therapy and aortorrhaphy. aneurysms may be conveniently classified signed to promote

21 Pages·2006·6.88 MB·English

SURGICAL CONSIDERATIONS OF INTRATHORACIC ANEURYSMS OF THE
AORTA AND GREAT VESSELS*
DENTON A. COOLEY, M.D., AND MICHAEL E. DE BAKEY, M.D.
HOUSTON, TEXAS
FROM THE DEPARTMENT OF SURGERY, BAYLOR UNIVERSITY COLLEGE OF MEDICINE, AND THE SURGICAL SERVICES
OF THE JEFFERSON DAVIS HOSPITAL AND THE VETERANS ADMINISTRATION HOSPITAL, HOUSTON
THE SURGICAL TREATMENT of intrathoracic proposed and employed in order to achieve
aneurysms of the aorta and its major trib- fibrotic organization of the process and thus
utaries remains a difficult problem and, for prevent or delay the inevitable perforation
the most part, unsatisfactory despite the ofthe sac. Matas37 classifiedtechnics which
remarkable advances in vascular surgery assist in this effort by "1-diminishing the
that have been made in recent years. This blood pressure, 2-retarding the velocity of
is exemplified by the fact that ideal surgical circulation, 3-increasing the coagulability
therapy, consisting of extirpation of the dis- of blood, 4-provoking thrombus formation
eased part and restoration of normal func- within the sac by agents which act directly
tion, has been applied to these lesions in on the aneurysmal tissues from within and
rare instances. In this presentation, an from without." Efforts have long been made
effort is made to review and evaluate the to devise ingenious therapeutic methods
various methods which have been proposed alongtheselines, including complicated die-
and employed in the surgical treatment of tetic, hygienic and medicinal regimens.
aneurysms ofthisregion andto direct atten- After extensive trial, they have been dis-
tion by illustrative case reports (Table I) carded as ineffectual or unreliable. Even
to the indications and value of excisional specific medicinal measures in syphilitic
therapy and aortorrhaphy. andmycoticaneurysms haveusuallyproved
The various procedures which have been ineffectual in controlling the fatal conse-
used in the surgical treatment of these quences of the process once the aneurysm
aneurysms may be conveniently classified is well developed. Certain other non-oper-
into three major groups: (1) Those de- ative technics which have yielded only oc-
signed to promote thrombosis and fibrotic casional good results by inducing throm-
organization of the process by ligation, in- bosis include refrigeration, prolonged com-
troduction of foreign material, or periarte- pression of the sac, acupuncture34 and the
rial fibroblastic reaction; (2) endo-aneurys- injection of sclerosing agents. Matas37 has
morrhaphy; and (3) extirpation of the thoroughly reviewed these and other tech-
lesion with or without restoration of blood nics whichhave been used for this purpose,
flow through the parent vessel.
but they are now only of historical interest.
PROCEDURES WHICH PROMOTE THROMBOSIS In the past75 years, however, some prog-
Various measures designed to induce ress has been made in the surgical manage-
thrombosis within an aneurysm have been mentof aneurysms of thethoracic aorta and
its great tributaries by inducing thrombosis,
* Read before the Southern Surgical Associa-
using one ormoreof thefollowing methods:
tion, Hot Springs, Va., December4, 1951.
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Volume 135 INTRATHORACIC ANEURYSMS OF THE AORTA
Number 5
ligation, introduction offoreign material, or two catgut ligatures just distal to its neck,
stimulation of periarterial fibrosis. thus closing the feeder trunk. At this point
Ligation. Ligation of the artery at differ- he committed an error, the significance of
ent points in relation to the aneurysm has which he realized later in that he did not
been employed with the of slowing the aneurysmal which
purpose remove sac was now
or arresting the circulation in the sac in empty and flaccid. He thought at the time
orderto encourage thrombosis and eventual of operation that the sacifleftinsituwould
obliteration. The ligature may be applied serve the dual purpose of preventing slip-
to the artery on the proximal side of the page of the ligature and of limiting hemor-
(Anel's operation), the distal rhage ifslippage did The immediate
aneurysm on occur.
side (Brasdor's operation), immediately seemed satisfactory, but the tenth
or course on
above and below the aneurysm (Pasquin's day after operation the sac was observed to
operation). The latter is known as Antyl- be gangrenous, and secondary hemorrhage
lus's operation if, in addition, the sac is ensued shortly after this, leading to death
evacuated and packed. These procedures three days later. Itmay be observed that in
have been employed for aneurysms involv- our Case 1, which to our knowledge is the
ing both the thoracic aorta and its major only case like Tuffier's, a similar fatal com-
branches. The recorded experience with plication developed despite the effort to
these various forms of ligation was thor- avert it by the use of an elastic ligature
oughly reviewed by Matas,37 in 1914, and encased with polythene-dicetyl phosphate
subsequently by a number of others.22 23 31, film to induce periarterial fibrosis.
33,47, 50 On the basis of these experiences Combined proximal and distal ligation
there seems to be general agreement that has been employed successfully by a num-
while occasional good results have been ber of observers and provides definite ad-
obtained from the procedure of distal liga- vantages over the previously mentioned
tion (Brasdor-Guinard method), it has not methods ofligation. Inmostinstances where
proved generally satisfactory, being asso- this is possible, permitting complete con-
ciated with considerable risk and only mod- trol of blood flow into the sac, it would
erate palliative value. Perhaps combined seempreferable to extend the operation fur-
with other means of inducing thrombosis, ther and excise the aneurysm, or if this is
such as wiring, distal ligation may have notfeasible, evacuate the clot.
greater usefulness.8' 50 Proximal ligation Introduction ofForeignMaterial. Numer-
alonehas alsonotprovided very satisfactory ous materials have been introduced into
results owing to the high incidence of aneurysms in order to promote coagulation
cerebral complications, recurrence of the of the blood, and of these, wire of various
aneurysm as a consequence of development types has had the widest and most success-
of anastomotic channels or incomplete oc- ful application. In 1865, Moore41 inserted
clusion by the ligature, and necrosis at the and left lengths of silver wire in a thoracic
site of ligation with resultant hemorrhage. aneurysm in order to induce clot formation
The latter complications are particularly andCorradi,14in 1879, added to this method
wellillustrated bythe case reportedby Tuf- the passage through the wire of a Galvanic
fier55 and by our Case 1. Tuffier's report, in current. The Moore-Corradi electrolysis
1902, is exceptionally noteworthy not only method enjoyed some popularity for several
because his "case is unique in literature,"37 decades, but the results were in general not
but also bec6;se'it reflects his courage and impressive. In order to avoid some of the
perspicacity. In this case of saccular aneu- difficulties involved in handling the wire
rysm ofthe ascending aorta, Tuffier applied and to obtain accurate insertion into the
661
COOLEY AN]D D)EDBEABAKKEEYY ~A~nn~aal~ys~,o~f~1SuM9rg8e5r2y
aneurysm, Colt,12 in 1903, devised a small polythene plastic films in syphilitic aneu-
wireumbrellawhich, afterinsertion through rysms of the thoracic aorta, with apparent
a cannula, expanded inside the aneurysm. benefit.
Using Colt's method, Borrie and Griffin8 Results from use of various types of
have recently reported satisfactory results cellophane-polythene films were unpredict-
in five of nine cases of syphilitic aneurysm able, inasmuch as some films were surpris-
of the thoracic aorta and its branches. ingly well tolerated by the tissues. In 1948,
The Moore-Corradi method was modified Yeager and Cowley57 identified dicetyl-
in 1938 by Blakemore and King,7 who de- phosphate, a stripping agent used in manu-
vised an accurate means of electrothermic facture, as the irritating substance, and
coagulation of anenrysms. A deposit of since thatdate, ithas been possible to select
TABLE I.
Color,
Case Sex, Date Aneurysm
No. andAge Operated Nature Situation Surgical Procedure Resultand Remarks
1. R.M. C.M. 12/22/48 Syphilitic Tzansversearch Proximalligation with cello- Apparentlywellfor2 months
46 phanereinforcedligature and then developed fatal
(rubbercatheter) hemorrhage
2. R.R. W.M. 4/28/50 Sponraneous Rt.subclav. Proximal and distal ligation Cured
32 with totrtlexcision
3. J.M. C.M. 7'12/5i Syphilitic Innominateand Ligation of subclavian and Cured
46 adjacentaorta catotid, aneurysmectomy,
andaortorrhaphy
4. F.D. W. I1O/ 4/51 Syphilitic Ascending and Aneurysmectomy and Died 14 hours after opera-
57 transversearch aortorrhaphy tion,diffusecerebraldamage.
anestheticcomplication
5. L.H. C.M. 9/ 6 51 Sylphilitic Terminal tho- Aneuirysmorrhaphy and cel- Died 18 days after opera-
41 racicaorta lophanewrapping,subse- tion, secondary hemorrhage
quent wiring
6. W.F. W.M. 9/ 7/51 Syphiliticand T!ansvcr'earch Cellophanewrapping Improved
56 arte;iosclerotic
tenacious, clot-stimulating, protein coagu- suitable polythene films for the purpose.
lum formed on the wire and tlhe thrombus Goodresults followingthe use ofpolythene-
extended throughout the aneurysm. Blake- cellophane in aneurysms of the aorta have
more6 has recently presented convincing been reported by a number of ob-
evidence of the value of this method in the servers.1' 15, 17, 39 4 From these experiences
reliefofpain, the protection against rupture as well as our own the use of polythene-
and the rehabilitation of the patients. cellophane film would appear to have defi-
Stimulation of Periarterial Fibrosis. In nite value in certaininstances where a more
1939, Page43 first called attention to the direct approach is not feasible.
irritating properties of cellophane, which he The recent suggestion of Berman and his
used to wrap the kidneys of dogs in order associates4 of the injection of a solution of
to produce experimental hypertension. The dicetyl phosphate (0.9 per cent in olive oil)
following year Pearse44 employed cello- provides distinct advantages over the
phane as an experimental means of gradual "wrapping" technic, in that it permits sim-
occlusion of large arteries, and three years pler and safer placement of the fibrous tis-
later Harrison and Chandy26 applied this sue-producing substance in contact with all
method in the treatment of an aneurysm of surfaces of the aneurysm.
the subclavian artery. Subsequently, Poppe Endo-aneurysmorrhaphy. Matas'35 contri-
and De Oliviera46 employedcellophane and bution of endo-aneurysmorrhaphy, in 1888,
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Volume 1335 INTRATHORACIC ANEURYSMS OF THE AORTA
Number 5
constituted the most important landmark in volving the left common carotid artery in its
the surgical management of aneurysms. This intrathoracic portion treated by this means.
experience led to his later development36' 37 There have been four cases of aneurysms
of the procedure in its three forms, the of the innominate artery successfully
obliterative, the restorative, and the recon- treated by complete or partial extirpation.
structive endo-aneurysmorrhaphy. For over The first was performed by Kimura,27 in
a half a century2' this principle of intrasac- 1908, in a 46-year-old male with a spontan-
eous aneurysm involving the innominate
artery near its bifurcation. After proximal
and distal, so-called "triple ligation," the
or
sac was partially removed. In the second
case, consisting of a saccular aneurysm of
the innominate artery in a 64-year-old fe-
male, proximal ligation first performed
was
by Tudor Edwards June 11, 1935, but
on
owing to recurrence and persistence of
symptoms a second operation was per-
formed on May 11, 1936, by E. R. Carling,
who excised the after ligating the
aneurysm
common carotid, subclavian and innominate
arteries.4 In the third saccular
case, a aneu-
rysm of traumatic origin in a 25-year-old
reported by Shumacker, partial
male,
proximal ligation done with fascia lata
was
and cellophane at the first operation and
two and one-half months later the carotid
and subclavian arteries distal to the aneu-
divided between ligatures, the
rysms were
innominate artery proximal to the aneurysm
doubly ligated, and the widely
was sac
opened and its contents evacuated. The
fourth mentioned by Blakemore,5
FIG. 1.-Roentgenogram of chest in Case 1 case was
showing widening of superior mediastinal shadow, in 1948, and while the precise nature of the
tsliiognhtantdraccahlecailfidciatsipolnacoefmtehnetatoorttihcearricghh.t and dilata- findings and procedure is not described, it
appears to have consisted of excision of a
cular suture has enjoyed wide usefulness in syphilitic aneurysm of the innominate artery
peripheral aneurysms but unfortunately it at its origin, with repair of the opening in
has not been found readily applicable to the aorta by running mattress suture. Sig-
intrathoracic aneurysms of the aorta and nificantly, in all but the last of these cases,
its major branches. Indeed the case re- the aneurysm did not involve the origin of
cently reported by Lane and Peirce31 ap- the artery.
pears to be the first recorded instance in Successful excision of an aneurysm in-
which endo-aneurysmorrhaphy was used in volving the intrathoracic part of the sub-
treating such an aneurysm. clavian artery has been reported in three
Excision. Few cases of extirpation of in- instances. The first case by Chapman,'0 in
trathoracic aneurysms of the aorta or its 1929, consisted of a traumatic aneurysm of
major branches have been recorded. To the right subclavian. Owing to severe hem-
our knowledge there has been no case in- orrhage, consequent to rupture of the thin-
663
COOLEY ANE) DEBAKEY AnnalsofSurgerY
walled sac during the operation, it was nec- tion, the aneurysms typically appear just
essary to ligate the innominate and carotid distalto the constriction andmaybe related
arteries as well as the subclavian distal to in some manner to the factors which pro-
the sac, which was then excised. The sec- duce the post-stenotic dilation commonly
ond case, reported by Temple54 in 1950, in encountered in the distal segment of that
a 40-year-old male, was probably of trau- vessel. Aneurysms of this type lend them-
FIG. 2.-Drawing of operative procedure and findings in Case 1, showing approach in A
and the sacciform aneurysm in B arising from the anterior superior border of the transverse
aortic arch between the innominate and carotid arteries, with placement of cellophane rein-
forced ligature around its neck.
matic origin involving the left subclavian selves more easily to extirpation because of
artery and arising about one inch from the the relatively low intraluminal pressure and
aortic arch. After proximal and distal liga- the well-developed collateral vessels which
tion of the main vessel, the aneurysm was supply the lower half of the body if the
removed. The third case, in a 38-year-old aorta must for any reason be occluded.
colored female, was recently reported by Alexander and Byron,2 in 1944, first suc-
Daniel'6 and concerned a large syphilitic cessfully removed such a lesion but did not
aneurysm arising from the right subelavian attempt restoration of aortic continuity.
arteryjust distalto its origin. Theaneurysm Shumacker52 excised completely a small
was excised after proximal and distal liga- aneurysm as well as the area of coarctation,
tion of the subelavian artery. and then anastomosed the aortic ends pri-
The reports of cases of excision of aortic marily. Using an aortic homograft Swan53
aneurysms can be conveniently divided into bridged the defect remaining after a similar
two groups, depending upon whether or excision, and recently Gross24 reported five
not there was an associated coarctation of such cases.
the aorta. In those associated with coarcta- We have been able to find only two suc-
664
Volume 135 INTRATHORACIC ANEURYSMS OF THE AORTA
Number 3
cessful cases of excision of an aortic aneu- CASE REPORTS
rysm not associated with coarctation. Tuf- It is apparent from this resume that var-
fier55 deserves credit for suggesting the ious methods of surgical attack have been
technic, which was also designed to pre- employed in the treatment of aneurysms of
serve the continuity ofthe aorta, despite his the thoracic aorta and its major branches.
unsuccessful attempts in several cases. For the most part these efforts have been
Ochsner42 described a casein September, concerned with palliative rather than cur-
1944, in a45-year-old malewith a suspected ative therapy and the results therefore have
mediastinal tumor of neurogenic origin. At been somewhat disappointing. In light of
operation he discovered a small sacciforni this fact and the grave prognosis of the
aneurysm of the descending thoracic aorta. disease, we have adopted a more aggressive
The base of the aneurysm was clamped, the surgicalpolicy inthehope ofapplying more
FIG. :3 4
FIG.
FIG. 3.-Roentgenogram ofchest in Case 2 showing widening of the superior mediastinum
to the right produced by the aneurysm, and notching of the ribs consistent with a diagnosis
of coarctation of the aorta.
FIG. 4.-Angiocardiogam in Case 2 showing visualization of the aortic arch, which is
slightly displaced to the left by the mediastinal mass containing some dye. The left subclavian
and both common and carotid arteries are readily visualized but no filling is apparent in the
right subclavian.
sac excised and the aorta was sutured. The effective surgical procedures. The various
patient made an uneventful recovery. factors influencing the feasibility and the
The second somewhat similar case, in a type of surgical therapy are illustrated by
20-year-old woman, was reported several the following case reports, which are sum-
later by Monod,38 who excised marized in Table
years an I.
aneurysm of the aorta distal to the left sub- Case 1.-R. M., a colored male, 46 years old,
clavian artery and then sutured the defect, was admitted November 30, 1948, to Jefferson
which was approximately 4 cm. in length, Davis Hospital. He complained of a paiful pul-
thus preserving continuity of that vessel. sating mass in the neck of one year's duration.
Therewas ahistoryofinadequately treated primary
665
COOLEY AND DEBAKEY AnnalsofSurgery
M ayv, 1 9 22
FIG. 5.-Drawing showing operative findings and procedure employed in Case 2.
syphilis 27 years before. The mass presented in of the trachea tothe right and some dilatation and
the left side of the neck above the sternoclavicular calcification of the aortic arch (Fig. 1). There
joint and pulsated vigorously. Blood pressure in were strongly positive serologic Kolmer and Kline
the right arm was 112/80 and in the left arm tests for syphilis. It was apparent clinically that
120/78. the mass was increasing rapidly in size, and the
Roentgenographic examination revealed a rel- painbecoming more marked. A diagnosis of aneu-
atively normal cardiac silhouette with a widened rysm ofthe arch ofthe aorta, probablv of syphilitic
superior mediastinal shadow, slight displacement origin, was made.
666
Volume 135 INTRATHORACIC ANEURYSMS OF THE AORTA
Number 5
Operation. On December 22, 1948, an anterior Comment. It is of interest that the same
thoracotomy was performed on the left side, re- error was committed here as by Tuffier 50
moving a portion of the second rib. Exploration After the neck of the
revealed a sacciform aneurysm arising from the yearsocacglou.dedbytheligature, the anesuhroyuslmd
anterior superior border of the arch of the aorta. was sac
In orderto obtain better exposure, the medial por- havebeen excised and the base sutured.We
tionoftheclaviclewasremoved subperiosteally and now join Tuffier in emphasizing the fact
the sternum was split to the level of the second that if proximal ligation is possible, then
interspace. The flap thus formed was retracted the rational procedure of excision and
laterally. The base of the aneurysm, which was more
located between the innominate and left common repair can be employed.
carotid arteries, was temporarily compressed and
pulsation in the mass ceased. A No. 24 French
rubber catheter was encased in a polythene dicetyl
FIG. 6.-Photograph of anterior chest of patient
in Case 2 taken twoweeks after operation showing
a well-healed incision for the thoracocervical ap-
proach used.
phosphate film and used as a ligature about the
neck, which measured 2.0 cm. in diameter (Fig. FIG. 7.-Angiocardiogram in Case 3 following
2). The pulsation in the mass was obliterated. injection of Diodrast into left antecubital vein
Apopsatrotpefrartoimvetracnosuiresnet weadsemauneovfentthfeul.leftTharem,matshse wisinhtnoohwmiginongoatddeivsivpseluiaanlciezbmayetnittohneaonfsdutphaeetrtireoinrguhamtteiidnoinnaosomtfiinntaahlteemravisegsih,nt
became pulseless and much smaller and there was and superior vena cava. It may also be noted that
complete relief ofpain when he was discharged on the trachea is displaced to the left by the mass.
January 7, 1949.
He was re-admitted to the hospital 2 months Case 2.-R. R., a white male of 32 years, was
later and died 36 hours after admission of uncon- admitted December 15, 19$9, to The Johns Hop-
trollable hemorrhage. kins Hospital. Two years prior to admission, while
At autopsy the aneurysm was found to be doing some heavy lifting, the patient experienced
ruptured at its distal portion with the opening sharp pain in the right lower neck. Pain came on
extending directly through the skin in the supra- suddenly but subsided spontaneously after three
sternal region. The neck of the aneurysm meas- weeks, but a non-pulsating .supraclavicular mass
ured about 1.5 cm. in diameter and was located persisted. Six days prio,.to this admission, again
on the anterior superior border of the arch be- while doing some heavy,1lfting, the patient expe-
tween the origin of the innominate and the car- rienced pain in the lower lpart of the neck which
otid arteries. There was dense fibrous tissue, in radiated down the right arm, and the mass was
some areas almost 1 cm. in thickness, surrounding larger.
the neck of the aneurysm and around the poly- Physical examination on admission revealed a
thene-encased catheter ligature. bloodpressure of 170/105 inthe upper extremities;
667
COOLEY ANE )DDEEBBAAKKEEYY ~An~n~aaly~s,~of~S1uM9rg5er2y
but no blood pressure was obtainable in the lower On January 30, 1950, exploratory thoracotomy
extremities. There was a pulsating and slightly by Dr. Alfred Blalock revealed a classical coarcta-
tendermass inthe right supraclivacular fossa above tion ofthe aorta of the adult type, and a resection
the proximal end of the clavicle. The trachea was with end-to-end anastomosis was done. Postoper-
deviated to the left. A systolic bruit was audible atively he had equivalent, normalpressures in both
over the mass. There was weakness of motor func- arms and legs. The mass in the right supraclavic-
tion in the right arm and distended veins were ular fossa appeared smaller, but it continued to
noted over this area. There was a Homer's sign pulsate. He was discharged on February 17, 1950,
.........
_. ~~~..~.~.~..~.~.~.~.~~~~.....
RtX..seo1~tt
_e:}^i:'^.e:X..-.9
from~t~h~e~~a~o~r~ti ac.A; Grfor clm'a
fro th aotcac. A Crfor clm_a
bordrofthe rtC rarc t-oroclde: heo
DIsa.controfiruaon inrtheaineurys :s in Case 3, showing incision in inset for
arising in the innominate artery at its origin
been applied tangentially across the superior
igin of the innominate artery and aneurysm.
is obtained by temporary occlusion with tape
around the right common carotid and subclavian arteries.
on the right. Serology and blood cultures were and re-admitted two months later as requested
negative. The venous pressure in the left arm was when an aortogram failed to reveal an aneurysm.
78 mm. of saline and in the right, 230 mm. of Since discharge he had developed a rightrecurrent
saline. Roentgenograms of the chest revealed a nerve palsy and a partial phrenic palsy. The pul-
prominent superior mediastinal shadow and satile mass was still present in the right supra-
markednotching ofthe ribs, consistent with a diag- clavicular region and there was venous distension
nosis of coarctation of the aorta (Fig. 3). Angio- over the right upper chest and shoulder. A diag-
cardiography showed slight displacement of the nosis of aneurysm of the subclavian artery was
aortic arch to the left bythe mediastinal mass, with made.
patency of the left subclavian and both common Operation. On April 28, 1950, exploratory
carotid arteries but no visualization of the right thoracotomy performed (D.A.C.) through the right
subclavian artery (Fig. 4). second interspace anteriorly, revealed a large
668
Volume 135 INTRATHORACIC ANEURYSMS OF THE AORTA
Number5
aneurysm approximately 12 x 8 cm. in size of the teal bed and the wound closed in layers (Fig. 6).
right subelavian artery. The superior vena cava His convalescence was uneventful. At the time of
was obstructed and the right innominate vein was discharge, the function in the right shoulder was
attenuated. The azygos vein was greatly enlarged. good. Two months later the Horner's syndrome
Additional exposure was obtained by extending had improved and roentgenograms revealed par-
the incision cephalad into the suprasternal notch tial return of motion in the right leaf of the
and performing a median sternotomy. The medial diaphragm. A letter dated August 28, 1951, ap-
third of the right clavicle was resected subperios- proximately 16 months after operation, indicated
teally. that he had returned to work and was well.
FIG. 9.-Drawing of operative procedure in Case showing completed
3
aortorrhaphy and ligated ends of right common carotid and subclavian
arteries after excision of aneurysm.
The aneurysm involved only the subelavian ar- Comment. The results obtained in this
tery (Fig. 5). After the artery was ligated proxim- case reflect the advances in vascular sur-
ally and distally, pulsations ceased. The aneurysm gery. In this patient, surgical correction was
iwas opened and the sac was excised after evac- obtainedfor two vascular lesions whichless
uating the clot (Fig. 5). The ends of the divided
subclavian artery were sutured with interrupted than a decade ago were considered to be
inoperable. The illustrates also the
silk. The segment of clavicle which had been case
removed was replaced as bone chips in the perios- type of aneurysm which, although exten-
369