A Mycotic SMA Aneurysm Secondary to Aortic Valve Endocarditis Causing Ischemic Strictures and Ischemic Colitis

Visceral aneurysms of mycotic origin are uncommon, yet potentially lethal conditions that require rapid diagnosis and intervention to reduce serious complications such as ischemia, hemorrhage, and mortality. In this report, we present a case of mycotic Superior Mesenteric Artery (SMA) aneurysms secondary to infective endocarditis, complicated with colitis and stricturing of the ascending colon. Treatment with bowel resection, aneurysm resection, and a saphenous vein graft repair was performed. Based on our review of the literature urgent diagnosis and surgical intervention remain the mainstay in treatment for this rare condition. Nawaf Abu-Omar1*, Jeffrey Gu1, David Kopriva2 and Gordie Kaban1 1Department of General Surgery, University of Saskatchewan College of Medicine, Canada 2Department of Vascular Surgery, University of Saskatchewan College of Medicine, Canada Nawaf Abu-Omar, et al., Annals of Short Reports Remedy Publications LLC. 2018 | Volume 1 | Issue 1 | Article 1001 2 hemicolectomy, and resection of the four distinct SMA aneurysms. Intra operatively, the general surgery team resected the ischemic and thick end ascending colon. Although edematous, the remaining bowel appeared healthy. Simultaneously, the vascular team obtained a saphenous vein graft. The SMA was isolated at the root of the mesentery. Several branches coming off the aneurysmal segment could not be saved and controlled for re-implantation. This was due to severe fibrotic reaction of the mycotic aneurysm and had to be suture ligated from inside the aneurysm. However, the two major outflow branches beyond the largest and most central aneurysmal were isolated and preserved. The saphenous vein graft was used to create an end to end anastomosis with the two outflow tracts. Another distal jejunaland ileum mesenteric aneurysm which was identified on CT was then resected; no bowel ischemia resulted from this. Due to the extent of the aneurysmal disease and bowel edema, no anastomosis was performed. A negative pressure wound vacuum was applied and the patient was transferred to the ICU for a planned second look laparotomy in 24 hours.The patient suffered from mild hypotension post-op, which responded to fluid resuscitation. No vasopressors were administered.The second look revealed a diffusely ischemic small bowel with only 70-85 cm of proximal small bowel maintain ingviability. The saphenous vein graft was inspected and although patent, ithad a high Doppler resistance signal indicating that the arterial system in the periphery of the mesentery was not permitting adequate bowel perfusion. Consequently, it was determined that the vast majority of small bowel was not viable and there were no further surgical options to save the patient.