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Ann Thorac Surg 1996;62:1831-1834
© 1996 The Society of Thoracic Surgeons

Case Report

Tuberculous Pseudoaneurysm of the Thoracic Aorta

Toshiya Ohtsuka, MD, Yutaka Kotsuka, MD, Kuniyoshi Yagyu, MD, Akira Furuse, MD, Teruaki Oka, MD

Departments of Cardiothoracic Surgery and Pathology, Faculty of Medicine, University of Tokyo, Tokyo, Japan

Accepted for publication June 15, 1996.


   Abstract
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 Abstract
Introduction
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Tuberculous pseudoaneurysm has been reported to be a fatal, but rare complication of tuberculosis. We report a case of a 68-year-old man who underwent successful surgical treatment for a tuberculous pseudoaneurysm of the thoracic aorta with bronchial communication, and review previous reports of patients who also underwent operation for similar lesions, focusing especially on the pathway of infection to the aorta.


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 Introduction
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Tuberculosis-related aortic aneurysms are expected to increase in incidence throughout the world, because tuberculosis has been reported to be increasing in developing areas, and is reemerging steadily in advanced countries.

A 68-year-old man was admitted in a shock state with massive hemoptysis, which had occurred suddenly at home. He had been healthy, and had no history of tuberculosis or syphilis. Chest x-ray films and contrast computed tomography demonstrated a solitary group of calcified subaortic lymph nodes and an aneurysm, 10.0 x 7.5 x 5.0 cm in size, which appeared as an irregularly bordered mass located on the mediastinal side of the left upper lobe, involving the cavity connected to the distal portion of the aortic arch (Fig 1Go). The calcified nodes were found retrospectively to have been present in a chest x-ray film taken 1 month previously in a medical check-up. Although hemoptysis ceased for several hours, the patient underwent operation immediately, because in general this type of mass is considered to bleed intermittently and pose a risk of catastrophic rupture.



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  		Fig 1. . Chest x-ray film showing an aneurysm of the distal aortic arch (small arrows) and a solitary group of calcified subaortic lymph nodes (large arrow), which were already evident 1 month earlier.

 
The patient was placed in the right lateral position, and thoracotomy was performed at the fourth intercostal space. Pleural adhesion was present all over the surface of the left lung, and this was dissected entirely, except where the hemorrhagenic mass was toughly adherent. After sufficient hemostasis for the dissected pleura, the dissection procedure in the remaining area was completed under cardiopulmonary bypass with arterial cannulation at the left external iliac and left carotid arteries, and venous cannulation at the pulmonary artery and left external iliac vein. The patient was cooled to a rectal temperature of 23°C. Iliac perfusion was stopped while selective cerebral perfusion was maintained. The aortic arch was incised and freed from the mass. The perforation of the aorta communicating with the mass was 1.0 cm in diameter and located just below the left subclavian artery. During repair of the aortic arch, this hole was widened to 2.5 cm in diameter, and its fragile and irregular edge was resected and then repaired by a prosthetic Dacron patch. Fresh blood clot, which essentially composed the mass, was removed from the pulmonary tissue, and the perforated pleura was closed after irrigation.

Histologic examination showed granulomatous tissue in the adventitia, which contained Langhans' giant cells (Fig 2Go). Acid-fast bacilli were positive by Ziehl-Neelsen staining.



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  		Fig 2. . Section of the resected aortic wall showing granulomatous tissue (arrows) in the adventitia. (Elastica van Gieson stain; x4 before 51% reduction.)

 
The postoperative course was uneventful. Isoniazid, ethambutol, and rifampicin have been used for postoperative chemotherapy. Laboratory studies and chest computed tomography was performed 12 months after the operation and showed, generally and locally, no signs of recurrent tuberculosis.


   Comment
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 Introduction
 Comment
References
 
To our knowledge, this is the eleventh report of surgically treated tuberculous pseudoaneurysm of the thoracic aorta (Table 1Go). Tuberculous pseudoaneurysm developed in 7 patients, despite preoperative medication for tuberculosis. Two pathways of tuberculous infection into the aortic wall have been suspected so far: direct extension from contagious lesions, such as infected lymph nodes, empyema, and pericarditis; and hematogenous or lymphangitic spread from primary lesions. In fact, the tuberculous pseudoaneurysm in all reported cases, except for the incompletely examined first patient, were complicated by other tuberculous lesions, which were pulmonary in 6 and extrapulmonary in 6. The pulmonary lesions were diffuse and miliary in 4 cases, and solitary tuberculoma in 1, whereas the extrapulmonary lesions were vertebral in 2 cases, hepatic in 2, and lymph nodal in 2. In spite of this variety of complicating tuberculoses, the tuberculous pseudoaneurysms were generated in either of two specific portions: five lesions, including the present case, were formed in contact with the distal aortic arch, and 6 were located at supradiaphragmatic portion. This coincidence in the place of origin could be explained exclusively by direct infection from two specific groups of mediastinal lymph nodes, which exist commonly in the vicinity of the distal aortic arch and in the left pulmonary ligament. This etiologic theory is supported by the finding in the present case that the tuberculous pseudoaneurysm was formed in the absence of any significant lesion except for the adjacent calcified lymph nodes, which were already evident 1 month earlier.


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  		Table 1. . Surgically Treated Patients With Tuberculous Pseudoaneurysm of the Thoracic Aorta
 
Although the resection of the infected aorta was less extensive than in the previous cases, the present patient has been doing well, his follow-up period being the second longest among the total of 11, who have a 27.2% (3/11) mortality.

As we are now facing a serious problematic worldwide resurgence of tuberculosis, partly because of the increasing number of patients with acquired immunodeficiency syndrome, we should be more alert than ever to this sort of life-threatening complication.


   Footnotes
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 References
 
Address reprint requests to Dr Ohtsuka, Cardiovascular & Thoracic Surgeons Inc, 2123 Auburn Ave, #401, Cincinnati, OH 45219.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. De Prophetis N, Armitage HV, Triboletti ED. Rupture of tuberculous aortic aneurysm into lung. Ann Surg 1959;150:1046–51.
  2. Yeoh CB, Ford JM, Garret R. Tuberculous pseudo-aneurysm of descending thoracic aorta. Arch Surg 1963;86:318–22.[Abstract/Free Full Text]
  3. Sunada T, Katsumura T, Kimura H, Hayashi I, Kaneko K. A case of tuberculous thoracic aneurysm, successfully treated, and the considerations on its clinical manifestations. Nippon Kyobu Geka Gakkai Zasshi 1973;21:823–31.[Medline]
  4. Felson B, Akers PV, Hall GS, Schreiber JT, Greene RE, Pedrosa CS. Mycotic tuberculous aneurysm of thoracic aorta. JAMA 1977;237:1104–8.[Abstract/Free Full Text]
  5. Fujiwara T, Yamane M, Takahara I, et al. A case report of surgically treated tuberculous false aneurysm of descending thoracic aorta. Kyobu Geka 1977;30:91–5.[Medline]
  6. Quaini E, Donatelli F, Bonacina E, Vitali E, Colombo T, Panzeri E. Mycotic tuberculous aneurysm of the descending thoracic aorta. Tex Heart Inst J 1985;12:257–60.
  7. Patra P, Gunness TK, Ferry D, et al. Tuberculous aneurysm of the descending thoracic aorta. J Vasc Surg 1987;6:408–11.[Medline]
  8. Sandron D, Patra P, Lelann P, Bouillard J, Pioche D. Tuberculous pseudo-aneurysm of the descending thoracic aorta. Eur Respir J 1988;1:565–7.[Abstract]



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This Article
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Akira Furuse
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