**9. Conclusions**

intervention at the same time [128]. Acutely occluded major coronary arteries or branches may require surgical revascularization at the time of valve surgery. Patients with aortic valve endocarditis, in whom preoperative coronary angiography may be contraindicated due to concerns of dislodging debris, may require empiric grafting [2]. An example of a mycotic

**Figure 7.** Mycotic aneurysm of the right coronary artery. The patient underwent venous bypass grafting. Source: Stawicki et al. [2]. Used under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

Distal septic emboli are well described in the setting of IE [30, 129]. A nontrivial proportion of SE associated with IE requiring valvular replacement affects the extremities, with some patients experiencing multiple embolic events [30, 129]. Clinical manifestations can vary from extremity pain to limb-threatening ischemia [30]. In less severe cases, ischemic symptoms may resolve with anticoagulation and antimicrobial therapy, while in more acute presentations

Secondary arterial changes and associated lesions have been reported in the setting of infectious embolization [75, 130]. Inflammatory changes were noted in the walls of arteries adjacent to an intracranial hematoma following septic embolization [75]. In one instance, brachial artery pseudoaneurysm (**Figure 8**) has been described in the setting of severe prosthetic aortic valve endocarditis [2]. In another case, a ruptured mycotic aortic abdominal aneurysm occurred in

surgical embolectomy or even amputation may be required [30].

**8.6. Arterial lesions associated with septic embolism**

coronary artery aneurysm associated with IE is shown in **Figure 7**.

cited.

**8.5. Septic emboli to extremities**

156 Contemporary Challenges in Endocarditis

Despite significant evolution of both diagnostic and therapeutic approaches, septic emboli continue to present a formidable challenge to the practicing clinician. In addition to high index of suspicion and early clinical recognition, prompt identification of the offending cardiac source and the institution of immediate goal-directed antibiotic therapy are all critical to successful outcomes. More widespread awareness of risk factors, clinical presentations, and management of SE is needed, with added focus on preventing embolic events and the management of associated complications.
