Open surgical management of multiple mycotic superior mesenteric artery aneurysms following staphylococcal infective endocarditis.

Mycotic superior mesenteric artery (SMA) aneurysms are rare but carry a substantial risk of rupture, bowel ischemia, and mortality. Their management is particularly challenging in the setting of multifocal disease involving major mesenteric branches. We present the case of a 32-year-old man with a history of intravenous drug use and recurrent infective endocarditis who developed multiple mycotic SMA aneurysms secondary to Staphylococcus aureus bacteremia. Following emergency mechanical aortic valve replacement, left ventricular outflow tract abscess repair, and prolonged antimicrobial therapy, surveillance imaging demonstrated three persistent patent SMA aneurysms. The patient underwent open surgical repair through a midline laparotomy. Two distal jejunal and ileal branch aneurysms were excised and ligated. The proximal complex aneurysm involved multiple jejunal branches and the right colic artery and was reconstructed using autologous internal iliac artery patch repair. This report outlines the operative strategy and multidisciplinary decision-making involved in the management of these challenging multifocal mycotic SMA aneurysms. Open reconstruction using autologous conduit remains an important treatment strategy for young patients with complex branch involvement and infected vascular pathology.