Peripheral mycotic aneurysms in infective endocarditis

Today, infective endocarditis (IE) remains a severe illness, with high mortality and morbidity. Mycotic aneurysms (MAs) are rare complications of IE. For most patients, surgical intervention represents the only hope for radical cure of extracranial MAs, and survival.

A total of 238 patients with IE was treated at the authors' center between January 1990 and December 2003. Among these patients, 10 underwent surgical intervention due to peripheral MAs.

Concomitant surgery for intracardiac and extracardiac pathology was applied in three patients with native valve endocarditis to excise infected material. Aneurysmectomy and revascularization were performed in four patients with native endocarditis, and in three with prosthetic valve endocarditis (PVE). The intracardiac pathologies of these seven patients were treated with antimicrobial agents. Eight patients underwent surgery after completion of three weeks' antibiotic therapy. An autologous saphenous vein interposition was performed in eight patients, but in two cases, due to size discrepancy, a polytetraflouroethylene (PTFE) graft was chosen as the initial conduit to achieve arterial continuity. Saphenous vein graft rupture occurred in one patient; a PTFE graft was used to achieve second revascularization. Limb salvage was achieved in nine patients. Below-knee amputation was necessary in one patient; this was due to prior embolism of the distal arterial tree. Two patients died, one due to cerebral embolism and another to rupture of undiagnosed visceral MA. All other patients remain alive, without complications.

Complete revascularization should be essential to treat peripheral MA in IE. Adequate resection, appropriate parenteral administration of antimicrobial agents and size discrepancy are far more important factors than the type of graft material in preventing suture-line infection and vessel or graft rupture.