Angiology Volume 57, Number1,2006 103
Recurrent Tuberculous Pseudoaneurysm of the Descending Thoracic Aorta
A Case Report
Mustafa Sirvanci, MD,* Levent Onat, MD,* Kutlay Karaman, MD,' NaciYagan, MD,t and BingurSonmez, MD,tIstanbul, Turkey
Tuberculous pseudoaneurysm of the aorta is a raredisease that is uniformly fatal ifnottreated properly. The authors present a case of a recurrent tuberculous false aneurysm of the descending thoracic aorta thatwastreated surgically with excision and primary repair of the lesion. To their knowledge,this is the first reportedcaseof recurrent disease aftera successful surgical treatment.
Introduction
Tuberculous pseudoaneurysm of the aortais an
exceedingly rare entity associated with high mortality. The extension of the infection from neighboring or contiguous inflammatory foci is the cause of the aortitis.1 These aneurysms are proneto ruptureorperforationintoadjacentor- gans, often resultinginfatal exsanguinating he- morrhage.1,2
There are few reports of such aneurysms treated surgicallyinthe literature. Inthis report, we present acase ofrecurrenttuberculous aneu-
Angiology 57:103-106,2006
FromtheDepartmentsof*Radiology and tCardiovascular Surgery,University of Kadir Has,SchoolofMedicine,Florence Nightingale Hospital,Istanbul, Turkey
Correspondence: Mustafa Sirvanci, MD,Velioglu sokak, Husnufirat apartmani,No:9/7, Ayazma,Uskudar,81160 Istanbul, Turkey
E-mail: sirvanci@ttnet.net.tr sirvanci@prizma.net.tr C2006WestminsterPublications,Inc., 708 GlenCoveAvenue, GlenHead,NY11545,USA
rysmofthedescending thoracicaortaaftera suc- cessful surgical therapyand an effective regimen of antituberculous chemotherapy.
Case Report
A65-year-oldmanpresentedto ourhospitalwith the beginning of complaints comprising cough and hemoptysis. Five months before his presen- tationhehadundergoneanoperationfor thoracic tuberculous spondylitis with posterior stabiliza- tionperformed on6th, 7th, and 8th thoracicver- tebrae. Hehadbeenreceivingafullcourseofan- tituberculous drug therapysincethattime. Blood pressure,pulse, hemoglobin, andhematocrit were withinnormallimits. Remotemedicalhistorywas unremarkable.
Computed tomography (CT) showed a cen- trally opacified periaortic 3.5 x5 cm mass com- patiblewith apseudoaneurysminthedescending thoracic aorta at the levelof thethoracic 7th and
104 Angiology Volume57, Number1,2006
8thvertebrae. The aneurysmoriginatedfromthe left lateral aspect of the descending thoracic aorta.Follow-upCTangiography (Figure 1), per- formed6days later,showed that the diameter of the aneurysmhadincreased, andemergencysur- gical therapywas decided. Conventional angiog- raphy done in preparation of the patient for surgery also confirmed the diagnosis of a pseudoaneurysm (Figure 2).
Operationwasundertakenvia aleftpostero- lateral thoracotomy and circulatory arrest. The aneurysm appeared to be ofthe false variety. It was resected and the holein the aortic wallwas closedby patch aortoplasty. Theexcisedmaterial was later demonstrated tobe necrotizing granu- lomatous inflammatory tissue containing innu- merable acid-fast bacilli and proved to be abun- dantlyculture-positive forM. tuberculosis. Thepa- tient's postoperative course was uneventful.
Antituberculous chemotherapy that was intro- duced preoperativelywas continued and the pa- tient was discharged from the hospital on day8 following surgery. Pseudoaneurysm was no longerseen oncontrolCTangiographyperformed 1 weeklater. The patient, 4 months later, devel- oped recurrence of his symptoms comprising cough and hemoptysis. CT angiography revealed a newpseudoaneurysm that arose from the pos- terior wall, at the same level of the pseudoa- neurysm thatwasoperatedonpreviously (Figure 3). The patient was reoperated on with an exci- sion-graftinanothercenter.
Discussion
Tuberculous aneurysm of the aorta is an ex-
tremelyrarebut potentially catastrophic compli- cation oftuberculosis. Volini et a1ldescribed the pathogenesis and complications of tuberculosis of the aorta. The most common (75%) mode of spreadto theaortaisby direct extension froman
adjacent tuberculous foci such as tuberculous lymphadenitis, pericarditis, empyema, spondyli- tis,and paravertebralabscess.3'4Lessoften(25%)
nocontiguous focus of disease can be described, and it is thought that the organisms reach the
aortaviahematogenous dissemination.5'6 Tuber- culous aortitis leads to the formation of an aneurysm in about half the cases.' The focus of aortitis thatoccurs causes adestructionin aortic wall. Caseatingnecrosisthat involves alllayersof the aortic wall results in transmural perforation with resultant massive hemorrhage orperivascu- lar hematoma. Perivascular hematoma, by tam-
ponade from surrounding tissues, is encapsulat- ed. Itiscalled falseaneurysm orpseudoaneurysm byvirtue of preservation ofits relation with aor- tic lumen. Most tuberculous aneurysms are sac-
cular andfalse,7 representing awalled-offperfo-
ration of the aorta.4
Thespecificsiteof involvementisusuallythe
thoracic orabdominal aorta. If leftuntreated, tu-
berculous pseudoaneurysm has extremely poor prognosis and potential catastrophic conse- quences. The aneurysm generally may rupture
Figure 1. CTangiographyobtained 6daysafter the initial CT examination (not shown).
A.Axialscan.Pseudoaneurysmoriginatingfrom thelateralwallof the descendingaorta. Broad communication is seenbetween thenativelumen ofthe aortaandthefalselumenof the aneurysm. The diameter of theaneurysmhas increasedwhencomparedwiththeprevious CTexamination (notshown).
B. Coronalreformattedimagenicelydemonstratesthepseudoaneurysm.
Sirvanci RecurrentTuberculousPseudoaneurysmofAorta
Figure2. Angiographic appearance of thepseudoaneurysm.
into an adjacent organ, depending on its site of origin. The usual symptoms of a tuberculous aneurysm, dependent on localization, are com- monly, pain, pulsatile mass, shock, orhemoptysis.
Inthe past, theradiographic diagnosis oftu- berculous aortic aneurysmhad rested onaortog- raphy. Since the first report ofits usebyHarris et al5 in 1978, CT examination performed with in- travenous (IV) contrastagent hasproved tobe a useful means ofdetection of the aneurysm. CT angiography better delineates the morphologyof the aneurysm. Magnetic resonance imaging (MRI) is a useful investigative procedure,8 and MRangiography by use ofIVGd-DTPA injection viainfusion pump is anefficient methodofdem- onstrating the aneurysms. However, we did not use MR angiography for our patient because of the possible occurrence of artifacts frommetallic hardware for posterior spinal fusion. CT angiog- raphy also was degraded by these artifacts that reduced the imagequality. In ourcase, asaccular centrally enhancing pseudoaneurysm demon- stratedbyCT atthelevel of previoussurgical op- eration for tuberculous spondylitis pointed to- ward the correctetiology.
Because early recognitionand perioperative antituberculous therapy combined with prompt surgical intervention is the only efficient treat- ment, no patientshad survived before the inno- vations in modern imaging techniques, antitu-
Figure 3. Follow-upCTangiography obtained 4 monthsafter the surgical operation. A. Axialscan. Recurrent pseudoaneurysm, originating fromthe posteriorwall of the aorta, locatedatthe samelevelasthe previous aneurysm.
B.Sagittal reformatted image shows the saccularaneurysm with broad
communication with the nativelumen.
berculous drugs, and vascular grafts became available. It is not known whether an asympto- maticpatient requires surgery. However,itisap- propriate to operate on an expanding lesion as inthis case.
The patientsneed periodicfollow-up forpos- sible tuberculous reactivation after the surgical treatment. Theoretically, a newaneurysmnear to the resection site or a newaneurysm near tothe patch closure may occur. To the best of our knowledge, this is the first reported case with a postoperative recurrence oftuberculous pseudo- aneurysm.
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