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OBJECTIVES:
Mycotic aneurysms resulting from Mycobacterium tuberculosis (TB) is a known but rare entity representing 0.85-2% of all abdominal aortic aneurysms. High mortality rate is associated with TB aortic aneurysms because rapid growth is common and classic presentation of aortic rupture if undiagnosed. A combination of surgical intervention and prolonged medical therapy is warranted for disease-free long term survival. The following report describes the successful surgical management and treatment of an aneurysm of the suprarenal aorta secondary to tuberculosis.
Methods:
An 81-year-old male, recently diagnosed with reactivation of military TB, presented with lower back pain associated with malaise and 30 pound weight loss. A CT scan of abdomen demonstrated a significant enlargement of an abdominal aneurysm found 3 months prior from 4.6-cm to 6.8-cm, with extension across the renal vessels.
A retroperitoneal approach was utilized for resection of aneurysm. After proximal and distal control was achieved, longitudinal arteriotomy was made posterior to the left renal artery extending through the infected inflammatory region. An extensive debridement of infected tissue was preformed, followed by placement of a rifampin-bonded 18-mm Dacron graft that had been soaking in 50milligram rifampin solution over a 30-minute time interval. (Image)
Results:
Cultures were positive for Mycobacterium tuberculosis. Antituberculosis drug therapy was maintained for 12 months. Screening for associated pulmonary TB remained negative. One-year post-operatively, CT scan was normal and the patient remained well, asymptomatic, and inflammatory markers were normal.
Surgical approaches can include extra-anatomic bypass which long term offers lower patency and in situ reconstruction which does not carry increased risk of graft infection and allows assess to difficult diseased wall.
Follow-up data regarding an endovascular approach is limited and causes concern for the inability to effectively remove infected and necrotic tissue.
CONCLUSIONS:
Medical and surgical treatment is required for treatment of tuberculosis mycotic aneurysms. Forty-one cases were reviewed and mortality was 100% (n=17) for patients not receiving both. This case reinforces the aggressive nature of tuberculosis mycotic aneurysms and certainly lends credence to an aggressive surgical approach employing the use of in situ reconstruction with antibiotic impregnated rifampin-bonded grafts for complex juxta and suprarenal aortic aneurysms.