Article ID: CJ-17-0937
A 48-year-old man without Marfanoid habitus, who had undergone aortic valve replacement for aortic valve prolapse and ascending aortic replacement for dissecting aortic aneurysm 10 and 4 years earlier, respectively, presented to a hospital with a 1-week history of fever, and received antibiotic treatment. Blood sample culture performed before antibiotic treatment indicated methicillin-susceptible coagulase-negative staphylococci. He presented at Keio University Hospital for further evaluation. Transesophageal echocardiography (TEE) showed vegetation (4.7 mm) on the annulus of the mechanical aortic valve. He was treated with antibiotics (cefazolin, gentamicin, and rifampicin) under the diagnosis of infective endocarditis (IE). Computed tomography (CT) on the second day of admission indicated aneurysms with a hazy thick vascular wall of 8 and 6 mm in diameter on the celiac trunk and ostium of the common hepatic artery (CHA), respectively (Figure 1A–C). These were diagnosed as mycotic celiac artery aneurysms. Follow-up CT on the sixth day showed that the celiac trunk and CHA aneurysms had expanded to diameters of 12 and 11 mm, respectively, in association with a newly developed dissected splenic artery (Figure 1D–F). On the 14th day, additional expansion of the celiac trunk and CHA aneurysms (14 and 12 mm in diameter, respectively) were observed and associated with progressive dissection of the splenic artery, leading to the disruption of antegrade blood flow to its distal site (Figure 1G–I). Follow-up TEE showed a thickened prosthetic valve leaflet and vegetation, suggesting that the IE was not resolved.
Developing celiac mycotic aneurysms. (A–C) Computed tomography angiography on day 2 showing aneurysms on the (A,C) celiac artery trunk (gray arrow) and (B,C) ostium of the common hepatic artery (CHA; white arrow). Serial examination on (D–F) day 6 and (G–I) day 14 showing rapid growth of aneurysms on the (D,F,G,I) celiac trunk (gray arrow) and (E,F,H,I) CHA (white arrow), in association with (F,I) a newly developed dissected splenic artery (SpA; white arrowhead). Ao, aorta.
Because of the rapidly growing aneurysms and frequent epigastric pain, the aneurysms were considered at a high risk of rupture and required immediate intervention. On the 19th and 24th days, embolization using platinum coils was performed within the celiac artery, proximal CHA, and dissected splenic artery as well as in the arteries that supplied blood to the aneurysms (Figure 2A,B). We evaluated aneurysm morphology using magnetic resonance angiography (MRA) as a substitute for CT because of artifacts caused by the metallic coils, as well as perfusion to the adjacent organs using contrast CT. On MRA the circulation of the celiac artery system was completely blocked at the proximal portion (Figure 2C). Nevertheless, perfusion to the liver and the spleen was normal via collateral circulation, without liver dysfunction or ischemic cholecystitis. On the 28th day, aortic valve replacement via Bentall procedure using cardiopulmonary bypass with full heparinization was performed without re-expansion of the mycotic aneurysms. After an additional 6 weeks of antibiotic therapy, the patient was discharged with complete resolution of IE and mycotic aneurysms.
Coil embolization of mycotic aneurysms. (A) Preprocedural selective celiac arteriography. (B) Postprocedural selective superior mesenteric arteriography. (A,B) Mycotic aneurysms of the celiac trunk and common hepatic artery (CHA; black arrow) were completely isolated, and the dissected splenic artery (SpA; narrowing of the vessel; gray arrow) was embolized at the proximal portion considered to be the entry site of the dissected lumen. (B) Blood flow into the aneurysms disappeared after embolization. (C) Postprocedural magnetic resonance angiography of the celiac artery showing that the blood flow to the celiac artery disappeared in the proximal portion (arrow). CT, celiac trunk; DPA, dorsal pancreatic artery; LGA, left gastric artery; Lt. IPA, left inferior phrenic artery.
Despite the poor prognosis of ruptured mycotic aneurysm,1 no established predictor of rupture has been identified; therefore, careful observation and prompt intervention are warranted when necessary. Also, although radical resection open surgery and endovascular therapy are options for therapy, there are no definite criteria for choosing the correct procedure. Mycotic aneurysm in the celiac artery is extremely rare: 1 patient was treated with endovascular therapy 8 months after infected valve replacement and the other 4 were treated with open surgery.2–6 Radical resection of aneurysms is standard therapy, but endovascular embolization was chosen in the present case, because of the high risk of surgical resection in multiple aneurysms within the celiac artery, and because of the requirement for subsequent open-heart surgery due to uncontrolled IE. Although the implantation of prosthetic materials in an environment that may have prolonged infection was a concern, the mycotic aneurysms were well treated with embolization and intensive antibiotic therapy, suggesting that endovascular therapy could be an option even in an actively infected mycotic aneurysm. We did not perform positron emission tomography-CT, which could have been useful to evaluate inflammatory status, as well as to assist in the differential diagnosis of non-inflammatory arteriopathy, including segmental arterial mediolysis. The ultimate decision of when and how to use surgical or endovascular treatment should be tailored to the individual patient, in conjunction with a multidisciplinary endocarditis team.
The authors declare no conflicts of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
