Ann Thorac Surg 1995;59:524-525
© 1995 The Society of Thoracic Surgeons
Case Reports
False Hydatic Aneurysm of the Thoracic Aorta
Paolo Biglioli, MD,
Rita Spirito, MD,
Maurizio Roberto, MD,
Alessandro Parolari, MD,
Marco Agrifoglio, MD,
Giulio Pompilio, MD,
Vincenzo Arena, MD
Department of Cardiac Surgery, Centro Cardiologico, University of Milano, Milano, Italy
Accepted for publication June 9, 1994.
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Abstract
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In this article we report the successful treatment of a lower descending thoracic aorta hydatidosis that mimicked a posterior saccular aneurysm; surgical excision was performed and the aorta was repaired with a prosthetic Dacron patch. At a 26-month follow-up, the patient is alive and conducting a normal life. Discussion about the management of this rare case also is given.
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Introduction
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Hydatid cysts may appear everywhere in the human body: primary hepatic and lung localizations are the most frequent ones, whereas some other localizations, such as the tissues surrounding thoracic aorta wall [1], are extremely rare in the literature. In this article we present a case of successful surgical treatment of a hydatid cyst of the descending thoracic aorta, mimicking a saccular aneurysm with a wide communication with the aortic lumen.
A 43-year-old man from an agricultural, sheep-raising area of southern Italy was referred by a peripheral hospital on July 1991. Ten days before admission he came to the surgical ward of a peripheral hospital complaining of the onset of exacerbating thoracolumbar pain radiating to the abdominal wall; he then underwent thoracoabdominal computed tomographic scan, which showed that the posterior wall of the descending thoracic aorta was surrounded by an inhomogeneous mass at the level of the lower mediastinum, with possible communication between the aorta and the mass. A total body magnetic resonance imaging was performed and a multilocular mass was detected around the inferior portion of the descending thoracic aorta (Fig 1
), which, at a sagittal scan, had the appearance of an ``arrow'' posterior thoracic aneurysm with a wide communication with the aortic lumen (Fig 2). No other cerebral, thoracic, or abdominal masses could be detected. The patient then was transferred to our cardiovascular operation unit.
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Fig 1. . Magnetic resonance imaging scan of the lower descending thoracic aorta involved by a multilocular mass.
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Fig 2. . Magnetic resonance imaging sagittal scan of the descending thoracic aorta with a posterior saccular aneurysm lying over the diaphragm.
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Because of exacerbating thoracolumbar pain, the patient underwent transesophageal echocardiography, which showed a multilocular mass around the lower portion of descending thoracic aorta, and digital aortography, which showed a saccular aneurysm of the posterior wall of the lower portion of the descending thoracic aorta lying on the left diaphragm with a wide communication with the aortic lumen (Fig 3); thoracic aorta hydatidosis or mediastinal teratoma were supposed and the patient was transferred to the operating room on the same day.
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Fig 3. . Arterial digital aortography of the descending thoracic aorta showing a wide communication with the posterior saccular aneurysm.
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Left posterolateral thoracotomy was performed, entering the sixth intercostal space. The lower left lung lobe was strictly adherent to a mediastinal pulsatile mass, so that dissection was extremely difficult; a wide, thick-walled mass was found to encircle the aortic wall. Descending thoracic aorta was clamped proximally and distally to the mass, with no distal bypass, then the mass was opened. A multivesicular cyst was found inside the lesion, and its contents (several daughter cysts) were entirely removed (Fig 4). The large communication between thoracic aorta and the cavity around the cyst was then closed with a Dacron patch, and the remaining wall, after formalin treatment, was mattressed over it. Aortic cross-clamp time was 15 minutes.
The postoperative course was uneventful; a postoperative total body computed tomographic scan did not reveal any residual cyst. The patient was discharged on the 10th postoperative day without postoperative antihelmintic drug therapy.
The patient underwent periodic (every 6 months) total body computed tomographic scans, which were negative until October 1993; at the time of last follow-up, he is alive and conducting a normal life.
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Comment
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Hydatid disease in humans is caused by parasitic infections with the larval stage of the Echinococcus granulosus; such a parasite is endemic in many sheep-raising areas in the world, especially in Mediterranean countries, North Africa, and South America.
Usually the parasite embryo crosses the intestinal wall and reaches the portal circulation, where it is frequently stopped. When this does not happen, it may be entrapped into the pulmonary circulation, or—quite rarely—it can reach the systemic circulation and implant elsewhere.
The arterial localization is an exceptional manifestation [1–4], and many hypotheses can be raised about the way the artery wall is reached. Although some authors point toward the presence of preexisting small intimal tears or aneurysms [5], others consider the possibility that the parasite may reach the arterial wall by means of the vasa vasorum [2, 3].
In this case, operation has been recommended on the basis of the risk of a possible descending thoracic aorta rupture and to avoid distal hydatid cyst migration.
Regarding the management of patients presenting with arterial hydatid cysts, no standard surgical technique currently is recommended because of the rarity of these events; in this case, closure of the communication between the pericyst and the thoracic aorta was achieved by the application of a prosthetic patch. In this way we were able to perform a low-risk procedure with no complications by means of a short thoracic aorta clamp time; in addition, serial computed tomographic scans performed at follow-up revealed neither dehiscence of the suture line nor pseudoaneurysm development.
Finally, postoperative medical therapy by benzimidazole derivatives has not been deemed necessary because of the absence of secondary cysts at preoperative computed tomographic and nuclear magnetic resonance scans; in fact, there is no substantial agreement in the literature on the efficacy of such a therapy, either prophylactic or curative [6].
Hydatidosis of descending thoracic aorta may be treated successfully by operation; strict follow-up is recommended to detect the recurrence of such disease earlier.
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Footnotes
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Address reprint requests to Dr Roberto, Department of Cardiac Surgery, University of Milano, Centro Cardiologico, Fondazione I Monzino IRCCS, Via Parea, 4, 20138, Milano, Italy.
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References
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- Hendaoui I, Siala M, Fourati A, Thameur MH, Hamza R. Case report: hydatid cyst of the aorta. Clin Radiol 1991;43:423–5.[Medline]
- Hadjiat N, Graba A, Mansouri H. Rupture d'une kyste hydatique rétropéritonéal dans l'aorte abdominale. Ann Chir Vasc 1986;1:483–5.
- Rada IO. Ischemic syndrome of the lower limb produced by a hydatid cyst. J Cardiovasc Surg (Torino) 1986;27:282–5.[Medline]
- Pardal HC, Marcos JMCO, Hernandez FD, et al. Hydatid mesoarteritis in the abdominal aorta: case report. Angiology 1985;1:889–94.
- Brycesom ADM, Cowie AC, McLeod V, et al. Experience with mebendazole in the treatment of inoperable hydatid disease in England. Trans R Soc Trop Med Hyg 1982;76:510–8.[Medline]
- Morris DL, Dykes PW, Marriner S, et al. Albendazole—objective evidence of response in human hydatid disease. JAMA 1985;253:2053–7.[Abstract/Free Full Text]
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Abstract
Introduction
