Endovascular treatment of a ruptured thoracic aortic pseudoaneurysm secondary to Pott disease during a spine surgery: A case report and a literature review

Abstract

Rationale: The coexistence of a tuberculous aortic pseudoaneurysm and Pott disease in patients with a history of tuberculosis (TB) is relatively rare, and the treatment strategies remain still controversial.

Patient concerns: A 57-year-old female patient with a history of primary pulmonary TB presented with symptoms of breathlessness, chest pain, weight loss, and fever. Magnetic resonance imaging (MRI) and computed tomography (CT) showed a thoracic aortic pseudoaneurysm secondary to Pott disease at T11/12 level.

Diagnoses: Tuberculous pseudoaneurysm at the descending thoracic aorta associated with tuberculous vertebral osteomyelitis.

Interventions: We originally planned a combined surgery consisting of posterior spine stabilization, anterior excision of the infected field, and aortic reconstruction. When we surgically stabilized the posterior spine, unexpectedly, the pseudoaneurysm ruptured. Immediately, we terminated the surgery and appropriately placed an endovascular stent graft, which successfully rescued the patient.

Outcomes: When the patient's conditions were stable, we anteriorly debrided all infected tissues and then performed a spinal fusion by grafting autologous iliac bone. After the debridement and spinal fusion, we arranged a 1-year anti-tuberculous chemotherapy for this patient and performed a 24-month follow-up. This patient had no signs of recurrent infection during the follow-up.

Lessons: For the patients with tuberculous aortic aneurysm(s) complicated with vertebral osteomyelitis, the endovascular repair of an aneurysm(s) should be considered a conventional therapy before the spine surgery, lowering the risk of aortic aneurysm rupture. Meanwhile, minimally invasive endovascular stent graft combined with anti-tuberculosis drugs may be considered one of the therapeutic regimens for the patients whose conditions are not suitable for open surgery, such as age, weakness, or severe organ failure.

Figure 1

A, Coronal CT scan shows left-side vertebral destruction with a paravertebral abscess (arrow). B, Three-dimensional CT scan shows the vertebral destruction in the 11th to 12th thoracic vertebrae. C, Anteroposterior radiograph of the chest shows a widened mediastinum and left pleural effusion. D, Axial enhanced CT scan shows that a tuberculous pseudoaneurysm (arrow-head) of the descending thoracic aorta was surrounded by a paravertebral abscess. CT = computed tomography.

Figure 2

A, Sagittal MRI scan indicates the vertebral erosion with a paravertebral abscess in the 11th to 12th thoracic vertebrae (arrow). B, Axial MRI scan shows a descending thoracic aortic saccular pseudoaneurysm (arrow-head). MRI = magnetic resonance imaging.

Figure 3

A, Thoracoabdominal angiography shows a ruptured tuberculous pseudoaneurysm at the descending thoracic aorta at the T11/12 level (arrow). B, Thoracoabdominal angiography shows that the pseudoaneurysm was successfully repaired by an endovascular stent graft placement. X-ray images show internal fixation of the spine and implanted endovascular stent (arrow-head) 24 months after surgery. C, Anteroposterior view. D, Lateral view.

Figure 4

A, Hematoxylin & eosin (H&E) staining of the resected tissues shows typical caseous necrosis (arrow) consistent with the pathological features of spinal TB (original magnification, ×40). B, Photomicrograph shows accumulation of epithelioid cells (arrow) and multinucleated giant cells (arrow-head) (H&E stain; original magnification, ×100). TB = tuberculosis.