Tuberculous aneurysms of the abdominal aorta

Cardiovascular Involvement in Tuberculosis: From Pathophysiology to Diagnosis and Complications-A Narrative Review

Although primarily a lung disease, extra-pulmonary tuberculosis (TB) can affect any organ or system. Of these, cardiovascular complications associated with disease or drug toxicity significantly worsen the prognosis. Approximately 60% of patients with TB have a cardiovascular disease, the most common associated pathological entities being pericarditis, myocarditis, and coronary artery disease. We searched the electronic databases PubMed, MEDLINE, and EMBASE for studies that evaluated the impact of TB on the cardiovascular system, from pathophysiological mechanisms to clinical and paraclinical diagnosis of cardiovascular involvement as well as the management of cardiotoxicity associated with antituberculosis medication. The occurrence of pericarditis in all its forms and the possibility of developing constrictive pericarditis, the association of concomitant myocarditis with severe systolic dysfunction and complication with acute heart failure phenomena, and the long-term development of aortic aneurysms with risk of complications, as well as drug-induced toxicity, pose complex additional problems in the management of patients with TB. In the era of multidisciplinarity and polymedication, evidence-based medicine provides various tools that facilitate an integrative management that allows early diagnosis and treatment of cardiac pathologies associated with TB.

Ruptured tuberculous aneurysms of the abdominal aorta: Two case series

Background

Ruptured aneurysms secondary to the tuberculous infection of the aorta are a rare and life-threatening disease. We report a single-center experience of two patients with ruptured infrarenal tuberculous aneurysms.

Case presentation

We report 2 patients with ruptures of the tuberculous aneurysm. All patients had acute abdominal pain and were diagnosed by echography then CT scan preoperatively. The first patient (male, 50 years old) had a ruptured saccular aneurysm. The second patient (male, 43 years old) had a retroperitoneal contained rupture. All were treated by open prosthetic repair, by vascular surgeons. The two patients were well after operations. The diagnosis was confirmed by pathology examination. Antituberculous treatment was introduced after the operation.

Conclusions

Ruptured tuberculous aneurysms are rare but life-threatening. The diagnosis requires a high degree of suspicion. The treatment includes early diagnosis and emergent surgical intervention, extensive excision of infected field, aortic reconstruction, and prolonged antituberculous drug therapy.

•

The tuberculous aortic aneurysm is a fatal condition if not early diagnosed and properly treated.

•

The diagnosis requires a high degree of suspicion.

•

Surgery is necessary for stenotic or aneurysmal lesions.

•

The treatment should be a combination of surgery and antituberculous medication.

Endovascular repair combined with adjunctive procedures in the treatment of tuberculous infected native aortic aneurysms

OBJECTIVE

The present study aimed to analyze the experience of a single center and assess the efficacy and durability of endovascular aortic repair (EVAR) in patients with tuberculous infected native aortic aneurysms (INAAs).

METHODS

All patients who underwent EVAR for INAAs between September 2014 and August 2021 were retrospectively reviewed. The primary endpoints were 30-day and overall mortality rates; the secondary outcomes included major complications, endoleak, recurrence, re-intervention rate, and thrombosis of the pseudoaneurysmal sac.

RESULTS

A total of 18 patients (average age 61.3 years; 10 female [55.6%]) were identified. Fifteen patients (83.3%) had adjunctive procedures in addition to EVAR. Both the in-hospital and 30-day mortality rates were 0%. The overall cumulative survival rates estimated by Kaplan-Meier were 100% at 1 and 6 months, and 92.3% at 12, 24, and 80.8% at 36 and 48 months. Type Ib and II endoleak each occurred in 1 (5.6%) patient and resolved without treatment after 1 month. No graft infections, strokes, paraplegia, ischemic abdominal complications, or other major complications occurred. The overall rates of cumulative freedom from recurrence of aneurysm and re-intervention were 83.9% and 81.8%, respectively, during the median follow-up period of 28.5 (1-72) months. The median time of administering anti-tuberculosis drugs was 10.5 (2-44) months.

CONCLUSIONS

EVAR combined with oral anti-tuberculosis medication is effective and may be an appealing treatment option for high risk INAAs patients. Adjunctive procedures, including targeted drug delivery to the site of infection, could be a solution to further controlling the infection but still needs further evaluation.

Resolution of coronary arteritis following tuberculosis treatment

Background

Coronary artery aneurysm (CAA) in an uncommon condition usually associated with atherosclerosis, but systemic vasculitides constitute important differential diagnoses. A less recognized cause of CAA, tuberculosis (TB) has also been noted to occur simultaneously in patients with such vascular abnormalities.

Case report

A 60-year-old female presented to the Emergency Department with a non-ST segment elevation myocardial infarction. Angiography demonstrated segmental aneurysms of the left anterior descending coronary artery. Shortly after, she was also diagnosed with cutaneous TB, and treatment was promptly initiated. Reevaluation conducted several months later demonstrated that levels of inflammation markers had significantly decreased. New catheterization of coronary arteries evidenced complete resolution of coronary aneurysm images.

Conclusion

Due to the clinical and radiologic resolution with only TB treatment, as well as lack of evidence supporting atherosclerotic or vasculitic etiologies, TB can be considered a possible contributor to aneurysm formation in this case. Prospective studies are necessary to reliably demonstrate causality between TB infection and CAA.

Tuberculous Aortic Pseudoaneurysm: An Unexpected Encounter with an Old Acquaintance

Introduction

Mycobacterium tuberculosis (MT) is a rare cause of mycotic aneurysms. Diagnosis and management of tuberculous arterial infection is challenging. A case of a patient diagnosed and successfully treated for an aortic pseudoaneurysm caused by MT infection is reported.

Report

An 83 year old man was admitted with recurrent back pain over five months associated with constitutional symptoms. Computed tomography angiography (CTA) revealed a psoas collection associated with terminal aorta and proximal left common iliac artery posterolateral wall ulceration. Percutaneous drainage was performed and both the acid fast bacillus test and the molecular test for MT DNA were positive. The patient started on anti-tuberculous treatment, showing an excellent response. Three month CTA revealed arterial ulceration stability. However, the six month CTA revealed evolution to an asymptomatic 40 mm pseudoaneurysm. He was submitted to open repair with an aorto-bi-iliac interposition silver acetate/triclosan collagen coated polyester graft. The post-operative course was uneventful.

Discussion

Increased awareness and pursuit of an histological and microbiological diagnosis along with close surveillance allow anticipation of complications that can develop without any warning symptoms, as reported in this case. Agent identification and a combination of prolonged anti-tuberculous drug therapy with extensive excision of the infected field along with aortic reconstruction contributed to a good outcome.

•

Compared with other agents Mycobacterium tuberculosis is an extremely rare cause of mycotic aneurysms.

•

M. tuberculosis aetiology should be included in the differential diagnosis of a mycotic aneurysm, especially when the arterial lesion co-exists with long lasting constitutional symptoms.

•

Mycotic aneurysms can be associated with life threatening complications without warning signs.

•

Considering their rarity, strong evidence regarding mycotic aneurysm management is still lacking.

Infections of the aorta

Infection of the aorta continues to be a clinical challenge with high morbidity and mortality. The incidence varies between 0.6 and 2.6%. There has been a steady increase in graft infections, especially endograft infections, due to increased procedures (0.2 to 5%). Staphylococcus species remains the most common organism; however, gram-negative and rare causative agents are also reported. The clinical presentation can be very diverse and a high degree of suspicion is necessary to diagnose them. Sometimes, they may present as an emergency with rupture or fistulation. Diagnosis is based on a triad of clinical features, microbial cultures and imaging. Culture-specific antibiotics are mandatory during the entire course, but seldom cure alone. Surgical management remains the standard of care and involves an integrated approach involving debridement, reconstruction and use of adjuncts. Various aortic substitutes have been described with advantages and limitations. Pericardial tube grafts have emerged as a good option. Endo-vascular options are practiced mostly as a bridge to definitive surgery. A small role for conservative management is described. Aortic fistulation to the gut and airway carries a very high mortality. There are no large series in the literature to define guideline-directed treatment and most often it is a customized solution. The 30-day mortality remains close to 30%. Outcomes depend on multiple factors including patient's age, the timing of presentation, diagnosis, causative organism, host status and the treatment strategy adopted.

Tuberculous mycotic aneurysm of aortic arch: a case report emphasising on multidisciplinary management approach

Although tuberculosis (TB) is a well-known infection worldwide, the disease involvement in blood vessels, mainly aorta, is quite rare. The objective of this case report is to address the importance of a multidisciplinary approach aiming at successful treatment of tuberculosis, especially when presenting with mycotic aneurysm. We report a case of a 45-year-old woman with the history of sputum positive pulmonary TB, presenting with seizures and eventually found to have developed disseminated infection involving multiple organs, including the aorta. The patient was started on WHO-recommended anti-tubercular treatment but ended up requiring surgical intervention for the aneurysm. Although the main modality of treatment is the use of proper and adequate medical therapy, vascular dissemination in the form of mycotic aneurysm is difficult to be dealt singlehandedly due to their irreversible and multifactorial nature, with infection being the leading cause and their tendency to progress despite the primary infection being treated.

Infected aortic aneurysm caused by Helicobacter cinaedi: case series and systematic review of the literature

Background

Helicobacter cinaedi is rarely identified as a cause of infected aneurysms; however, the number of reported cases has been increasing over several decades, especially in Japan. We report three cases of aortic aneurysm infected by H. cinaedi that were successfully treated using meropenem plus surgical stent graft replacement or intravascular stenting. Furthermore, we performed a systematic review of the literature regarding aortic aneurysm infected by H. cinaedi.

Case presentation

We present three rare cases of infected aneurysm caused by H. cinaedi in adults. Blood and tissue cultures and 16S rRNA gene sequencing were used for diagnosis. Two patients underwent urgent surgical stent graft replacement, and the other patient underwent intravascular stenting. All three cases were treated successfully with intravenous meropenem for 4 to 6 weeks.

Conclusions

These cases suggest that although aneurysms infected by H. cinaedi are rare, clinicians should be aware of H. cinaedi as a potential causative pathogen, even in immunocompetent patients. Prolonged incubation periods for blood cultures are necessary for the accurate detection of H. cinaedi.

Thoracic endovascular aortic repair for aortobronchial fistula: a case series

Background

Aortobronchial fistula (ABF) formation following the rupture of thoracic pseudoaneurysm is a rare clinical entity. Its aetiology includes atherosclerosis, infections, trauma, post-surgery, and post-endovascular aortic repair. The clinical presentation of ABF includes intermittent or massive haemoptysis, acute respiratory distress, hypotension, and even death. These patients require an emergency aortic intervention to stop active haemorrhage. Thoracic endovascular aortic repair (TEVAR) is a less invasive, safe, and effective treatment compared to conventional open surgical repair

Case summary

We hereby report three cases of ruptured descending thoracic aortic pseudoaneurysms resulting in a fistula formation. The first two cases had tuberculosis as their underlying aetiology, while the third case was the result of previous open post-aortic surgery. All patients presented with massive haemoptysis and were successfully treated by emergency TEVAR and had favourable outcomes.

Discussion

Thoracic endovascular aortic repair is a rapid, less invasive, and effective treatment for emergency management of ABF. It has more than 85% technical success rates in the reported literature. We had procedural success in all three cases. The short and midterm outcome of ABF following TEVAR is favourable and encouraging.

Miliary tuberculosis in a patient with tuberculous mycotic aneurysm of the abdominal aorta: Case report and review of the literature

The combination of miliary tuberculosis and tuberculous mycotic aneurysm has been described in the literature. We present the case of an 84-year-old man who was diagnosed with a mycotic aneurysm of the abdominal aorta and an adjacent soft tissue mass, after a 3- month history of fever. The patient underwent endovascular restoration of the aneurysm and was treated with broad-spectrum antibiotics. One and a half months later the fever relapsed and the chest CT scan revealed findings consistent with miliary tuberculosis and opacities of both upper lobes not present before, while the abdominal CT scan revealed an increase in the size of the para-aortic mass. Tuberculosis was documented by positive culture for M. tuberculosis of bronchial washing and by the CT-guided para-aortic mass biopsy. The patient received anti-TB treatment for 9 months leading to a spectacular improvement of his clinical condition and imaging findings. A review of the literature since 2008 revealed 28 more cases of tuberculous mycotic aneurysm. The treatment and outcome of all cases are described. Mycotic aneurysm of tuberculous etiology remains a reality and has a relatively good prognosis. Although miliary tuberculosis affects mortality even elderly patients may benefit from "aggressive" management and treatment.

[The aneurysms of the aorta of tuberculous]

Tuberculosis is a public health problem in Morocco, which is difficult to eradicate despite the recognized efficiency of health policies. Aortic aneurysm is rare and lethal complication of spontaneous evolution. Pathophysiological characteristics and the difficulty of early diagnosis worsen the prognosis.

Disseminated tuberculosis in an immunocompetent patient

Miliary tuberculosis refers to the clinical disease resulting from the hematogenous dissemination of Mycobacterium tuberculosis. A tuberculous aneurysm of the aorta is exceedingly rare. Contiguous tuberculosis in the form of lymphadenitis is generally responsible for the aortic involvement. We report a case of tuberculous mycotic aneurysm in patient with miliary disease, not affected by a cellular immunodeficiency and with no other common risk factor for infection. He received anti-tubercular therapy and endovascular stenting before the identification of Mycobacterium tuberculosis in lung, lymph nodes, and gastric lavage. The clinician should be aware that a mycotic abdominal aortic aneurysm could be caused by M. tuberculosis, even if microbiological confirmation is lacking or is negative, especially if a contiguous focus of tubercular infection is detected.

New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience

OBJECTIVES

To assess causative pathogens and surgical outcomes in patients with primary infected aorto-iliac aneurysms at our institution.

DESIGN

Retrospective study of patients treated at a university hospital between 1992 and 2009.

RESULTS

We identified 26 patients (median age, 63 years) with primary infected aneurysms on the aorta (descending thoracic, n = 2; thoraco-abdominal, n = 3; suprarenal, n = 2; infrarenal, n = 15) or iliac arteries (n = 4). Among them, 22 were symptomatic, including 13 with ruptured aneurysms. The causative organisms, identified in 25/26 patients, were Campylobacter fetus, n = 6; Streptococcus pneumoniae, n = 4; Listeria, n = 3; Salmonella, n = 2; Mycobacterium tuberculosis, n = 2; Staphylococcus aureus, n = 1; and other, n = 7. Immune suppression was a feature in 10 (38.4%) patients. Revascularisation was performed in situ in 23 patients (10 allografts, eight grafts, three superficial femoral veins, and 2 stentgrafts) and by extra-anatomic bypass in three patients. Hospital mortality was 23% (in situ group, 17.4%; extra-anatomic group, 66.7%; χ(2)(Yates), P = 0.24). During follow-up in the 20 survivors (median, 48.5 months), there were two non-infection-related deaths (five and 24 months) and six (30%) vascular complications.

CONCLUSIONS

The bacteriological spectrum of primary infected aorto-iliac aneurysms was wider than previously reported. The availability of new diagnostic tests and increased prevalence of immunosuppression may explain this finding.

Primary aortic infections and infected aneurysms

Primary infections of the aorta and infected aortic aneurysms are rare and are life threatening. Most of them are due to bacterial infection occurring in an atheromatous plaque or a pre existing aneurysm during bacteremia. Rarely spread from a contiguous septic process may be the cause. The reported hospital mortality ranges from 16-44%. Gram positive bacteria are still the most common causative organisms. More recently, Gram negative bacilli are seen increasingly responsible. The mortality rate is higher for the Gram negative infection since they most often cause supra renal aneurysms and are more prone for rupture. Best results are achieved by appropriate antibiotics and aggressive surgical treatment. Excision of the infected aneurysm sac as well as surrounding tissue and in situ reconstruction of aorta is the preferred treatment. Pedicled omental cover also helps to reduce infection. Long term antibiotic is needed to prevent reinfection. Mortality is high for those who undergo emergency operation, with advanced age and for nonsalmonella infection.

Diagnosis and management of aortic mycotic aneurysms

We reviewed all papers most recently reported in the literature (January-December 2008) with regard to infected arterial aneurysms (IAAs) affecting the aorta. Most of the recently reported knowledge is limited to case reports and small series of aortic mycotic aneurysms. Most patients are elderly men and have comorbidities at presentation. Aneurysms were most commonly associated to Salmonella and Staphylococcus. However, several cases of aortic IAAs caused by atypical pathogens were also reported, likely due to an increase in immunosuppressive illnesses, increased life expectancy, improved diagnostic methods, and increasing medical awareness. Open surgical therapy of IAAs remains the gold standard. Some have reported successful outcomes with endovascular methodologies for patients medically compromised or for particular challenging clinical or anatomical scenarios. However, at this time, conclusive evidence is lacking and it should be in general considered a bridge to open repair. The latter should be planned at the earliest possible, when medically permissible.