in that artery with relatively frequency. Lewis and Schrager recorded a series of ninety-two mycotic aneurysms in sixty-five patients and found twenty-five located in the superior mesenteric artery [I]. Stengel and Wolferth recorded a series of 264 mycotic aneurysms in 217 patients ; 38 of these aneurysms involved the inferior mesenteric artery and its branches [Z]. In Scott’s analysis of 115 abdominal aneurysms at the Johns Hopkins Hospital, there were twenty-one mycotic aneurysms, five involving the superior mesenteric artery [3]. Since bacterial endocarditis was formerly a highly fatal disease, mycotic aneurysms were largely of academic interest; but with the successful treatment of endocarditis with antibiotics, they are now more frequently encoun-
A
CASE REPORT A thirty-six year old Negro male patient was admitted to the Vascular Service of Newark Beth Israel Hospital on October 26, 1964 with a tender abdominal mass and a history of frequent episodes of obstipation, relieved by enema. In three months his weight fell from 189 to 104 pounds. He had been previously hospitalized in July 1964 with fever, cough, paralysis of the right side of the face and upper extremity, and paresis of the right leg. He denied having previously had hypertension, measles, diphtheria, or rheumatic heart disease. A blood culture showed nonhemolytic Staphylococcus
TABLE SUCCESSFULLY
I
TREATED
PATIENTS
Year
Cause
Treatment
DeBakey and Cooley [4]
1953
Bacterial endocarditis
West [5]
Katz and Jacobson [6]
1954 1957
Unspecified Bacterial endocarditis
Horton [7]
1959
Bacterial endocarditis
Buchman and Martin [8]
1962
Bacterial endocarditis
Poblacion, McKenty, and Campbell [9] Alvares, Parsonnet, and Brief (present case)
1964 1964
Bacterial endocarditis Bacterial
Resection of the aneurysm and inferior mesenteric vein Restorative aneurysmorrhaphy Resection of aneurysm and nonviable small intestine Resection of aneurysm and right hemicolectomy Resection of aneurysm, vein, and nonviable ileum in 18 to 24 hours Ligation Obliterative endoaneurysmorrhaphy
Case
Vol. 111, February
1966
237
Alvares, Parsonnet, and Brief
FIG. 1. A and B, photograph and diagram of translumbar aortogram revealing abrupt cut-off of superior mesenteric artery due to the aneurysmal mass, and the rich collateral flow through the Arch of Riolan. The aneurysm itself was not visualized on the early films because of slow filling due to extensive thrombosis and poor run-off.
albus. He was discharged with the diagnosis of subacute bacterial endocarditis, mitral insufliciency, and cerebral embolism with hemiparesis. On September 9, 1964 the patient was admitted to the Medical Service of the Newark Beth Israel Hospital in congestive cardiac failure. Blood cultures on September 10, 1964 revealed Staphylococcus aureus and Bacillus aerogenes; he was treated with digitalis, diuretics, and large doses of penicillin and Benemid.@ The patient was an alert, cooperative, emaciated Negro man with long thin extremities suggesting archnodactyly, but with no other stigmas of Marfan’s syndrome. The heart was enlarged with the point of maximal impulse in the sixth intercostal space; there was a precordial systolic thrill, a grade 4 holosystolic murmur loudest at the apex, and a soft first sound and a loud second sound of the mitral valve. Blood pressure was 100/60 mm. Hg in the right arm; the lungs were clear. The patient’s abdomen was moderately distended; there was a tender mass measuring about 8 cm. in diameter with expansile pulsation palpated below the left costal border which could be moved about 4 cm. to the right and left. A soft systolic bruit could be heard on auscultation. The liver was palpable two fingerbreadths below the costal margin. The left radial, femoral, popliteal, and pedal pulses were not palpable, apparently being occluded by previous systemic embolization. The neurologic examination was noncontributory. Laboratory examination revealed hemoglobin of 9.5 gm. per cent, hematocrit 37 per cent, white blood cell count 10,800 per cu. mm., and sedimentation rate 27. Blood cultures revealed no abnormalities. Blood urea nitrogen was 18, chloride 95.5, sodium
135.5, potassium 4, carbon dioxide 28, and blood sugar 88. The electrocardiogram showed left atria1 hypertrophy with nonspecific ST-T changes and abnormal P waves. X-ray films of the chest revealed minimal cardiomegaly, mild pulmonary congestion, and a compression deformity of the mid-dorsal vertebra. Abdominal films disclosed a soft tissue mass extending 6 cm. to the left of the lumbar spine, and measuring about 12 cm. in diameter. A gastrointestinal series and intravenous pyelogram were noncontributory. A translumbar aortogram revealed an abrupt cut-off of the superior mesenteric artery near its origin, suggesting an aneurysm. (Fig. 1.) At operation on November 4, 1964 about 180 cc. of yellow fluid were found in the peritoneal cavity. The mass, which was expansile, pulsatile, and edematous, was situated at the root of the mesentery of the small bowel, adherent to the transverse mesocolon, and it occupied the mesentery of the first portion of the jejunum; it was 12 cm. in diameter. (Fig. 2.) An attempt was made to encircle the neck of the aneurysm in the inframesocolic portion. This was not feasible due to adherence of the mass to the superior mesenteric vein. The gastrocolic ligament was opened and the superior mesenteric artery was encircled with an umbilical tape below the middle colic and inferior pancreaticoduodenal branches as it crossed the third portion of the duodenum. While the artery was occluded with a tourniquet, further dissection of the aneurysmal sac was undertaken. Multiple tributaries from the mesenteric vein were densely adherent to the posterior wall and it was thought that sacrificing these would impair
Mycotic
Aneurysm
of Superior
hiZestenteric
Artery
Frc:. :! l’lwto:rapil of aneurysm with ascending and transwrse col~m toward the left and small intestine toxvard the right. The aneurysm, with the peritoneal surface partiali>- btripped off, projects form-ard from the
mescntery.
the viability oi the jejunum. Therefore, the aneurysma1 sac was opened through an incision on its anterior wall. the clot evacuated, and the proximal opening of the superior mesenteric artery closed with a No. 5-O Mersilenes suture. (Fig. 3.) The anterior wall of the aneurysm was resected, leaving the posterior portion in place. No retrograde bleeding was encountered from distal arteries which apparently were thrombosed. The anterior leaf of the mesentery and redundant wall were closed with No. 3-O chromic sutures. No change in color was noted in the small intestine or colon. The encircling tapes were removed and the peritoneal cavity was closed in layers. The patient received 500 cc. of whole blood during the operation, and withstood the procedure well. The postoperative course was complicated by transient hemiparesis of the right side, presumably embolic in nature. He was discharged as fully recovered on Sovember 23, 1964. Since that time the patient has undergone cardiac catheterization and a diagnosis of mitral and tricuspid insufficiency was made. In addition, chromosome studies for Marfan’s syndrome ha\-e given negative results. In May 1965 the patient underwent a successful operation for Starr valve replacement of his mitral valve. COMMENTS
summarizes reports of the patients treated successfully. Stevenson in 1895 was apparently the first to attack surgically a mycotic aneurysm of the superior mesenteric artery. He introduced two yards of fine steel wire into the sac through a cannula [IO]. The patient died of hemorrhage twenty-seven hours later. In 1898 Reed reported an operation performed by Finney in which a galvanic current was used to induce Table
I
Vol. 111, February 1966
FIG. 3. Diagrammatic rcpreaentatiou of tllc aneurysm and operative pl-ocedurc; a segment of transverw co11m has been omitted for illustrative purposes. A, c,;.cr-all view oi anatomic arrangement; a tape encircles tlte superior mesrutcric artery below the pancreas. R aneurysm opened, thrombi evacuated, and orifice of the superior mesentcric artery sutured. C, closure of peritoneum and residual aneurysmal wall.
thrombosis ; the patient died twenty days postoperatively [11]. Stern reported on the first patient on whom extirpation of the aneurysm was performed in 1908; this patient died of hemorrhage after reoperation for recurrence [12]. In 1923 Kolin reported on a patient in whom the stem of the aneurysm was ligated. The latter was removed in toto, sacrificing the inferior mesenteric vein. However, the patient died seventeen hours later of cardiac failure
P31. The type of procedure will depend on the findings at surgery. The method reported herein successfully obliterated the aneurysm and was performed in a short time with minimal blood loss. SUMM.~RY
A case of mycotic aneurysm of the superior mesenteric artery secondary to bacterial endocarditis is reported. This was the seventh
Alvares, known successful resection of the superior mesenteric
an aneurysm
Parsonnet,
and Brief
of
artery.
8.
REFERENCES
1. LEWIS, D. and SCHRAGER, V. L. Embolomycotic aneurysms. J.A .M.A., 53: 1808, 1909. 2. STENGEL, A. and WOLFERTH, C. C. Mycotic (bacterial) aneurysms of intravascular origin. Arch. Int. Med., 31: 527, 1923. 3. SCOTT, V. Abdominal aneurysms: report of 96 cases. Am. J. Syph., 28: 682, 1944. 4. DEBAKEY, M. D. and COOLEY, D. A. Successfully resection of mycotic aneurysms of superior mesenteric artery: case report and review of literature. Am. Surgeon, 19: 202, 1953. 5. WEST, J. P. Bneurysm of the superior mesenteric artery ; successfully treated by restorative aneurysmorrhaphy. Ann. Surg., 140: 882, 1954. 6. KATZ, B. and JACOBSON, L. Aneurysm of superior mesenteric artery successfully treated. Surgery, 41: 613, 1957. 7. HORTON, R. E. Ruptured mycotic aneurysm of
9.
10.
11.
12.
13.
superior mesenteric artery. Brit. J. Surg., 46: 541, 1959. BUCHMAN, R. J. and MARTIN, G. W. Management of mycotic aneurysm of the superior mesenteric artery. Ann. Surg., 155: 620, 1962. POBLACION, D., MCKENTY, J., and CAMPBELL, M. Mycotic aneurysm of the superior mesenteric artery complicating S.B.E. : successful resection. Canad. M. A. J., 90: 744, 1964. STEVENSON, W. F. Case of abdominal aneurysm treated by laparotomy and introduction of wire into sac with death. Lance& 1: 22, 1895. REED, M. D. Aneurysms in the Johns Hopkins hospital; all cases treated in the surgical service from the opening of the hospital to January, 1922. Arch. Surg., 12: 1, 1926. STERN, K. Operation eines Aneurysma embolomycoticum einer Mesenterealarterie. Be&. k&z. Chir., 57: 315, 1908. KOLIN, L. Zir Kenntinis der Anatomic, Klinik and Therapie des -4neurysma der Arteriae mesentericae superioris. Arch. klin. Chir., 123: 684, 1923.
American Journal of Surgery