Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 204-207

Bovine pericardial graft for revascularization of the lower limb following mycotic aneurysm complicating infective endocarditis


Department of Cardiac Surgery, La Rabta Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia

Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. M Sobhi
Department of Cardiac Surgery, La Rabta Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_9_19

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  Abstract 


Mycotic aneurysm, which complicates 2.5%–10% of cases of infectious endocarditis, is an important cause of morbidity and mortality despite antibiotic therapy. Elective surgery remains the cornerstone of the treatment of mycotic aneurysms because of the major risk of rupture. For femoral arteries, the surgical treatment is based on the resection of the aneurysm, with revascularization of the territory downstream. The recommended materials for revascularizations are in the first place biological grafts such as veins grafts (great saphenous vein) and homograft. In our observation, faced with the small diameter of the internal saphenous vein and the lack of homograft availability, and considering the high risk of infection recurrence at the operating site, we opted for the confection of biological graft using bovine pericardium and we think that it will be more resistant to infection than prostheses. According to our knowledge, this technique has not been reported before in the literature, and the validation of this technique on a series of cases and in the long term is necessary.

Keywords: Bovine pericardium, infectious endocarditis, mycotic aneurysms, revascularization


How to cite this article:
Sobhi M, Mohamed M, Bilel D, Jalel Z, Taoufik K. Bovine pericardial graft for revascularization of the lower limb following mycotic aneurysm complicating infective endocarditis. Indian J Vasc Endovasc Surg 2019;6:204-7

How to cite this URL:
Sobhi M, Mohamed M, Bilel D, Jalel Z, Taoufik K. Bovine pericardial graft for revascularization of the lower limb following mycotic aneurysm complicating infective endocarditis. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Sep 19];6:204-7. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/204/265784




  Introduction Top


An aneurysm is a localized permanent dilatation of an artery >50% of its expected normal diameter.[1] Its formation can be attributed to various causes. Femoral artery aneurysms are most often the result of traumatic injury. Atraumatic aneurysms are rare and usually thought to be of degenerative or unknown etiology.[2] This article describes a femoral artery false aneurysm secondary to bacterial endocarditis and its embolic sequelae.


  Case Report Top


A 47-year-old man with a medical history of aortic valve replacement in 1995 consults in the emergency room for a fever at 39°C for 4 days. Clinical examination finds a blood pressure at 80/50 mmHg, a heart rate at 115 bpm, systolic murmur in the mitral focus, and a painful 2 cm mass in the right groin initially retained as lymphadenopathy; however, peripheral pulses are present without signs of lower limb ischemia. White blood cells were 15800 and C-reactive protein was 117. The diagnosis of infective endocarditis is confirmed by Doppler echocardiography which showed severe mitral valve regurgitation, many labile vegetations on the ventricular face of the aortic prosthesis with abscess of the aortic ring, and left ventricular ejection fraction of 60%. Three blood culture were negative. Cerebral and thoracoabdominal computed tomography showed renal and splenic infarction. Four-day antibiotic treatment based on amoxicillin, Bristopen, and gentamicin was performed. Given the persistence of sepsis, the patient was operated. He had a mitral and aortic valve replacement. Immediate operative follow-up was simple. Initial antibiotic was changed by vancomycin because bacteriological specimens were positive at Citrobacter koseri.

Three weeks after the operation, he presented with a mass of the right groin increasing in size, painful and pulsatile, associated with cyanosis and toes pain of the same lower limb and pulses' disappearance. CT scan showed a 4-cm false aneurysm of the common femoral artery with short occlusion at the origin of the superficial femoral artery [Figure 1]. The patient was urgently operated. The first operative step was the control of the arterial axes as well as the resection of the aneurysmal pocket and the evacuation of the infected hematoma. The second operative time was to restore the arterial continuity. Given the infectious context, our choice is oriented toward a biological graft. The great saphenous vein has shown a small diameter, and as the nonavailability of homograft, we sutured a 7 mm-diameter tube by bovine pericardium [Figure 2] and used it as a graft between common femoral artery and superficial femoral artery with reimplantation of the deep femoral artery [Figure 3]. Immediate follow-up showed symptom free, recovery of all pulses and cyanosis disappearance. Follow-up at 1 year showed the absence of local infection recurrence and patency preserved.
Figure 1: Computed tomography scan of lower limbs showed a 4-cm false aneurysm of the common femoral artery

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Figure 2: Confection of 7 mm-diameter tube by bovine pericardium

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Figure 3: Graft between common femoral artery and superficial femoral artery with reimplantation of the deep femoral artery

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  Discussion Top


Mycotic aneurysm is one of the major causes of IE morbidity and mortality despite antibiotic therapy. According to Sexton et al., it complicates an infectious endocarditis in 1.2% to 5.4%.[3] It is often diagnosed late because of its asymptomatic nature and may progress to rupture, the outcome of which may be fatal.[4]

Four mechanisms of occurrence of these infectious aneurysms have been proposed:

  • The development of an infection on an altered arterial vascular wall (especially an athermanous plaque)
  • The development of a false aneurysm on a healthy arterial wall following an infectious embolism. Moreover, it is the case of mycotic aneurysm
  • False aneurysms by contiguity, caused by the spread of an infectious center of proximity
  • Finally, false aneurysms by direct posttraumatic infectious inoculation (for example, after endovascular operation).


Osler is the first doctor who described mycotic aneurysm formation in 1885. It is recognized to be the result of an infected embolus (usually vegetative) lodging within an artery leading to an exudative mesarteritis and subsequent partial digestion of elements of the arterial wall. The eventual result is focal mural necrosis and subsequent aneurysm formation.[5]

Embolism may occur in 22%–50% of patients with endocarditis and is most likely to lodge at arterial branch points. It usually results in arterial occlusion rather than aneurysm formation.[6] Mycotic aneurysms occur most frequently in the intracranial arteries (65%), followed by visceral arteries and vessels of the upper and lower limbs. The preferential site of lower limb embolism is the common femoral artery bifircation like in our case. Regarding peripheral locations, proximal involvement seems to be more frequent. Brudon and al reported 21 cases of mycoyic aneurysms from which 9 had ilio-femoral and 8 popliteal locations.[7]

The rate of embolism decreases after the first 3 weeks of antimicrobial therapy although it can still occur after the total period of antibiotic therapy has been completed.

The bacteriological profile of mycotic germs has changed over time. Previously, as shown in the study of Stengel and Wolferth, nonhemolitic streptococcus, Pneumococcus, and Staphylococcus were first implicated in the genesis of mycotic aneurysm.[8] Currently, bacterial germs are different on whether the aneurysm occurs in the general population or seen in intravenous drug users or whether it occurs on a native or prosthetic valve. In the general population and on a native valve, the germs usually found are Streptococcus viridans (22%) and Staphylococcus aureus (20%). In the addicted population, the primary microorganisms were S. aureus (36%).[9]

In addition to the clinical examination, additional explorations are sometimes necessary to confirm the diagnosis of mycotic false aneurysm and to establish the therapeutic strategy. Computed tomography (CT) angiography is the most useful and has the additional advantage of being more available than angiomagnetic resonance imaging (MRI). CT angiography allows the diagnosis of these aneurysms, with sensitivity and specificity of 90% and 86%, respectively. Angio-MRI is an emerging technique, allowing this diagnosis with a sensitivity of 87% and a specificity of 95%.[10] Finally, positron emission tomography (PET or PET scan) with fluorodeoxyglucose labeled with fluorine-18 could be a promising technique, but additional studies analyzing its diagnostic performance (sensitivity and specificity) are indispensable.[4]

Valvular surgery has an important role in the prevention of embolism with the greatest benefit being seen in the early stages of the disease. Patients with large vegetations, recurrent embolism, antibiotic-resistant organisms, and prosthetic valves are at particularly high risk of embolic phenomena.[11] The classical treatment of mycotic aneurysms is medical by antibiotics and surgical by the exclusion of the aneurysm. The combination of both is indispensable in the majority of cases. Indeed, in the absence of surgical treatment, medical treatment alone is destined to fail in 95%–100% of cases.[4] For some authors, preoperative antibiotic therapy for at least 1 week may reduce the risk of subsequent complications such as recurrence and adhesions. There is, however, no consensus regarding the optimal duration of antibiotic therapy although the usual recommended duration is 6 weeks.

The management of mycotic aneurysms complicating an infectious endocarditis includes both the treatment of the valve disease (starting point of septic embolism) and the treatment of vascular ectasia (who has his own evolutionary genius). Elective surgery remains the cornerstone of the treatment of mycotic aneurysms because of the major risk of rupture (between 38% and 50% of cases). In general, the therapeutic options associate more or less an arterial ligation, aneurysmectomy, vascular reconstruction, or arterial embolization. For femoral arteries, the surgical treatment is based on the resection of the aneurysm, with revascularization of the territory downstream. The recommended materials for revascularizations are in the first place biological grafts such as veins grafts (great saphenous vein) and homograft and in the second place, polytetrafluoroethylene-expanded prostheses which seem to be more resistant to infection than Dacron prostheses.[12],[13],[14]

In our observation, faced with the small diameter of the internal saphenous vein and the lack of homograft availability, and considering the high risk of infection recurrence at the operating site, we opted for the confection of biological graft using bovine pericardium. Bovine grafts have been used, and we think that it will be more resistant to infection than prostheses. According to our knowledge, this technique has not been reported before in the literature, and the validation of this technique on a series of cases and in the long term is necessary.


  Conclusion Top


Infectious endocarditis can complicate vascular sites, producing visceral aneurysms from septic emboli. Mycotic aneurysm, which complicates 2.5%–10% of cases of IE, is an important cause of morbidity and mortality despite antibiotic therapy. The management of mycotic aneurysm depends on its size and location. The artery may be embolized angiographically or ligated surgically if sufficient distal blood flow can be maintained; otherwise, revascularization by biological bypass is necessary. In case of small great saphenous vein and the lack of homograft availability, the confection of biological graft using bovine pericardium could be a solution to prevent infection recurrence at the operating site.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991;13:452-8.  Back to cited text no. 1
    
2.
Eppinger H: Pathogenesis (Histogenesis and Aetiology) of Aneurysms including the aneurysm equi veminosum. Arch Klin Chir 1887;1:563-9.  Back to cited text no. 2
    
3.
Sexton DJ, Bashore TM. Infective endocarditis. In: Topol J, editor. Textbook of Cardiovascular Medicine. Philadelphia: Lippincott-Raven; 1998. p. 607-37.  Back to cited text no. 3
    
4.
Miranda S, Janvresse A, Plissonnier D, Levesque H, Marie I. Infectious aortic aneurysms. A case series of 10 patients. Rev Med Interne 2010;31:255-61.  Back to cited text no. 4
    
5.
Knirsch W, Gunthard J. New recommendations for prophylactic antibiotic therapy of endocarditis in children in Switzerland. Paediatrica 2009;20:35-40.  Back to cited text no. 5
    
6.
Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr., Bolger AF, Levison ME, et al. Infective endocarditis: Diagnosis, antimicrobial therapy, and management of complications: A statement for healthcare professionals from the committee on rheumatic fever, endocarditis, and Kawasaki disease, council on cardiovascular disease in the young, and the councils on clinical cardiology, stroke, and cardiovascular surgery and anesthesia, American Heart Association: Endorsed by the Infectious Diseases Society of America. Circulation 2005;111:e394-434.  Back to cited text no. 6
    
7.
Brudon JR, Ravat F, Desthieux JM, Descotes J. Mycotic aneurysm of arteries of the lower limbs. Apropos of 21 cases. Chirurgie 1988;114:482-9.  Back to cited text no. 7
    
8.
Stengel A, Wolferth CC. Mycotic (bacterial) aneurysms of intravascular origin. Arch Intern Med 1923;31:527-54.  Back to cited text no. 8
    
9.
Magilligan DJ Jr., Quinn EL, editors. Active infective endocarditis. In: Endocarditis: Medical and Surgical Management. New York: Marcel Dekker; 1986. p. 207-19.  Back to cited text no. 9
    
10.
Kuo I, Long T, Nguyen N, Chaudry B, Karp M, Sanossian N, et al. Ruptured intracranial mycotic aneurysm in infective endocarditis: A natural history. Case Rep Med 2010;2010. pii: 168408.  Back to cited text no. 10
    
11.
Vilacosta I, Graupner C, San Román JA, Sarriá C, Ronderos R, Fernández C, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 2002;39:1489-95.  Back to cited text no. 11
    
12.
Castier Y, Paraskevas N, Maury JM, Karsenti A, Cerceau O, Legendre AF, et al. Cryopreserved arterial allograft reconstruction for infected peripheral bypass. Ann Vasc Surg 2010;24:994-9.  Back to cited text no. 12
    
13.
Fujitani RM, Bassiouny HS, Gewertz BL, Glagov S, Zarins CK. Cryopreserved saphenous vein allogenic homografts: An alternative conduit in lower extremity arterial reconstruction in infected fields. J Vasc Surg 1992;15:519-26.  Back to cited text no. 13
    
14.
Brown KE, Heyer K, Rodriguez H, Eskandari MK, Pearce WH, Morasch MD, et al. Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up. J Vasc Surg 2009;49:660-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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