Asian Cardiovasc Thorac Ann 2003;11:346-348
© 2003 Asia Publishing EXchange Ltd
Repair of Tuberculous Aneurysm of Distal Aortic Arch
Keshavamurthy Suresh, MCh,
Vallikapathalil M Kurian, MCh,
Nainar Madhu Sankar, PhD,
Alpesh Patel, MS,
Peter Joseph, MRCP,
Kotturathu M Cherian, FRACS
Institute of Cardiovascular Diseases, Chennai, India
For reprint information contact: Kotturathu M Cherian, FRACS Tel: 91 44 2656 5961 Fax: 91 44 2656 5859 email: icvd{at}eth.net Institute of Cardiovascular Diseases, 4A, Dr J J Nagar, Mogappair, Chennai, 600 050, India.
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ABSTRACT
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A 65 year old female patient presented with one episode of massive haemoptysis requiring transfusion and subsequently cough with streaky haemoptysis. Computerized tomographic scan and angiogram revealed aneurysm of the distal aortic arch. She underwent elective repair of the psuedoaneurysm through median sternotomy and the bronchial communication was closed through left thoracotomy. Tubercle bacilli were identified in the contents and excised wall of aortic tissue.
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INTRODUCTION
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Advances in diagnosis and treatment have seen a decline in the number of cases of tuberculosis as well as tuberculous aneurysms. Despite these advances, tuberculous aortitis with aneurysm or rupture is a major challenge to surgeons because of the presence of persistent infection and the nature of the walled–off perforation in the aorta.
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CASE REPORT
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A 65 year old female presented with episodes of cough with haemoptysis for over a year and a recent episode of massive haemoptysis requiring transfusion. She was a known hypertensive as well as diabetic. Physical examination was unremarkable except for bronchial breath sounds in the interscapular area over the back on the left side. Haematological parameters were normal except for slightly elevated ESR. (15/40 mm at 
and 1 hour). Chest radiograph revealed a superior mediastinal widening pronounced on the left side. An echocardiogram showed good ventricular function. There was evidence of minimal pericardial effusion posterior and lateral to left ventricle.
Computerized Tomographic (CT) scan of the chest revealed a saccular aneurysm of the distal aortic arch at the origin and the same was confirmed by angiogram (Figure 1
). Her coronaries were normal. She was taken up for elective repair of the aneurysm through a median sternotomy. The right subclavian artery was exposed through a subclavicular incision. Cardiopulmonary bypass was instituted with an aortic and right atrial cannula and the patient was cooled to 18°C. The right subclavian artery was cannulated with an 18 F Biomedicus cannula. The arch vessels were selectively clamped and circulation was arrested. At this point of time, selective cerebral perfusion was done though the right subclavian artery. The aneurysm was dissected and opened and clots were evacuated. A punched out defect roughly 1.5 cm in size was found and repaired using a patch of aortic homograft. Circulation was re-established and the patient was easily weaned off CPB. However, during haemostasis we were confronted with a massive air leak in the vicinity of the aneurysm repair. It was not possible to ascertain the site of leak easily. Hence after sternal closure the patient was turned and a (L) posterolateral thoracotomy was performed through the 4th intercostal space.
The air leak was found to originate from segmental bronchi of the left upper lobe - the part of the left lung densely adherent to the aneurysmal sac. These communications were obliterated with chromic catgut suture and the thoracotomy wound closed over drains. The patient made an uneventful recovery and was extubated on the first postoperative day. Samples of aneurysmal contents and aortic wall returned positive for tubercle bacilli and she was started on anti-tuberculous chemotherapy comprising of Isoniazid, Rifampicin, Ethambutol, Pyrazinamide as well as Ofloxacin. She developed respiratory distress later on and required intubation the next day. Bronchoscopy done through the endotracheal tube revealed blood clots in the left upper lobe and small bleeding from the apico posterior segment of the left upper lobe. Bronchial washings were sent for microbiological examinations. Endotracheal aspirate suggested the presence of candida and she was treated with oral Fluconazole. She was gradually weaned off a ventilator over a period of 6 days following which she made an uneventful recovery. She was discharged from the hospital on the 15th postoperative day on anti-tuberculous therapy. At follow up 6 months later she is doing well. Anti-tuberculous therapy was changed to Ethambutol, 1g per day, and Ciprofloxacin, 750 mg per day, for 1 year in view of hypersenstivity to Isoniazid, Rifampicin and Pyrazinamide.
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DISCUSSION
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Tuberculous aneurysms of the aorta are exceedingly rare and account for 0.3% of all aneurysms.1 Only 19 cases affecting the thoracic aorta have been reported since 1945.2 Two cases have been reported in patients with HIV. Septic intimal contact, septic invasion of the vasa vasorum, contiguous arterial infection through infected lymph nodes,3 empyema or pericarditis,4 traumatic inoculation and secondary infection of a pre existing aneurysm have been a few of the mechanisms postulated for their occurrence. Atheromatous plaques have been associated with foci of tuberculous aortitis and are believed to be predisposing lesions for tuberculous aortic aneurysms.5
Persistent pain, major bleeding or expanding pulsating mass form the usual ways in which these patients present. Tuberculous aneurysms are diagnosed using chest x-ray, CT scans and angiogram. The diagnosis is confirmed by microbiological and histopathological findings of tubercle bacilli in the excised specimen, i.e acid fast bacilli on Ziehl-Nielson stain, evidence of granuloma with Langhans type of giant cells respectively.3
The aneurysms are usually saccular with an abrupt origin from the wall of the parent vessel and a relatively narrow communication with its lumen.6 Tuberculous aneurysms tend to rupture early7 and therefore operation is recommended as early as possible. The appropriate surgical approach varies with the location and extent of damage. Extra anatomic bypass is rarely resorted to nowadays. The surgical treatment comprises of resection of the aneurysm and an evacuation of contents.8 Repair of the vessel using PTFE or Dacron grafts covered with omentum have been described.9,10 Homograft replacement / patch is an attractive alternative when available.11 The use of circulatory arrest or low flows for better visualization and technical ease needs to be stressed. We prefer antegrade cerebral perfusion through the right subclavian artery as opposed to retrograde cerebral perfusion during the period of circulatory arrest.
The repair of bronchial communications resulting in large air leaks as in our patient compounds the problem. In order to properly visualize and obliterate these communications thoracotomy is the better option. Prompt institution of perioperative anti-tuberculous chemotherapy yields better results.
Patients of tuberculous aneurysms of the aorta treated by both anti-tuberculous therapy and surgery have an 87% reported survival rate whereas those treated with either anti-tuberculous therapy or surgery only, or no treatment at all, have no reported survivors. This underscores the importance of prompt surgical repair and concomitant anti-tuberculous chemotherapy.
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REFERENCES
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ABSTRACT
INTRODUCTION
