|Year : 2022 | Volume
| Issue : 1 | Page : 29-31
Pseudoaneurysm of an Internal Mammary Artery Due to Tuberculosis
Jayabal Pandiaraja1, Arumugam Shalini2
1 Department of General Surgery, Shree Devi Hospital, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Chennai, Tamil Nadu, India
|Date of Submission||27-Nov-2021|
|Date of Acceptance||11-Dec-2021|
|Date of Web Publication||8-May-2022|
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Tuberculosis is the most common pulmonary infection in developing countries. Vascular complications are known to occur as a part of disease progression. Aneurysm associated with internal mammary artery can be true aneurysm or pseudoaneurysm. Pseudoaneurysm of the internal mammary artery can be due to invasive procedures or as a part of infective etiology. Tuberculosis destroys the wall of blood vessels leading to the formation of pseudoaneurysm. Early identification and intervention of pseudoaneurysm will avoid complications of hemorrhage, hemothorax, and hemorrhagic shock. We present a case of tuberculous empyema that causes pseudoaneurysm of an internal mammary artery managed with coil embolization along with antituberculous treatment.
Keywords: Coil embolization, internal mammary artery, minimally invasive procedure, pseudoaneurysm, tuberculosis
|How to cite this article:|
Pandiaraja J, Shalini A. Pseudoaneurysm of an Internal Mammary Artery Due to Tuberculosis. Amrita J Med 2022;18:29-31
| Introduction|| |
Internal mammary artery aneurysm is a rare entity. It can be true aneurysm and pseudoaneurysm. Pseudoaneurysm is more common than true aneurysm. More than two-thirds of cases are pseudoaneurysms. A true aneurysm is more common following connective tissue disorder, genetic disorder (Marfan syndrome and Ehlers-Danols syndrome), vasculitis (Kawasaki disease, polyarthritis nodosa, systemic lupus erythematosus), and atherosclerosis. Internal mammary artery pseudoaneurysm can occur following complications of invasive procedure, infective disease, and trauma. It can occur following sternotomy, cardiac bypass surgery, sternotomy, central venous catheter placement, and percutaneous biopsy. It can occur following tuberculosis, actinomycosis, and staphylococci infection.
| Case Report|| |
A 42-year-old man presented with complaints of chest pain and palpitations for 2 days. There was a history of swelling in the right side of the chest for 1 month. There was no history of coronary artery bypass grafting and sternotomy. There was no history of contact with tuberculosis. He was not a known case of diabetes, hypertension, ischemic heart disease, and bronchial asthma. There was no history of prolonged medication intake. Local examination showed swelling of 4 cm × 3 cm near the right costoclavicular junction. There was no local warmth or tenderness. The swelling is pulsatile in nature.
Blood investigations showed hemoglobin of 8.7 g/dL, leukocytosis of 13,000 cells/cumm, raised erythrocyte sedimentation rate of 105/h, fasting blood sugar of 101 mg/dL, and postprandial blood sugar of 124 mg/dL. Findings of serological diagnosis of HIV 1 and 2, hepatitis B surface antigen (HbsAg), and hepatitis C virus (HCV) were negative. Ultrasound examination of local lesion showed moderately defined hypo and heterogenous lesion of size 4 cm × 3 cm seen in the anterior chest wall of the right side. The lesion is seen in the muscular plane and extending into the intercostal plane and in contact with the pleura. Contrast computed tomography (CT) of the chest with aortogram showed fairly defined heterogeneous soft-tissue density lesion seen in right anterior chest wall near the first costochondral junction and sternocostal joint [Figure 1]. The lesion measures around 3.9 cm × 4 cm × 5.4 cm causing bony destruction with the first costochondral junction. There were multiple bony fragments seen. There were posteriorly enchasing right internal mammary arteries with pooling of contrast in arterial phase which is suggestive of pseudoaneurysm of an internal mammary artery [Figure 2]. There was bilateral pleural effusion (R>>L) with right upper lobe fibroatelectatic changes.
|Figure 1: Contrast computed tomography of the chest with aortogram showing fairly defined heterogeneous soft-tissue density lesion seen in right anterior chest wall near the first costochondral junction and sternocostal joint|
Click here to view
|Figure 2: Angiogram showing posteriorly enchasing right internal mammary arteries with pooling of contrast in arterial phase, which is suggestive of pseudoaneurysm of an internal mammary artery|
Click here to view
He was planned for percutaneous coil embolization. An angiogram was performed via the right femoral artery. Contrast extravasation was observed in the right internal mammary artery. Embolization was performed with an interlocking coil. There were no postprocedure complications. The patient was then started on antituberculosis treatment. The patient is under follow-up for more than 2 years without recurrence or complications.
| Discussion|| |
Tuberculosis is the most common pulmonary infection in developing countries. Vascular complications are known to occur as a part of disease progression. These vascular complications occur as a part of the direct involvement of blood vessels or as a consequence of contiguous spread. Tuberculosis can cause arteritis, thrombosis, and pseudoaneurysm formation as a consequence of disease progression. Following infection, there is a destruction of adventitia and media and the formation of granulation tissue. Later this granulation tissue is replaced with fibrin. Pseudoaneurysm is formed following the progressive weakening of fibrin.
Internal mammary artery aneurysm is mostly asymptomatic. It can present as a pulsatile parasternal mass over the chest, hemoptysis, chest pain, dyspnea, mediastinal hematoma, hemothorax, and hemorrhagic shock due to rupture. Early diagnosis and treatment of pseudoaneurysm are mandatory to avoid life-threatening complications such as rupture, bleeding, hemothorax, hemorrhagic shock, and death. Intervention is recommended for all types of internal mammary artery aneurysms regardless of the size of the lesion, as the lesion eventually grows and leads to rupture in most cases.
Ultrasound with Doppler, CT, and magnetic resonance imaging are the investigations used to diagnose pseudoaneurysm of the internal mammary artery. Contrast-enhanced multidetector CT is the investigation of choice to detect pseudoaneurysm of an internal mammary artery. But sometimes it is not possible to look at the entire aneurysm due to the presence of thrombosis.
The type of treatment depends on the size of the aneurysm, the presence of symptoms, and the speed of development. Surgery is recommended in patients with large aneurysms, pseudoaneurysms, aneurysms caused by connective tissue disorder, and aneurysms associated with hemothorax. Both open surgery and endovascular surgery can be performed in patients with pseudoaneurysms of an internal mammary artery. In the current era minimally, invasive procedures are preferred over open surgery due to the risk of anesthesia complication, wound infection, postoperative bleeding, and prolonged recovery. Coil embolization and stent implantation are accepted procedures of choice. Ultrasound-guided direct thrombin injection is considered one of the successful minimally invasive procedures for the pseudoaneurysm of an internal mammary artery. Apart from the treatment of pseudoaneurysm, the cause for the pseudoaneurysm must be treated either medically or surgically.
| Conclusion|| |
Pseudoaneurysm of the internal mammary artery should be considered one of the differential diagnoses of costoclavicular swelling. Tuberculosis pyemia can cause osteomyelitis of the costoclavicular joint along with a pseudoaneurysm of an internal mammary artery. Endovascular coil embolization is an acceptable treatment option for the pseudoaneurysm of an internal mammary artery. Tuberculosis should be addressed with the help of antituberculosis treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rose JF, Lucas LC, Bui TD, Mills JL Sr. Endovascular treatment of ruptured axillary and large internal mammary artery aneurysms in a patient with Marfan syndrome. J Vasc Surg 2011;53:478-82.
Wani NA, Rawa IA, Pala NA, Kosar T. Pseudoaneurysm of internal mammary artery caused by pulmonary actinomycosis. Br J Radiol 2010;83:e235-8.
Yadav MK, Bhatia A, Kumar S, Khandelwal N. Internal mammary artery pseudoaneurysm: A rare fatal complication of tubercular empyema. Lung India 2013;30:341-3.
] [Full text]
Bohatch MS, Tanure T, de Oliveira AL, Ribeiro MS, Joviliano EE. Endovascular treatment of left internal thoracic artery aneurysm. J Vasc Bras 2020;19:e20200042.
Müdüroğlu A, Yüksel A. A false aneurysm of internal mammary artery: A case report. Turk Gogus Kalp Damar Cerrahisi Derg 2019;27:384-7.
Miyazaki M, Nagamine H, Hara H, Sugita H, Kawase Y. Successful treatment of a right internal mammary artery aneurysm with thoracoscopic surgery. J Vasc Surg Cases Innov Tech 2019;5:269-72.
Falconieri F, Raevsky E, Davies S, Moat N. Pseudoaneurysm of a branch of left internal mammary artery: A late and potentially fatal complication after redo-sternotomy. Interact Cardiovasc Thorac Surg 2015;20:866-7.
Jefferson J, Nuffer Z, Butani D. Thrombin injection to treat an iatrogenic internal mammary artery pseudoaneurysm. J Med Ultrasound 2017;25:177-9.
[Figure 1], [Figure 2]