Surgical treatment of thoracic aortic pseudoaneurysm caused by Brucella melitensis

A 65 year-old man was admitted to our hospital with a 2 month history of intermittent fever and hoarseness. The patient suffered from brucellosis 8 years ago and recovered post-treatment. Then, he previously engaged in the slaughtering industry. Brucella agglutination test was positive. A computed tomographic (CT) scan showed a huge pseudoaneurysm of the proximal descending thoracic aorta, involving the left subclavian artery and distal arch (Fig. 1). Hematologic investigations show CRP, ESR and RF increased. And the Brucella agglutination test shows positive. So, the treatment with doxycycline, ceftriaxone and amikacin for one month started it here, and the next treatment with doxycycline and rifampicin for two months preoperative.

Fig. 1figure 1

Preoperative computed tomographic scans showing a huge aortic pseudoaneurysm (58 × 56 mm, arrow indicating) involving the distal arch, proximal descending aorta, and left subclavian artery. A and The computed tomography of aortic pseudoaneurysm. B Front view. D Posterior view

Surgery was performed in the right decubitus position through the fourth intercostal approach with the left posterolateral incision, under deep hypothermic circulatory arrest with the left femoral artery, and left femoral vein cannulation. After the patient cooled down to 20 °C, a deep hypothermic circulatory arrest occurred, the distal arch and proximal descending aorta were opened and inspected, and the anastomotic margin of the arch just distal to the left common carotid artery was trimmed. During the operation, there were unclean secretions in the pseudoaneurysm, the pseudoaneurysm body showed ulcerative manifestations, and the adventitia adhered to the surrounding tissues. The pseudoaneurysm and its contents were excised till the adjacent normal artery wall, and those closely adhered to the surrounding tissues that cannot be removed shall be cauterized with electrocoagulation and disinfected with iodophor. The proximal end of the self-made bovine pericardial (Guanhao Biotechnology Co., Ltd.) duct with a 10 mm single artificial branch (Fig. 2A) was anastomosed with the distal aortic arch. The 10 mm single branch was connected to the arterial perfusion tube to resume cardiopulmonary bypass and start rewarming. The distal end of the bovine pericardial duct is anastomosed to the distal end of the descending aorta. The 10 mm single-branch artificial vessel was anastomosed to the left subclavian artery. The cardiopulmonary bypass and deep hypothermic circulatory arrest times were 140 and 27 min, respectively. The patient recovered uneventfully. The duration of mechanical ventilation support was 16.72 h. The duration of the intensive care unit stay was 83.87 h. The postoperative hospital stay was 7 days. Detection of PD-seq pathogenic macrogenomic DNA and RNA of fresh-frozen surgical tissues of thoracic aortic pseudoaneurysm indicated Brucella melitensis infection.

Fig. 2figure 2

A A 24 mm-diameter and 120 mm-long duct (white arrow indicating) with a 10 mm diameter artificial vessel (yellow arrow indicating) was made from a bovine pericardial patch (120 × 80 mm). B A postoperative computed tomographic scan showing an unobstructed bovine pericardial duct and good reconstruction shape of the left subclavian artery by a 10 mm branch

Postoperative CT showed that the bovine pericardial duct was unobstructed, and the left subclavian artery reconstructed by a single branch was good (Fig. 2B). At post-discharge, doxycycline and rifampicin oral antibiotics were continuously administered. The patient did not have any further symptoms of infection such as fever during the follow-up. The patient had hoarseness before the operation, and there was hoarseness after the operation without aggravation.

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