Surgical Considerations of Dissecting Aneurysm of the Aorta

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Surgical Considerations of Dissecting Aneurysm of the Aorta'
iMICHAEL E. DE BAKEY, MI.D., DENTON A. COOLEY, iM.D., AND OSCAR CREECH, JR., iM.D.
1louiston, Texas
Fr(om7t the Dep)arztment of Surgery, Baylor Univerrity Collegeof Medicine,andtheJefferson Davis, leth-
o(ist, ati(I Veteranis Adminisistration Hospitals, Hotuston, Texas
THE WVELL-DEFINED CLINICAL and patho- Edmeades aild Griffith'4 reported that 36
logical features of dissecting aneurysms of per cent of their patients died within 48
the aorta have been recognized for over a hours of onset, 37 per cent within three to
century, but treatment for this grave dis- 60 days, and only 25 per cent with the
ease has remainied largely symptomatic chronic or so-called healed form of the dis-
and unsatisfactory.'3' 17. 21, 2(, 27 Unlike sac- ease survived three months to eight years.
ciform and fusiform aneurvsms in which Thus, it would appear that the condition is
excisional therapy mav be readilv em- rapidly fatal in from 75 to 90 per ceilt of
ployed, dissecting aneurysms of the aorta the cases.
constittute an entirelv different problem, Few attempts hlave been mladle to attac^.
owing to the pathologic nature of the this problem by surgical means, and all
lesion. For one thing it is rarely sufficiently have proved unisuccessful. The first ofthese
well localized, the lesion often extending is believed to be the report of Gurin, Bul-
throughout the extent of the aorta, to per- mer and Derby,9 in 1935, whose efforts
mit application of this form of surgical at- were directed primarily toward relief of
tack. For another it usuallv arises in the acute arterial inllsufficiency in the rigbt
upper reaches of the aorta abouit the aortic lower extremity of a patient with an acute
arch, and most often in the ascending dissecting aneurysm of the aorta. After ex-
aorta26 (Fig. 1). It is thlus apparent that plorinlg the femoral arterv aild finding it
the surgical approach to this lo oblem re- pulseless blut intact, the right external iliac
quiires somenwhat different priinciples than artery vas exposed about three inches
those uinderlying excisioilal therapy. above Poupart's ligament and found to
The cliallenging inature of this disease is have "an infiltration of dark blood in its
further emphasized by its highlv fatal lateral third, extending as far as could be
couirse. This is Nwell illtustrated by the re- seen in both directions," representing the
ports of a number of observers. Shennan,26 dissecting aneurysm. No expansile pulsa-
for example, in bis analvsis of 143 collected tion was present in any part of the vessel.
cases fouinid that death occurred within 24 After applying occluding clamps to the
hoturs in 58 per ceint anld in one day to one artery above and belowv, a longitudinal in-
Nveek in 26 per cent. Among the cases re-
cision about 1 iinch in length was made in
corded by Weiss, Kiinney and Mahr,29 only
the unaffected anterior wall. Upon enter-
about 10 per cent survived for a significailt
ing the true lumen of the artery it was
period of time. Mlore recently Levinson,
found narrowed by the dissecting aneur-
* Presented before the American Suirgical As- ysm, and completely occluided by an athero-
sociation, Philadelphlia, Pa., April 28, 1955. matous mass. The intima and media oppo-
Stupported in part by a Grant from the Houiston site the atheroma 'were incised from within
D)istrict Chapter, Texas Heart Association, and the
the vessel, thlus creating an opening into
Cora anld WN,ebb IMading Ftund for Surgical Re-
the false lumen of the dissecting aneurysm,
search.
586
1,oltin,io 142 DISSECTING ANEURYSMI OF THE AORTA
Ntumiiber 4
EX T E N T OF DIS S E C TI 0 N 287 C A S E S (S H E N N A N)
'I
/
ascending aorta ascending aorto ascending aorta to
ascending aorta transverse to mid arch to distal arch descending thoracic
84 (29.9%) arch 6(2%) 1 1 (3.9%) 31 (10.8%) 21 (7.3%)
ascending aorta left subclavian
into abdominal aorta to dia p h r agm
3 0 (10 %) 10 (3.4%)
ascending aortb' to iliacs left subclavian to abdominal
or beyon d 41 (14.2%) aorta or beyond 53 (18.4%)
FIG. 1. Diagramii showing results of analysis of 243 collected cases of dissecting aneurysms
of aorta (Shennan26).
through which bright arterial blood spurted ported application of a surgical procedure
uipon momentary release of the proximal somewhat similar to that employed by
clamp. Following closure of the incision in Gurin and associates. Here again the major
the anterior N7all of the vessel and removal manifestations were those of acute arterial
of the occluiding clamps, pulsations were insufficiency of the lower extremities. Upon
restored in the extremity, but the patient exposure transperitoneally ofthe abdominal
died on the sixth postoperative day of aorta and iliac arteries no pulsations were
renal failuire. In 1953, Johns12 reported the palpable in these vessels. The procedure
repair by suiture closure of a perforated employed consisted essentially in making
dissecting aneurysm of the abdominal a longitudinal incision into the aneurysm
aorta, buit this patient also sucecumbed in the lower abdominal aorta, extracting a
from renal insufficiency on the eighth post- soft clot from its lumen, permitting free
operative day. The pathologic features of bleeding from above, making a small win-
this case wouild suiggest that it was a rather dow into the true aortic lumen by excising
unuisual and perhaps atypical form of dis- a 2 X 2.5 cm. piece of the internal aneu-
secting aneuirysm. rysmal wall, closture of the lower plane of
In a more typical case of anI acute dis- the dissecting aneurysm with interrupted
secting aneurysm Shaw25 has recently re- mattress sutures, and repair of the aortot-
587
DEBAKEY, COOLEY AND CREECH A-IIllils of Suirgery
October, 1953
A B
Fiw;. 2 A and B. Roentgenograimis of chest in Case 1 in postero-anterior and lateral projec-
tions, showingtortuouis, dilated descendingthoracic aorta extendinginto leftparavertebral sulcus.
FIG. 3. Drawing made at operation in Case 1, showing aneurysm projecting posteriorly and
tothe left.
588
Nultalmn 142 D)ISSECTING ANEURYSM. OF THE AORTA
Numbeitil 4
0; 0X4RKC m
FIG. 4. Photograph made at operation in Case 1, showing aneurysm mobilized prior to
application of occluding clamps.
omx. Following completion of the pro- duration. One year previously he had experienced
cedure good pulsations were restored in sudden, severe, constrictingpaininthechest, which
the aorta, iliac, femoral and popliteal ar- beganposteriorlyandradiatedalongtheribmargins
bilaterally. He was hospitalized for about 10 days,
teries. Unfortunately the patient died of
and during the first 3 or 4 days the pain was of
renal insufficiency on the ninth postopera- such severity that opiates gave only partial relief.
tive day. After release from that hospital he was well until 3
Our experience with the surgical treat- months prior to the present admission, when exer-
ment of this disease is based upon six cases. tional andparoxysmal nocturnal dyspnea developed
and the feet began to swell.
Although the underlying principles of the
surgical procedures employed were essen- Physical examination revealed a blood pressure
of 230/130 mm. Hg. Minimal excursion of the
tially similar, certain variations in their diaphragm was noted, and generalized expiratory
application seemed desirable on the basis wheezes were heard throughout both lung fields.
of (lifferences in the pathologic features of The heart was enlarged to the left, and there were
the lesions encountered (Fig. 1). bothapicalandaorticsystolicmurmurs.Aloud,pro-
longed systolic murmur was audible over the poste-
REPORT OF CASES rior aspect of the left side ofthe chest beneath the
Case 1. P.M., 58-yvear-old white mian, was ad- scapula.
mitted to the Veterans Administration Hospital on Laboratory studies on admission were not re-
May 4, 1954, complaining of shortness of breath markable, and serologic test for syphilis was nega-
on exertion and swelling of the feet of 3 months' tive. Radiologic examination ofthe chestrevealed a
589
DE BAKEY, COOLEY AND CREECH Annals of Surgery
October, 1953
FIG. 5. Drawing made at operation in Case 1, showing occluding clamps applied above and
below the aneurysm and the levels of transection of the aorta.
FIG. 6. Drawing made at operation in Case 1, showing double ltmnen in distal segment of
arota and singlelumenproximally.
rounded density in the posterior inferior medias- scendingthoracic aorta (Fig. 2 A and B). An elec-
tinum that projected into the left hemithorax, and trocardiogram showed evidence suggestive of a
appeared to be a markedly tortuous, dilated, de- previous posterior myocardial infarction.
590
VoIuIIIIO 142 DISSECTING ANEURYSM OF THE AORTA
Nuumber 4
FIG. 7. Drawin.g made at operation in Case 1, slhowing (A) obliteration of the false lumen
in the distal seginent; and (B, C a-Id D) anastomiiosis of the two ends by continuous suture.
OnJuly 7, 1954, operationiwasperforml-edunder was then performed by end-to-end anastomosis
induced body hypothermia after lowering rectal (Figs. 7 B, C, D, and 8). The occluding clamps
temperature to 90° F. Thoracotomy was performed were removed 44 minutes after application.
through aleft posterolateral incision, with resection Examination of the resected specimen revealed
of the fifth rib. The lung was retracted anteriorly, a well-formed thrombus in the false lutmen. The
revealing a U-shaped aneurysm of the descending proximal level of aortic resection was above the
thoracic aorta which projected posteriorly and to aneurysm, and the area of original intimal tear was
the left (Fig. 3). The mediastinal pleura was in- demonstrated (Fig. 9).
cised, and umilbilical tapes were passed about the Convalescence was uneventful. Three months
aorta above and below the aneurysm. Three pairs later roentgenograms, including angiocardiogram,
ofintercostal arteries wereligated anddivided, thus revealed a relatively normal outline of the descend-
mobilizing the aneuirysm throughout its length ing thoracic aorta (Fig 10 A and B).
(Fig. 4). Occluidiing clamps were applied proximal
and distal tothe aneuirysmii, andthe intervening seg- Case 2. W.C., a46-year-old whiteman, was ad-
ment of aorta was excised (Fig. 5). Examination mitted to the Methodist Hospital on November 20,
of the distal end of the aorta revealed a double 1954, with a diagnosis of aneurysm of the thoracic
lumen, forme(d by the dissecting process (Fig. 6). aorta. The patient had been in good health until
The false lumen was obliterated by re-approximat- May, 1954, whe he developed severe pain in the
ing the dissected layer with several interrupted left chest, at which time a roentgenogram disclosed
stutuires (Fig. 7 A). Restoration of aortic continuity an aneuirysmn involving the distal arch and de-
591
DEBAKEY, COOLEY ANI) CREECH AOncntaoIbs eofr, ti1i9r5g5e-ry,
-. rAib_.:...".-.. ".
Fic.. 8. Drawing ma(le at operation in Case 1, showing completed anastomiiosis.
scending thoracic aorta. Convalescence from this showed an occasional erythrocyte and hyaline cast.
illness was satisfactory, and the patient remained The electrocardiogram indicated left ventricular
relatively symptom-free uintil November 11, 1954, preponderance, but no evidence of myocardial in-
wlhen he experienced hemoptysis, which continued farction.
intermittently for the next 6 days. On November 23, 1954, operation was per-
Physical examination revealed awell-developed, formed under general body hypothermia, at rectal
well-nourished white man. The blood pressure was temperature of 830 F. Left thoracotomy was per-
170/112 mm. Hg. A Horner's syndrome was evi- formed through a posterolateral incision, resecting
dent on the left. There were prominent pulsations the fifth rib. Exploration revealed an aneurysm of
inthesuprasternal notch, andasoftsystolicmurmur the distal arch of the aorta, beginning at the origin
was audible over the aortic valviilar zone of the of the anomalous right subclavian artery and ex-
precordium. Pulsations in the l6ower extremities tending to the middle third of the descending tho-
were normal. racic aorta (Table I). The right and left common
Roentgenographic examination of the chest re- carotid arteries arose from a common trunk near
vealed a fusiform aneurysm of the thoracic aorta the center of the aortic arch. The right subclavian
which began in the posterior portion of the arch artery was ligated and divided. Since the left sub-
and involved the upper portion of the descending clavian artery arose from the aneurysm, it, too, was
thoracic aorta (Fig. 11 A and B). It appeared that ligated and divided near its origin. Occluding
the aneurysm had increased in size significantly clamps wereappliedjustdistaltothecommoncaro-
since its detection 5 montlhs previously. An angio- tid artery above and to the descending thoracic
cardiogram outlined the aneurysm, and demon- aorta below, and the aneurysmii was excised. Exam-
strated the false passage created by the dissecting ination of the specimen disclosed a dissecting aneu-
process (Fig. 12). There appeared to be an anom- rysm, with the false passage beginning just below
alous right subclavian artery arisingfrom the poste- the proximal line of resection and extending below
rior aspect ofthe distal arch andpassingbehindthe the level of transection distally (Fig. 13). At the
esophagus. The left subclavian artery was not lower level of aortic transection there was a double
visualized. lumen, and therefore the false passage was obliter-
Laboratory findings revealed a hemoglobin of ated suturing the dissected layers together. Aortic
11.3 Gm., and hematocrit, 36 per cent. Urinalysis continuity was then re-established by insertion of a
592
V'oltime I42 DISSECTING ANEURYSMI OF THE AORTA
Niiniber 4
Fic. 9. Photograph of specimen removed in Case 1, showing well formed thrombus in the
false lumilen.
freeze-dried homograft. The duration of aortic oc- pneumonectomy was done, but no attempt was
clusion was 65 minutes. During the rewarming pe- made to resect the aneurysm. After this operation
riod, respiration was being assisted when a left she had been well until one month prior to the
pneumothorax developed in spite of the under- present admission, when pain developed in the left
waterdrainagewithsuction. Cardiacarrestoccurred interscapular region and left shoulder.
rapidly, followed by ventricular fibrillation, but Physical examination revealed a blood pressure
cardiacresuscitation, includingcardiacmassage and of 115/80mm. Hg. The chestwas somewhat asym-
electrical defibrillation, restored heartbeat. The metrical due to the previous repair of the pectus
patient did not regain consciousness, however, and excavatum and left pneumonectomy, but no ab-
death occurred 14 hours after operation. normal masses or pulsations were evident. The re-
Autopsy revealed the presence of a dissecting mainder ofthe physical examination was essentially
aneurysm, which extended from the descending normal.
thoracic aorta into the common iliac arteries (Fig. Roentgenograms disclosed opacification of the
14). No re-entry point was found. The homograft entire left hemithorax, and displacement of the
was intact. hearttotheleft. Angiocardiograms revealed a large
dissectinganeury'sm ofthethoracicaorta,beginning
Case 3. C.F., a 40-year-old white woman, was just distal to the left subclavian artery and extend-
admitted to Methodist Hospital onJanuary 6, 1955, ingdistallytothelevelofthediaphragm (Fig. 15).
for treatment of an aneurysm of the arch of the The true aortic lutmen was heavily opacified, and
aorta. In September 1953 a severe pectus excava- appeared relatively normal in diameter. An electro-
turn was repaired elsewhere, and after operation cardiographic tracing was normal, and laboratory
theleftlungfailedtoexpand. Adiagnosisofstenosis studies revealed no significant findings.
of the left main stem bronchus was made at bron- On January 10, 1955, left thoracotomy was per-
choscopy. Atelectasissubsequentlyfailedtorespond formed through the bed of the resected fifth rib.
to repeated bronchoscopy, so in December, 1953, a The pleural cavity contained a small quantity of
left thoracotomy was performed. At that time an serous fluid. There was a globular aneurysm, meas-
aneurysm of the arch of the aorta just distal to the uring approximately 12 cm. in its greatest diameter
left subclavian artery was discovered. Becauise the in the distal arch of the aorta, beginning just distal
aneurysm was pressing on the bronchus, a left to the left subclavian artery and extending to the
593
DJE BAKEY, COOLEY AND CREECII A.imals of Surgery
October, 1953
A
FIG. 10. A (top) and B (bottomi). Roentgen-
ogram of chest and angiocardiogramii in Case 1
made 3 months after operation, showing absence
of the aneurysm and relatively normal outline of
descending thoracic aorta.
B
594
YN'uoml1t.ibmeer1442 D)ISSECTING ANEURYSM OF THE AORTA
A\ B$
FIG. 11 A and B. Roentgenograms ofchest in Case2, in postero-anterior and lateral projec-
tions, showing a fusiform aneurysml invxolving the dlistal arclh and descending thoracic aorta.
s_ltt is Lin
A B
FIG. 12. Angiocardiograin in Catse 2, showing outline of dissecting aneurysm arising near
thi anomolous right subelavian artery and extending to the level of the diaphragm. The true
Itimien ofthe arota is more densely opacified than the false passage.
59.5