A 42-year-old woman who two months earlier had undergone surgical drainage of a psoas abscess was found to have relapsed. Cultures of the abscess had been positive for Mycobacterium tuberculosis, but chest radiographic finding were normal. The patient took anti-tuberculous drugs (isoniazid, rifampin and pyrazinamide) for two months, but abdominal pain and a palpable mass developed in the right lower quadrant. CT revealed that in the suprarenal abdominal aorta, a saccular aneurysm about 6×5×3 cm in size was surrounded by a large abscess involving the right psoas muscle and posterior pararenal space. There was associated destruction of adjacent vertebrae (). Due to the high risk involved, surgery was not attempted, and urgent repair of the aneurysm by mean of an endovascular stent graft was thus required. The stent consisted of three Z-segments covered with expanded polytetrafluoroethylene (Taewoong Medical, Seoul, Korea) and with the upper one-third partially fenestrated to ensure flow along the celiac axis (). A right femoral arteriotomy was performed after skin preparation, and using a 5-F pigtail catheter, an abdominal aortogram was obtained. This revealed occlusion of the superior mesenteric artery at the orifice, due to surrounding inflammation, and that supply of this vessel, from the celiac axis and inferior mesenteric artery, was retrograde. An 18-F introducer (Cook, Bloomington, IN), 50 cm in length, was cut and modified for pre-loading of the stent graft. After pre-loading, the introducer was inserted over an Amplatz heavy-duty wire (Cook, Bloomington, IN), and after exact orientation, the stent graft was deployed. To confirm successful occlusion and the patency of arterial branches, aortography was then repeated. Post-procedural angiography and CT showed that the celiac axis, renal artery, and superior mesenteric artery were patent. After stent graft placement, anti-tuberculous medications were prescribed for seven months, and CT images obtained one year after the procedure showed that the aneurysm had completely disappeared and the psoas abscess completely healed. Although the stent graft was placed in an inflamed aorta, neither CT () nor two-year clinical evaluation revealed complications such as prosthetic infection, tuberculous bacteremia, the recurrence of the psoas abscess or aortitis, or aneurysmal rupture.
A 42-year-old woman with large aortic aneurysm and psoas abscess.