Extra Cranial MAs
Intrathoracic or intra-abdominal MAs are often asymptomatic until leakage or rupture occurs. Most extracranial MAs (ECMAs) will rupture if not excised. The appearance of a tender, pulsatile mass in a patient with IE should suggest an ECMA. Hematemesis, hematobilia, and jaundice suggest rupture of a hepatic artery MA; Arterial hypertension and hematuria suggest rupture of a renal MA; Massive bloody diarrhea suggests the rupture of an ECMA into the small or large bowel. Proximal and distal ligation with excision of all infected material and revascularisation with interposed vascular grafts or autologous venous grafts is ideal.Mortality among patients with IE and ECMA is high, which is attributable to suture line infection with vessel or graft rupture.
Anticoagulation Issues
Anticoagulation is contraindicated in native-valve endocarditis because of the risk of intracerebral hemorrhage. Patients with prosthetic valve endocarditis who normally take maintenance anticoagulation, however, are usually maintained on anticoagulant therapy during treatment of IE, provided there is no evidence of cerebral events.