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CASE REPORT
Year : 2023 | Volume
: 24
| Issue : 3 | Page : 163-165
An unusual complication of infective endocarditis treated by percutaneous intervention
Galal Abushahba1, Lana Robinson2, Paul Keelan3, Niamh F Murphy3, Venu Reddy Bijjam3
1 Cardiology Department, Royal Lancaster Infirmary, Lancaster, United Kingdom
2 Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
3 Cardiology Department, Our Lady of Lourdes Hospital, Drogheda, Ireland
Correspondence Address:
Dr. Galal Abushahba
Royal Lancaster Infirmary, Lancaster
United Kingdom
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_125_22
Abstract
Mycotic pseudoaneurysms (PA) are an infrequent complication of infective endocarditis (IE). However, due to advanced imaging modality and early therapy, this complication has been seen less frequently in the past few years. The reported incidence is 5%–15% of the patients, with the most common site being intracranial vessels (up to 65%), followed by abdominal and then peripheral vessels. We describe a young patient with a bicuspid aortic valve complicated by IE, who developed a giant mycotic PA. This was treated with a cover stent of the aneurysmal segment, which was complicated by distal stent migration and eventually managed with bypass surgery.
Keywords: Atrial covered stent, bicuspid aortic valve, infective endocarditis, popliteal pseudoaneurysm
Introduction 
A pseudoaneurysm is a breach in the walls of an artery, causing blood to collect between two layers of the artery; the tunica adventitia and the tunica media. This creates a channel between the aneurysm and the arterial lumen, allowing for more blood to collect and for the PA to grow. PAs are commonly caused by direct trauma to an artery and by infections such as infective endocarditis. They typically present as swelling and pain to the area affected and can become complicated by further infections. When PAs become infected, they have a higher risk of complications such as thrombosis and rupture.
Case Presentation A 40-year-old patient with a known bicuspid aortic valve (BAV) was admitted with Streptococcus oralis endocarditis.
The transthoracic echocardiography showed BAV, with a small mass attached to the valve, likely to be vegetation, with moderate aortic insufficiency and normal left ventricular function [Figure 1]a, [Figure 1]b, [Figure 1]c.
Figure 1: (a-c) ECHO showing a BAV, with a small mass attached to the valve, likely to be vegetation, with moderate aortic insufficiency and normal left ventricular function (d) CT angiogram showed popliteal PA, measuring 43 mm × 41 mm (e) CT angiogram revealing migration of the stent distally with recurrence of the PA (f) CT angiogram showing 6 m × 22 m length covered atrial stent deployed in the proximal end of indwelling 5 mm stent. PA: Pseudoaneurysms, BAV: Bicuspid aortic valve, CT: Computed tomographyThe patient complained of pain in the left calf, and computed tomography (CT) angiogram showed popliteal pseudoaneurysms (PA) [Figure 1]d, measuring 43 mm × 41 mm. After a discussion with the vascular surgeon and the interventional radiologist, a decision was made to cover the aneurysmal segment with a 6 mm × 59 mm length-covered atrium graft stent.
A few days later, the patient complained about a recurrence of the pain and swelling. A repeat CT angiogram revealed migration of the stent distally with recurrence of the PA [Figure 1]e.
A multidisciplinary team meeting decision was made to cover the aneurysm with another stent, this time a 6 mm × 22 mm length covered atrial stent, which was deployed within the proximal end of the indwelling 5 mm stent with favorable results [Figure 1]f.
Definitive treatment with vascular bypass will be considered after the scheduled aortic valve replacement.
Discussion Staphylococcus, Streptococcus, Pneumococcus, and Pseudomonas aeruginosa are the most common organisms in infective endocarditis (IE). The size and mobility of vegetation by echocardiogram are the most predictive factors of embolism. Arterial complications are often seen as acute ischemia of the limbs (20%–30%)[1]. Trill, bruit, pain, pulsatile mass, and fever are the clinical findings from the physical examination.[2],[3]
The treatment should consist of the administration of intravenous antibiotics and valve replacement surgery. However, there are other alternative therapies to surgery. These include endovascular interventions, for example, stenting, coil embolization, and thrombin injections which can be used in certain situations, such as a bridge to definitive surgery or if the patient's condition is unstable. Surgical treatment modalities of PA include excision, ligation bypass, and primary repair.[4]
Conclusion Popliteal pseudoaneurysms are an uncommon presentation of valvular endocarditis. Surgery is the definitive treatment; however, other treatment options including percutaneous interventions with stent could offer an alternative/temporary treatment in selected cases.
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 
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