Acute
occlusion of superficial femoral artery due to complications of infective
endocarditis
(Portuguese
PDF version)
Roberto
Jamacaru de Aquino Filho,1 André de Oliveira Porto,1 Francisco
Henrique Peixoto da Silva,1 Márcia Andréa Moura
Baptista de Carvalho,2 Fabiano Jucá3
1.Vascular
Surgeon, Vascular Surgery Service, Hospital e Maternidade São
Vicente de Paulo, Barbalha, CE, Brazil.
2.ICU Physician, Intensive Care Unit, Hospital e Maternidade
São Vicente de Paulo, Barbalha, CE, Brazil.
3.Cardiothoracic Surgeon, Cardiac Surgery Service, Hospital
do Coração de Barbalha, Barbalha, CE, Brazil.
Correspondence:
Roberto Jamacaru de Aquino Filho
Rua Pergentino Maia,160/04, Parque Grangeiro
CEP 63106-070 - Crato, CE
Brazil
E-mail: jamacaru@uol.com.br
ABSTRACT
The
authors report on a 26-year-old infirmary inpatient with acute arterial
occlusion of the femoral popliteal segment in the left lower limb.
The patient underwent an embolectomy with satisfactory development,
the macroscopic aspect of the thrombus was unusual, with fiber-elastic
consistence, and brown-white coloration. During the inpatient period
a diagnosis of bacterial endocarditis was made, blood culture yielded
Streptococcus viridans. Echocardiogram identified double
lesion of aortic valve, associated with vegetations and mitral valve
insufficiency. The patient developed cardiac failure, with dyspnea
at rest, and was submitted to a cardiac surgery for the replacement
of the aortic valve by a metallic one presenting uneventful evolution
after surgery. Septic embolism is not reported as a common etiology
of acute arterial embolism in lower limbs.
Key-words:
endocarditis, embolism, lower extremities.
Palavras-chave: endocardite, embolia, membros inferiores.
J
Vasc Br 2004;3(3):281-4
Acute arterial
occlusion is a complication of the vascular surgery domain that presents
high morbi-mortality rates, with an incidence of 17 patients per 100,000
inhabitants/year.1 It is an arterial pathology that may be associated
with a remote embolic event, and a wide range of etiologies may end
in acute arterial occlusion. The heart is responsible for 78 to 96%
of cases1,2 and atrial fibrillation, frequently secondary to valvulopathy
or atherosclerosis, is the cause of almost all the cases of embolism.
The septic embolism is a complication of the infective endocarditis
and its real incidence is not uniform in the literature.1 There are
reports of tromboembolic episodes in 24% inpatients with acute infective
endocarditis,3 especially in small arteries. Usually, larger arteries,
such as the femoral or popliteal, are affected by fungus, and most of
these events affect the lower limbs (33 to 75% of cases).4 The occlusion
of the superficial femoral artery caused by bacteria is rarely reported
in the literature.
CASE
REPORT
We report
on a patient, J.C.A.C., 26 years-old, farmer, admitted to a medical clinic
ward with persistent fever associated with polyarthralgia of ankle and
knee in the last 15 days. The patient presented with significant systolic
murmur (+++/4+) in the aortic valve site, PMI (Point of Maximal Impulse)
displaced laterally to the left and dyspnea on mild effort. The chest
x-ray showed cardiomegaly (Figure 1) with cardiothoracic index higher
than 0.6. A syndromic diagnosis of infective endocarditis was made and
the following tests were requested: blood culture (three samples), blood
count, and biochemistry, besides an electrocardiogram and an echocardiogram.
Crystalline penicillin 5,000.000 UI was administered every four hours.
An examination of the teeth revealed advanced caries with abscesses in
the upper right molars (Figure 2).
 Figure
1 - Simple thoracic x-ray showing cardiomegaly.
Figure
2 - Odontological examination showing caries with abscesses.
The echocardiogram
results showed an ejection fraction of 70% with vegetation and double
aortic lesion with pressure gradient of 41. After seven days, the patient
developed sudden pain in the left lower limb. The physical examination
revealed pallor, coldness up to the distal thigh and absence of anterior
and posterior popliteal-tibial pulses. The vascular clinic that made
the diagnosis of acute arterial occlusion was contacted and the patient
was submitted to digital arteriography via femoral puncture. The examination
showed superficial femoral arterial occlusion in the inferior third
of the adductor channel (Figure 3). The patient underwent an emergent
Fogarty embolectomy of the popliteal artery in the left lower limb.
Figure
3 - Digital
arteriography yielding superficial femoral artery occlusion.
After revascularization, we observed that the thrombus was not featured like an atrial-origin coagulum, which is the most frequent. It presented a firm fibroelastic consistency and a brown-white coloration. It was submitted to another blood culture test, which showed the same result as the first one.
The patient had instant recovery of the distal flow, remaining only with a cyanotic lesion that later became dry and painless (Figure 4).
Figure
4 - Dry
and painless cyanotic lesion.
On the fifth postoperative day, the patient developed severe decompensated cardiac insufficiency, with dyspnea at rest, and entered the ICU, receiving vancomycin and clindamycin. A cardiothoracic surgery with aortic and mitral valves exploration and replacement of the metallic valve was carried out (Figure 5). The aortic valve showed a double lesion associated with infectious vegetation (Figure 6). The patient was discharged from hospital on the 10th postoperative day and was given coumarinic (oral) 5 mg/day and furosemide (oral) 40 mg/day. The left inferior limb had a small and dry gangrene area with restored pulses and the patient was without fever.
Figure
5 - Cardiothoracic surgical intervention.
Figure
6 - Aortic valve aspect.
DISCUSSION
The distal
septic embolism is an uncommon complication in patients with infective
endocarditis, however, it can be the first clinical manifestation of
this infectious disease.2 In a study carried
out at the St. Josef Hospital, Ruhr-Universitat Bochum, the authors
attempted to set echocardiographic criteria that could be associated
with peripheral embolization, in patients with bacterial endocarditis.
A higher risk was assigned to vegetations with more than 10 mm, especially
if they were in the mitral valve. However, because there were not controllable
variables, the real risk of vegetations was not possible to be predicted,
as both bacterial and fungal endocarditis may present such features.
Among bacterial endocarditis, the most frequent pattern of embolization
is the occlusion of small arteries and arterioles, with fingers and
small parts of the body, such as cerebral branches, ophthalmic artery
and others,6 presenting necrosis. The risk
of loosing a member is not common. The literature shows that endocarditis
caused by Staphylococcus sp. is more acute and virulent than
those with streptococcic origin.7 The incidence
of embolic phenomena shows not to be directly associated with the period
of endocarditis symptoms, but early surgical interventions and adequate
antibiotic therapy were found as important prognostic factors for limbs
presenting with embolism.
Eventually, we emphasize that possible embolic complications should
be attentively handled in patients of other medical clinics and the
possibility of infectious etiology in cases of acute arterial occlusion
in patients with cardiac diseases presenting fever should be considered.
The central emboligenic source should be assessed and handled by clinical
and surgical cardiologic staff for the complete and definitive management
of the disease.
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Principles of Internal Medicine. 12th ed. New York: McGraw-Hill Medical
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Schmidt D, Zehender M. Arterial occlusion of the eye in infectious endocarditis.
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Cassada DC, Moniz M, Stevens SL, et al. Factors affecting the surgical
management of infective endocarditis. Am Surg 1999;65:307-10.
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