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Asian Cardiovasc Thorac Ann 1998;6:318-319
© 1998 Asia Publishing EXchange Pte Ltd

CASE STUDY

Pseudoaneurysms of Bilateral Popliteal Arteries Following Infective Endocarditis

Filiz Özerkan, MD, Ceyhun Ceyhan, MD, Ümit Ertürk, MD, Yüksel Atay , MD1, Münevver Yüksel , MD1

Department of Cardiology
1 Department of Cardiovascular Surgery Ege University Medical School Izmir, Turkey
For reprint information contact: Filiz Özerkan, MD 1468 Sokak No. 16/A Alsancak, Izmir, Turkey Tel: 90 232 422 1348 Fax: 90 232 422 4537

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A rare complication of infective endocarditis is pseudoaneurysm of the arterial wall. Aneurysms arise either from occlusion of vessels by septic emboli with secondary arteritis and vessel wall destruction or from bacteremic seeding of the vessel wall through the vasa vasorum. This paper reports on what the authors believe to be the first case of endocarditis presenting as pseudoaneurysm of the bilateral popliteal arteries.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Between 2% and 10% of patients with endocarditis have mycotic aneurysms. These aneurysms arise either from occlusion of vessels by septic emboli with secondary arteritis and vessel wall destruction or from bacteremic seeding of the vessel wall through the vasa vasorum. Mycotic aneurysms may resolve during antimicrobial therapy or they may rupture. Rupture of these aneurysms can result in life-threatening hemorrhages or pseudoaneurysms. A rare complication of infective endocarditis is pseudoaneurysm of arterial wall. We report the case of a patient who developed bilateral popliteal artery pseudoaneurysms due to infective endocarditis.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 34-year-old male with a history of acute rheumatic fever was admitted to a local hospital because of fever, extreme fatigue, weakness, headache, vomiting and nausea, edema, and pain in the right calf. Infective endocarditis was diagnosed and he received antibiotic therapy for 20 days. Thrombophlebitis in his right leg was diagnosed at the same hospital and oral anticoagulant treatment was initiated. On admission to our cardiology department, his temperature was 39°C, blood pressure 120/50 mm Hg, and pulse rate 98 beats·min–1. A 3/6° diastolic souffle and 3/6° systolic souffle were heard in the aortic area. The lung auscultation was normal. There were peripheral findings of aortic regurgitation and splenomegaly. On neurologic examination, stiffness of the neck, and the signs of Kernig and Brudzinski were observed. The right calf was found to be painful and edematous. An electrocardiograph showed sinus tachycardia and left ventricular hypertrophy. A chest radiograph revealed mild cardiomegaly. Transthoracic and transesophageal echocardiography demonstrated multiple small vegetations on the aortic valve, severe aortic regurgitation, and marked dilatation of aortic root (Figure 1Go). Anemia, leukocytosis, increased erythrocyte sedimentation rate, and raised gamma globulin level were detected on laboratory examinations. The prothrombin time was 35 seconds. Six blood cultures were negative. A left occipital hematoma and a splenic hematoma were seen on computed tomography and magnetic resonance imaging. After 50 days of vancomycin, 20 days of gentamicin, and supportive therapy, the patient's symptoms and signs of infective endocarditis and his neurologic situation improved. However, in spite of thrombophlebitis therapy, his right calf pain continued. Doppler ultrasound examination of the lower extremities showed bilateral popliteal artery pseudoaneurysms. The venous system was found to be normal. Angiography of both lower extremities confirmed the ultrasound findings (Figure 2Go).



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  		Figure 1. Multiple small vegetations on the aortic valve seen in multiplane transesophageal echocardiographic transverse view.

 


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  		Figure 2. Angiography of the lower extremities showing pseudoaneurysms of the bilateral popliteal arteries (arrowed).

 
The patient underwent resection of the bilateral popliteal artery pseudoaneurysms and aortic valve replacement. The echocardiographic findings were confirmed at surgery. Saphenous vein graft interposition was performed after resection of the popliteal artery pseudoaneurysms. Microbiological examination of the explanted valve and the arterial structures were sterile. Pathologic examinations showed an inflammatory reaction. Doppler ultrasound examination of the popliteal arteries was normal after surgery (Figure 3Go). The patient made a good recovery and he was well at the last follow-up, 11 months postoperatively.



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  		Figure 3. Doppler ultrasonography of the bilateral popliteal arteries after surgery. PA = popliteal artery, PV = popliteal vein.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Mycotic aneurysms involve the cerebral arteries in 1% to 5% of cases.1 Cerebral mycotic aneurysms occur at branch sites in the cerebral vessels. Streptococcosis aureus is commonly implicated in the former and viridans streptococci in the latter.2 Mycotic aneurysms may resolve during antimicrobial therapy. Aneurysms that have not leaked should be followed angiographically during antimicrobial therapy. Surgery should be considered for a single lesion that enlarges during or following anti-microbial therapy. Mycotic aneurysms may rupture and infection leads to the formation of abscesses. These infected zones can subsequently rupture and then pseudoaneurysms may occur. We found case reports of pseudoaneurysms of the left ventricle, left ventricular outflow tract, perivalvular, and right femoral artery.3–5 To our knowledge this is the first reported case of bilateral popliteal artery pseudoaneurysms due to infective endocarditis. Although it is rare, pseudoaneurysm should be kept in mind in management of patients with infective endocarditis.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Salgado AV, Furlan AJ, Keys TF. Neurologic complications of endocarditis: 12-year experience. Neurology 1989;39: 173–8.[Abstract/Free Full Text]

  2. Hart RG, Kagan-Hallet K, Joerns SE. Mechanisms of intracranial hemorrhage in infective endocarditis. Stroke 1987;18:1048–56.[Abstract/Free Full Text]

  3. Bansal RC, Graham BM, Jutzy KR, Shakudo M, Shah PM. Left ventricular outflow tract to left atrial commu-nication secondary to rupture of mitral-aortic intervalvular fibrosa in infective endocarditis: diagnosis by trans-esophageal echocardiography and color flow imaging. J Am Coll Cardiol 1990;15:499–504.[Abstract]

  4. Jorge SC, Sampaio MF, Leao PP. Embolomycotic pseudoaneurysm of the common femoral artery in infective endocarditis. Arq Bras Cardiol 1993;61:53–5.[Medline]

  5. Sharma SN, Bahl VK, Venugopal P. Left ventricular pseudoaneurysm following infective endocarditis: a case report. Indian Heart J 1991;43:395–6.[Medline]





This Article
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