AbstractAneurysm of the superior mesenteric artery is rare. More than 50% are mycotic. An aneurysm at this site ruptures easily and is difficult to manage. Here, we report a 49-year-old man with a mycotic aneurysm of the superior mesenteric artery, which was successfully resected, with revascularization from the infrarenal aorta using a retrograde vein graft

Chang, Bee-Song

Chang, Jui-Chih

Chao, Shen-Feng

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Successful Resection of a Mycotic Aneurysm of the Superior Mesenteric Artery 

© 2007 Buddhist Compassion Relief Tzu Chi Foundation
available at http://ajws.elsevier.com/tcmj
Tzu Chi Medical Journal
Case Report
Successful Resection of a Mycotic Aneurysm of the 
Superior Mesenteric Artery
Jui-Chih Chang*, Shen-Feng Chao, Bee-Song Chang
Department of Thoracic and Cardiovascular Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
Article info
Article history:
Received: May 11, 2007
Revised: June 25, 2007
Accepted: July 6, 2007
Keywords:
Mycotic aneurysm
Saphenous vein graft
Superior mesenteric artery
Abstract
Aneurysm of the superior mesenteric artery is rare. More than 50% are 
mycotic. An aneurysm at this site ruptures easily and is difficult to manage. 
Here, we report a 49-year-old man with a mycotic aneurysm of the supe-
rior mesenteric artery, which was successfully resected, with revasculari-
zation from the infrarenal aorta using a retrograde vein graft. [Tzu Chi 
Med J 2007;19(4):257–258]
 TZU CHI MED J  December 2007  Vol 19  No 4
*Corresponding author. Department of Thoracic and Cardiovascular Surgery, Buddhist Tzu 
Chi General Hospital, 707, Section 3, Chung-Yang Road, Hualien, Taiwan.
E-mail address: med.ray@msa.hinet.net
1. Introduction
Visceral aneurysms are relatively uncommon. 
Aneurysm of the superior mesenteric artery (SMA) 
accounts for 5.5% of all visceral aneurysms. More 
than 50% are mycotic [1,2]. Aneurysms at this site 
are difficult to manage even in elective situations.
2. Case report
A 49-year-old man with a history of drug addiction 
presented with fever and severe epigastric pain for 
1 week. In the emergency department, a blood pres-
sure of 110/70 mmHg with a body temperature of 
38.0°C were recorded. Abdominal examination 
revealed muscle guarding, but no rebound tender-
ness. No masses were palpated.
A peripheral blood smear revealed leukocytosis 
with neutrophils predominant. The initial blood cul-
ture grew Gram-positive cocci. Abdominal computed 
tomography (CT) showed an abnormal cystic lesion 
around the SMA trunk with rim enhancement and a 
perianeurysmal inflammatory reaction (Fig. 1). An angi-
ogram showed an SMA aneurysm with poor perfusion 
of the right and middle colic arteries. According to 
the clinical symptoms and signs and imaging stud-
ies, an SMA mycotic aneurysm with thrombosis of the 
right and middle colic arteries was suspected.
Two-dimensional cardiac ultrasonography revealed 
mild mitral and aortic regurgitation. Left ventricle systo-
lic function was preserved. No vegetation was noted.
Because of the patient’s intractable pain, bactere-
mia and SMA mycotic aneurysm with thrombosis of the 
right and middle colic arteries, surgery was performed. 
Under general anesthesia, the patient was placed in 
a supine position. A 20-cm portion of the right great 
saphenous vein was harvested by endoscopy. An 
upper midline laparotomy was performed. Liver cir-
rhosis and splenomegaly were noted. Dissection of the 
aneurysm was very difficult because of severe inflam-
matory changes. The supraceliac abdominal aorta was 
exposed first. The aneurysm and the distal part of 
the SMA were dissected from the surrounding tissue 
and isolated. After systemic intravenous administra-
tion of heparin (5 KU), the distal SMA was controlled 
and divided. Distal reconstruction of the SMA was per-
formed first, using a retrograde aorto-SMA bypass with 
the saphenous vein graft. The distal thoracic aorta was 
than controlled, and the aneurysm was resected. The 
stump of the proximal SMA was ligated using a 3-”O” 
polypropylene running suture.
The postoperative course was uneventful. The 
patient received a complete course of antibiotic ther-
apy with teicoplanin for 6 weeks due to both SMA 
aneurysm and blood culture growth of methicillin-
resistant Staphylococcus aureus. A follow-up abdom-
inal CT 1 week postoperatively showed patency of 
the saphenous vein graft and good perfusion of the 
area supplied by the SMA (Fig. 2).
Pathological examination of the specimen con-
firmed that it was a mycotic aneurysm with Gram-
positive cocci.
3. Discussion
Visceral aneurysm is rare. SMA aneurysm accounts 
for only 5.5% of all visceral aneurysms. About 60% 
of SMA aneurysms are mycotic [1,2]. CT is the most 
useful diagnostic tool [3]. Angiography helps to delin-
eate the characteristics of the aneurysm. Cardiac 
ultrasonography helps to identify endocarditis.
De Bakey and Cooley were the first to report 
successful excision of an SMA aneurysm [4]. Direct 
reconstruction of the SMA and the aorta after aneu-
rysmectomy has been reported. Revascularization can 
be performed with a vein graft or a Dacron graft [5].
Direct arterial re-anastomosis of the SMA after aneu-
rysmectomy in this patient was not suitable because 
of the distance between the root of the SMA and the 
distal SMA and the fragile root of the SMA. Due to an 
infectious process, an artificial graft was inappropri-
ate, so an autologous graft was chosen. In this case, 
revascularization of the distal SMA with a retrograde 
arterial bypass from the infrarenal aorta was done 
before resection of the aneurysm. This method allows 
for early revascularization of the area supplied by the 
distal SMA. In addition, we could deal with the infected 
aneurysm free from the risk of ischemic bowel.
In conclusion, we present a case of successful 
treatment of mycotic SMA aneurysm without complica-
tions such as rupture and bowel ischemia. Retrograde 
arterial bypass from the infrarenal aorta to the SMA is 
a good option for the surgical treatment of a mycotic 
SMA aneurysm.
References
1. Upchruch GR Jr, Stanly JC, Zelenock GB. Vascular Surgery, 
6th edition, Denver: Elsevier Saunders, 2005:1565–81.
2. Stanley JC, Wakefield TW, Graham LM, Whitehouse WM Jr, 
Zelenock GB, Lindenauer SM. Clinical importance and 
management of splanchnic artery aneurysms. J Vasc Surg 
1986;3:836–40.
3. Chu PH, She HC, Lim KE, Chu JJ. Mycotic aneurysm of the 
superior mesenteric artery in a young woman. Int J Clin 
Pract 2005;59:614–6.
4. De Bakey ME, Cooley DA. Successful resection of mycotic 
aneurysm of superior mesenteric artery; case report and 
review of literature. Am J Surg 1953;19:202–12.
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258 TZU CHI MED J  December 2007  Vol 19  No 4
Fig. 1 — Abdominal computed tomography shows an 
abnormal cystic lesion around the superior mesenteric 
artery trunk with rim enhancement (arrow).
Fig. 2 — Abdominal computed tomography shows patency 
of the saphenous vein graft (arrow) and good perfusion 
of the area supplied by the superior mesenteric artery 
1 week after surgery.


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Successful Resection of a Mycotic Aneurysm of the Superior Mesenteric Artery

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