1. CASE PRESENTATION
Jeong Jae Kim, MD
Department of Radiology

2. Case
50/F C. C. : Lt shoulder pain, back pain (1 YA)

3. Chest AP

4. outside CT
Title
Pre
Arterial phase

5. outside CT
Title
Pre
Arterial phase

6. outside CT
Title
Pre
Arterial phase

7. outside CT
Title
Pre
Arterial phase

8. outside CT
Title

9. outside CT

10. outside CT
Title

11. Op record
수술일자: 수술명 - Resection of abdominal aortic aneurysm (Descending thoracic aorta replacement with rifampin-soaked Hemashield straight graft 16mm ) 수술소견 * Descending thoracic aorta replacement - Diaphragm level의 descening thorcic aorta rupture가 확인되었고 주위는 pseudoaneurym with hematoma가 관찰됨 - Clamp at mid descending thoracic aorta and supraceliac aorta - Ruptured aorta and abscess removal =>culture done - Intercostal artery : sacrified - Descending thoracic aorta to supraceliac abdominal aorta replacement with rifampin- soaked Hemashield straight graft 16mm

12. CTA Aorta
Title
Arterial phase
Delayed phase

13. CTA Aorta
Title

14. Case
8개월 뒤, 내원 3일전부터 복통 있으며 Fever 38.8 보여 타병원 내원하여 시행한 CT 상 r/o fistula 등으로 전원 문의 후 내원함. 내원 1달 전부터 기침 달고 사는 것 외 특이소견 없다고 하며 구토, 설사 등 부인함. 또한, 1달 전부터 Lt subclavian area 부풀어 오르기 시작하여 찜질하면서 지켜봤고 discharge도 있었다고 함.

15. Chest AP

16. outside CT
Title
Pre
Portal phase

17. outside CT
Title
Pre
Portal phase

18. outside CT
Title
Pre
Portal phase

19. outside CT
Title
Pre
Portal phase

20. outside CT
Title
Pre
Portal phase

21. outside CT
Title

22. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

23. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

24. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

25. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

26. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

27. Title 2016-03-28 CT Angio + 3D abdominal aorta and branch
Arterial phase
Delayed phase

28. 2016-03-28 CT Angio + 3D abdominal aorta and branch
Title

29. Op record
수술소견
* Lt. thoracoabdominal incision (previous wound extension)
- cartilage 및 muscle 사이에도 이전 chest wound 에서 나온 whitish cheese- like abscess가 관찰됨.
* Mycotic pseudoaneurysm abodminal aorta aneurysm
- Infrarenal abdominal aorta에 infection으로 2*1.5cm perforation 이 관찰되 었으며 abscess pocket에 abscess (+) : culture done
- Debridement and irrigation 후 vancomycin powder 넣었음.
- proximal margin은 beveling하여 Rt. renal artery은 포함하여 anastomosis 하고 vancomycin powder 뿌려둠.
- Lt renal artery는 Rimfapin-soaked graft 6mm을 이용하여 reimplantation 함.

30. Pathology report Soft tissue, anterior chest, left, excision :
Chronic granulomatous inflammation
with 1) extensive necrosis
2) multinucleated giant cells
3) dystrophic calcification
1. AFB staining : POSITIVE (a few acid fast bacilli were observed)
2. TB PCR : POSITIVE
Blood vessel, "aorta", excision :
1. Chronic granulomatous inflammation in perivascular soft tissue
2. Vascular wall with myxoid degeneration
Ziehl-Neelsen is POSITIVE for acid-fast bacilli.

31. Tuberculous Aortitis RadioGraphics 2011; 31:435–451, Korean J Thorac Cardiovasc Surg 2012;45: , Diagnostic Imaginc Cardiovascular 2nd edition, J Vasc Surg 2008;48:1012-6, Korean J Thorac Cardiovasc Surg 2012;45:
Infectious aortitis
Normally very resistant to infection
Abnormal aortic wall, like that associated with atherosclerotic disease, preexisting aneurysm, cystic medial necrosis, diabetes, vascular malformation, medical devices, or surgery
Staphylococcus aureus and Salmonella species

32. Tuberculous Aortitis RadioGraphics 2011; 31:435–451, Korean J Thorac Cardiovasc Surg 2012;45: , Diagnostic Imaginc Cardiovascular 2nd edition, J Vasc Surg 2008;48:1012-6, Korean J Thorac Cardiovasc Surg 2012;45:
Tuberculous aortitis
Co-infection with HIV and multiple drug-resistant tuberculosis
Usually involves the distal aortic arch and descending aorta
Generally due to direct extension from contiguous mediastinal lymph nodes, empyema, or pericarditis or to hematogenous or lymphatic spread of distant infection
** 75% of the Tb mycotic aneurysms appeared to originate from aortic wall erosion by a contiguous focus.
Occurs in less than 1% of patients with latent tuberculosis, with mortality rates as high as 60%

33. Tuberculous Aortitis RadioGraphics 2011; 31:435–451, Korean J Thorac Cardiovasc Surg 2012;45: , Diagnostic Imaginc Cardiovascular 2nd edition, J Vasc Surg 2008;48:1012-6, Korean J Thorac Cardiovasc Surg 2012;45:
Tuberculous aortitis
Caseation necrosis involving the entire thickness of the aortic wall results in perforation, either with massive hemorrhage or formation of perivascular hematoma
may become encapsulated and retain communication with the lumen, known as pseudoaneurysm
high mortality associated with this disease is related to the perforation of the pseudoaneurysm into the adjacent organs, causing fatal extravasation
Most of the aneurysms (90%) : saccular and false
One-half of cases : disseminated tuberculosis

34. Tuberculous Aortitis RadioGraphics 2011; 31:435–451, Korean J Thorac Cardiovasc Surg 2012;45: , Diagnostic Imaginc Cardiovascular 2nd edition, J Vasc Surg 2008;48:1012-6, Korean J Thorac Cardiovasc Surg 2012;45:
Tuberculous aortitis
Imaging finding (CECT, CTA)
≥ 1 saccular aneurysm(s) of variable size, arising from aortic wall, usually focal involvement
Lobular contours of aneurysm
Enhancement of periaortic soft tissue
Rim enhancement in case of abscess

35. Tuberculous Aortitis RadioGraphics 2011; 31:435–451, Korean J Thorac Cardiovasc Surg 2012;45: , Diagnostic Imaginc Cardiovascular 2nd edition, J Vasc Surg 2008;48:1012-6, Korean J Thorac Cardiovasc Surg 2012;45:
Tuberculous aortitis
Tuberculous aortic aneurysm might develop despite anti-tuberculous medication, probably due to poor drug penetration into caseous necrotic tissue
requires a combined medical and surgical approach

36. RadioGraphics 2011; 31:435–451
J Vasc Surg 2008;48:1012-6