A 25-year-old man was admitted with high fever and heart murmur. Echocardiogram showed left ventricular chamber dilatation and vegetations attached to the aortic valve. Blood cultures obtained on admission revealed Streptococcus viridans. Despite adequate antibiotic therapy, congestive heart failure progressively worsened and large splenic abscesses were detected by computed tomography. Urgent aortic valve replacement and splenectomy were performed. The aortic valve was bicuspid and markedly destroyed. Pathology of the spleen showed findings consistent with large infarct and abscesses due to septic emboli. The postoperative course was uneventful.

Background: In abdominal aortic aneurysm (AAA) repair, European and the United States' guidelines recommend performing proximal anastomosis as close to the renal arteries as possible. A long infrarenal residual aorta (IRA) raises concern about the risk of enlargement and aneurysmal formation in the future. There are no descriptions of proximal anastomosis in Japanese guidelines. Objective: To investigate the relationship between the length of the IRA and its long-term enlargement. Subjects: 100 patients who underwent open repair for AAA at our hospital between June 2002 and November 2016 were included. The mean age was 70.2±8.2 (SD) years, and the mean observation period was 8.5±3.3 years. Group S (n=24) consisted of patients whose IRAs were less than 2 cm in length, and Group L (n=76) consisted of patients whose IRAs were more than 2 cm in length. The preoperative diameter of the infrarenal aorta and the length and diameter of IRA in the immediately after surgery, in the early postoperative period (within 1 year), in the mid-term (2 to 9 years), and in the remote period (after 10 years) were measured. Results: There was no significant change in IRA diameter between preoperative and immediate postoperative periods. The preoperative diameter of the infrarenal aorta were 23.0 [21.0-26.0] mm in group S and 22.0 [20.0-24.5] mm in group L. There was no significant difference of the preoperative IRA diameter between the two groups. The IRA diameters in the postoperative period and thereafter were 22.0 [20.0-26.0] mm, 23.0 [21.0-27.0] mm, 24.0 [22.0-28.0] mm, 26.0 [23.3-32.8] mm in group L, showing a significant dilatation immediately after operation (p<0.01). In addition, although there was no statistically significant difference, the group with a preoperative infrarenal aorta diameter of 26 mm or greater showed a larger dilatation after the midterm postoperative period. Conclusions: An association was found between IRA length (≥2 cm) and postoperative IRA dilatation.