Brachial Mycotic Pseudoaneurysms Due to Prosthetic Valve Infective Endocarditis: A Case Report and Review of the Literature

Abstract

Brachial mycotic pseudoaneurysms (BMPA) are a rare complication of infective endocarditis (IE), but potentially could be a limb-threatening condition. We present the case of a 38-year-old male referred to our department, complaining of the sudden onset of a painful pulsatile mass 5 x 10 cm in the right antecubital fossa that slowly progressed over time. Two years before this, he underwent aortic and mitral valve replacement with mechanical prosthetic valves and tricuspid annuloplasty for IE with methicillin-susceptible Staphylococcus aureus after a six-week course of intravenous antibiotherapy with oxacillin. Clinical examination of the right upper limb revealed a pulsatile and compressible mass with a normal temperature and without other clinical signs of inflammation. Pulse of the axillary artery, brachial and radial arteries were palpable. He was diagnosed by Doppler ultrasonography and digital subtraction angiography with BMPA. Furthermore, transesophageal echocardiography (TEE) revealed normal function of the aortic and mitral prosthetic valve with no signs of prosthetic valve endocarditis and no feature of congestive heart failure. Considering these clinical findings, surgical treatment was planned. He underwent re-section of the brachial pseudoaneurysm and arterial reconstruction. One year after the pseudoaneurysm resection, evolution was excellent. This manuscript presents this rare, uncommon complication after IE and also reviews the available surgical management strategies for this pathology.

A Brachial Artery Pseudoaneurysm Treated with a Bifurcated Y-Shaped Artificial Vessel Graft

“…The pathophysiology of the disease is the formation of aneurysm by the occupation of arterial vasa vasorum wall by septic emboli coming from infective endocarditis. 1 Patients may not show any symptoms when aneurysms are small. This is why our patient has presented with a palpable mass years after aorta replacement and infective endocarditis.…”

“…5 For large defects, interposition can be done using autologous vessel graft or prosthetic conduit. 1 Using prosthetic conduit may have long-term problems or potentially cause infection. 8 If patients accompany with limb ischemia, embolectomy with Fogarty catheter can be considered.…”

“…It frequently occurs in the cerebral arteries and brachial arteries are affected in 3 to 10% of the time. 1 Brachial artery aneurysm is a rare disease. It usually occurs as a false aneurysm secondarily caused by infection, trauma, or iatrogenic event.…”

“…2 Specifically, brachial mycotic pseudoaneurysm can arise rarely after infective endocarditis. 1 3 4 With infection of the arterial wall, pseudoaneurysm formation can occur without any iatrogenic injury from surgical or endovascular arterial intervention. 1 This is referred as mycotic aneurysms.…”

“…Mycotic aneurysm commonly occurs from septic emboli created by native or prosthetic valve endocarditis, intravenous drug abuse, or invasive endovascular catheter use. 1 Mycotic pseudoaneurysm occurs in the upper limb in 10% of the cases and the prevalence is known to be 0.03% annually. 1 Despite its low incidence, prompt diagnosis and treatment are necessary to prevent severe complications such as limb amputation.…”