Tuberculous abdominal aortic aneurysm: Management and outcomes

Abstract

Background: Tubercular aortic aneurysms (TBAAs) occur by extension of infection from contagious lesions like lymph nodes, empyema, paraspinal abscess, or hematolymphogenous dissemination and can involve any part of the aortic segment. A high index of suspicion is required to attribute a tubercular nature to an infected aortic aneurysm if there is no underlying history of tuberculosis. Histopathology, culture of aneurysm wall with thrombus, and real-time fluorescent polymerase chain reaction (RT-PCR) should be performed to confirm the diagnosis. Patient status at presentation, the complexity of surgical reconstruction, and the possibility of performing efficient surgical debridement influence the selection of various therapeutic strategies. In the present study, the authors present the management results of TBAAs and their follow-up. Methods: This was a retrospective study of patients who received intervention for TBAA at two institutions from June 2016 to June 2024. Data were collected from medical records. Results: Nine patients were studied; five were male and four female. All patients had abdominal pain and three (33%) had a fever of 2 to 3 months duration at the time of presentation. One patient presented with an aortoenteric fistula (AEF) owing to TBAA. Three patients were diagnosed with pulmonary tuberculosis before aneurysm detection and mycobacterial culture of the aortic wall was positive in two of these. Granulomas and RT-PCR were positive in the aortic tissue of four patients. In situ reconstruction was done in two patients, one patient had a suprarenal aneurysm and another patient infrarenal aneurysm. Extra-anatomical bypass was done in three patients: one with AEF and two others with infrarenal aneurysms with significant periaortic involvement with infected tissue. Endovascular aneurysm repair was performed in two patients with a high risk for open aneurysm repair. Neo-aortoiliac system was done for two patients. Perioperative mortality occurred in one patient (11%) with chronic kidney disease who underwent axillobifemoral bypass. Surgical site infection occurred in AEF patient requiring secondary suturing of laparotomy wound. Conclusions: A high suspicion for the tubercular nature of an infected aneurysms is required for timely diagnosis and treatment. Real-time fluorescent polymerase chain reaction for mycobacterial complex should be considered in mycotic aneurysms because some patients may show an unexpected tubercular etiology. Surgical techniques should be tailored to the presentation, and functional status of the patient weighing the risk-benefit ratio of infection-related complications, patency of revascularization, and ability to tolerate the procedure.

Keywords

• Tuberculous aortic aneurysm
• Antituberculosis therapy
• Granulomas