Hepatic Artery Aneurysms in Infective Endocarditis: Report of 10 Cases and Literature Review

Abstract

Hepatic artery aneurysms (HAAs), albeit rare in infective endocarditis (IE), are associated with a life-threatening morbidity. Retrospective review of 10 HAA-IE patients based on a total of 623 IE patients managed in 2 institutions (2008-2020) versus 35 literature cases. In our patient population, HAAs (10 males, mean age 48) were incidentally found during IE workup. All were asymptomatic. IE involved mitral (n=6), aortic (n=3), or mitral-aortic valve (n=1). Predisposing factors for IE were as follows: prosthetic valve (n=6), previous IE (n=2), IV drug user (n=1). Streptococcus species (spp.) were predominant (n=4), then staphylococcus spp (n=2) and E. faecalis (n=2). All patients presented associated lesions: infectious aneurysms (n=5), emboli (n=9), abscesses (n=5), and spondylitis/spondylodiscitis (n=2). HAA patterns on abdominal CT angiography (CTA) were solitary (70%), mean diameter 11.7mm (range 2-30), intrahepatic location (100%) involving the right HA in 9 out of 10 (90%) patients. In 2 patients, HAAs were complicated (rectorragia and hemobilia in 1, cholestasis in the other). Six patients underwent endovascular hepatic embolization (2 with multiple HAAs). Three HAA-IEs <15mm resolved under antibiotherapy on abdominal CTA follow-up. All patients underwent cardiac surgery. Late outcome was favorable in all followed patients (5/10). Literature review showed the preponderance of Streptococcus spp., of right lobe and intrahepatic HAA localization. Complications revealed HAAs in patients under antibiotic therapy and/or after cardiac surgery in 17 literature cases of delayed diagnosis. Abdominal CTA was pivotal in the initial IE workup. Small aneurysms (≤15mm) resolved under antibiotherapy. The usual treatment modality was HAA embolization and endovascular embolization before valve surgery was safe.