The Surgical Treatment of Dissecting Aneurysm of the Ascending

15 Pages·2006·4.25 MB·English

The Surgical Treatment of Dissecting Aneurysm
of the Ascending Aorta: *
With a Report of Four Cases in the Chronic Stage
LEWIS H. BOSHER, JR., M.D., JAMES W. BROOKS, M.D., ALLEN J. POIS,** M.D.
From the Section of Thoracic and Cardiovascular Surgery, Department of Surgery,
Medical College of Virginia, Richmond, Va.
TiH OCCURRENCE of chronic dissecting Current surgical interest in the treatment
aneurysm in the ascending aorta has gen- of dissecting aneurysm of the aorta justifies
erally been considered uncommon because a report of our experience with this small
of the rapidly fatal outcome in most acute series. The surgical treatment of this dis.-
dissections involving this segment of the ease entity has developed from the contri-
aorta, usually by rupture into the pericar- butions of Gurin, Bulmer and Derby,8 in
dium. This serious prognosis is probably 1935, who were the first to employ the
less applicable to dissections occurring sec- concept ofare-entrywindowfor iliac artery
ondarily in fusiform aneurysms of the as- obstruction; of Johns,14 who performed a
cending aorta already established and due direct suture repair of a ruptured, dissect-
to cystic medial necrosis. ing aneurysm of the abdominal aorta in
The chronic dissecting aneurysm is found 1953; of Shaw,20 who in 1955, created an
more commonly in those cases in which the abdominal aortic fenestration for a dissect-
intimal tear is located at or just beyond ing aneurysm complicated by iliac artery
the left subelavian artery. Often a second- obstruction; and of DeBakey, Cooley and
ary saccular aneurysm develops near the Creech5 who in 1955 described aneurys-
site of the intimal tear with later rupture. mectomy for dissecting aneurysm of the
Complications arising in the presence of descending thoracic aorta as well as a re-
chronic dissecting aneurysm include further entry procedure to be employed primarily
dissection, congestive heart failure, external for those dissections extending proximally
rupture and uremia. in the arch and ascending aorta. Warren,
Of thefour patients wehave encountered Beckwith and Muller,23 in 1956, elaborated
with chronic dissecting aneurysm of the further on the re-entry procedure.
ascending aorta two of these exhibited pro- The largest series of surgically treated
gressively enlarging secondary saccular cases is that of DeBakey, Henly, Cooley,
aneurysms developing at the site of intimal Crawford and Morris," reported in 1961.
tear and one of these patients was pro- Among their 72 cases were four patients
tected by a DeBakey re-entry procedure. in whom the pathology was limited to the
Two patients had in addition severe aortic ascending aorta and arch and in whom
insufficiency. excision of the ascending aorta was per-
formed. Although recorded information re-
*Presented before the Southern Surgical Asso- garding these patients is meager, three of
ciation, Hot Springs, Virginia, December 10-12, the four apparently survived.
1963.
**Virginia Heart Association Fellow. Wheat,24 in 1959, was able to correct a
829
830 BOSHER, BROOKS AND POIS Annals of Surgery
June 1964
dissecting aneurysm associated with aortic insufficiency resulted from prolapse of one
insufficiency by suture of the proximally or more aortic leaflets as the aortic valve
dissected intima with re-attachment of the attachment dissected away at the commis-
valve commissures. At the same time he sures. At operation reattachment of the
closed the intimal tear and partially excised commissures and suture obliteration of the
the wall of the ascending aorta. proximal and distal planes of dissection
In 1960 Bahnson and Spencer2 and, sufficed to correctthe insufficiency and con-
shortly thereafter, Muller, Dammann and trol the dissection. Complete circumferen-
Warren18 each reported two cases of aneu- tial rupture was noted in some patients
rysm of the ascending aorta due to cystic and repaired by distal and proximal suture
medial necrosis with secondary dissections of the layers with reanastomosis. In those
treated by excision and graft replacement. cases in which the tissues were unusually
Three of the four patients survived. These friable, excision of the ascending aorta and
authors discussed in detail many of the graft replacement was employed. Five of
technical problems encountered during re- seven patients survived. Hufnagel and Con-
section of the ascending aorta including the rad11 subsequently reported three addi-
management of associated aortic insuffi- tional patients in two of whom the com-
ciency. pletely detached intima of the ascending
Bahnson and Spencer believed that mod- aorta had intussuscepted distally as far as
erate aortic insufficiency could be con- the left subclavian artery. At the time of
trolled by reducing the circumference of surgery the intussusception was reduced
the proximal aortic cuff as this was sutured into the ascending aorta and fixed by su-
to the prosthetic tube. One of the two pa- ture and reanastomosis. Thus, seven of his
tients, however, had a residual diastolic ten patients survived.
murmur postoperatively. Muller, Dammann More recent reports have dealt specifi-
and Warren employed bicuspidization to cally with the problem of acute dissecting
control severe aortic insufficiency. aneurysm of the ascending aorta. One such
Creech,4 in 1960, identified one of the patient was mentioned by Ankeney,' in
causes of aortic insufficiency as release of 1962, and treated by circumferential suture
the valvular support due to the proximal reattachment and anastomosis. Morris17 re-
dissection. Correction was accomplished by ported on a physician operated upon six
bicuspidization as well as resuture of the hours after onset of dissection in whom a
valve support. In 1962, Dillard, et al.7 re- similar type repair was successfully carried
ported a patient with Marfan's disease with out. In an abstract summarizing patients
aortic aneurysm, dissection and aortic in- operated upon with dissections in the as-
sufficiency managed by excision of the cending aorta, Morris et al. 18 cited a total
aneurysm and bicuspidization of the aortic of 16 cases, two treated in the acute stage.
valve. Spencer and Blake21 treated a pa- Information regarding the exact procedures
tient with Marfan's disease who had devel- carried out and the number of patients sur-
oped dissection and aortic insufficiency 43 viving was not given. Rohman, Goetz and
days previously by excision of the ascend- State19 reported three surgical cases treated
ing aorta and re-attachment of the valve with excision ofthe ascending aorta and su-
commissures. ture attachment of the valve commissures
Hufnagel and Conrad,10 in 1962, de- and anastomosis. Two of these patients
scribed various reconstructive procedures were in the acute stage with manifestations
employed to repair aortic insufficiency in of hemopericardium. All had developed
association with dissection of the ascending aortic insufficiency to a moderate degree.
aorta. In four patients of the group aortic Two of the three patients survived. Starr22
Volume 159 DISSECTING ANEURYSM (DF THE ASCENDING AORTA 831
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mentioned one patient withacute dissection after the onset of a sudden epigastric pain, radiat-
in whom total replacement of the aortic ing into the lower substemal region, to the back
valve was performed after failure of the and into the scapular area. The pain subsequently
extended over the upper abdomen and into the
suture re-attachment technic. Michael right groin, and became more intense. Numbness
Hume and Krosnick13 reviewed the prob- of the entire right leg developed. When first ex-
lem of dissecting aneurysm occurring in as- amined at her home 45 mintes after the onset,
sociation with pregnancy and presented a pulses were absent in the right leg and the lower
leg was cool. She was a known hypertensive with
patient successfully treated 20 days post-
a blood pressure of 160-200/110 and had been
partum by suture re-attachment and anas-
treated with Serpasil for about a year.
tomosis to correct both aortic insufficiency On admission the blood pressure was 160/100,
and the intimal tear. pulse 88. There was a short, soft apical systolic
Thus, approximately 40 patients are re- murmur. The epigastrium was slightly tender. A
ported in the literature in whom a dissect- soft bruit was heard over the lower abdomen and
femoral arteries. At this time all pulses were equal
ing aneurysm of the ascending aorta has and normal. A chest roentgenogram revealed mod-
been excised or treated by a direct surgical erate prominence of the thoracic aorta. Electro-
procedure. At least five of these cases are cardiogram showed left ventricular strain. Hemo-
known to have been in the acute stage, globin was 14.4 Gm. and the white count 16,200.
Twenty-eight hours after the onset of her pain
that is, less than two weeks since onset.
she suddenly lost consciousness, the blood pressure
At least five of the reported dissections dropped to 40/0, venous distention was noted in
were secondary in that they arose within the neck and a soft diastolic murmur was heard
established fusiform aneurysms due to cys- over the precordium for the first time. Blood pres-
tic medial necrosis. Several of the patients sure was elevated with Levophed to 110/80 and
an emergency pericardicentesis yielded 50 cc. of
were known to have Marfan's disease. In
nonclotting blood. Following this, she regained
the majority of cases severe aortic insuffi- consciousness.
ciency was present and this appears to She was taken as rapidly as possible to the
have directed the patient to the thoracic operating room and a standard DeBakey proce-
surgeon in many instances. Accurate mor- dure was performed in the upper thoracic aorta.
A considerable amount of blood was evacuated
tality figures are not available for the en-
from the pericardium, but active bleeding had
tire group. A variety of surgical procedures ceased. The dissection extended below the dia-
have been employed in the above cases: 1) phragm. Left atrium-to-femoral bypass technic
excision and graft; 2) excision and graft; was employed. The anastomotic line was wrapped
bicuspidization; 3) excision and graft; su- with knitted Dacron after creation of the re-
entry window. Biopsy of the thoracic aorta showed
ture of valve support; 4) excision and graft;
cystic medial necrosis.
partial or complete valve replacement; 5) The postoperative course was complicated by
suture of valve support; circumferential su- the development of congestive failure with ac-
turing and re-anastomosis; and 6) recovery cumulation of serous fluid in the left pleural space
of intima, suture of valve support, circum- on several occasions. She experienced a transient
ferential suturing, re-anastomosis. auricular fibrillation and a urinary tract infection
both of which responded to treatment.
To this collected series we wish to add
She remained active and in reasonably good
four cases treated by excision ofthe ascend- health until August 1961 when she began to com-
ing aorta and insertion of a graft. Two of plain of anginal pain. Progressive enlargement of
the patients with severe aortic insufficiency the ascending aorta and increasing aortic insuffi-
were managed by partial or complete valve ciency were evident (Fig. 1). By August 1962
replacement, respectively, and one patient her symptoms were becoming more pronounced
and the diastolic pressure had dropped to 70.
had in addition abicuspidization procedure.
An aortogram showed marked aortic insuffi-
Case 1 (L. A.). A white woman, 48 years of ciency with escape of the contrast medium into
age, was admitted to the Medical College Hospital a saccular aneurysm communicating with the main
on the Medical Service on May 13, 1958 soon channel of the aorta just distal to the aortic valve
832 BOSHER, BROOKS AND POIS Annals of Surgery
June 1964
FIG. 1. L. A.: Series (9/24/59, 5/15/62, 1/28/63) of chest roentgenograms beginning
four months after DeBakey reentry procedure showing progression of cardiomegaly and ascend-
ing aortic aneurysm. Note encroachment on right atrium.
FIG. 2. L. A. Retro-
grade aortogram showing
sequence of films 2, 4,
8, 12. Note large saccular
aneurysm arising ataortic
valve and progressively
opacifying. Aortic insuffi-
ciency well shown in No.
4. False lumen in upper
descending thoracic aorta
I opacifies in numbers 8
.F
and 12.
Volume 159 DISSSECTING ANEURYSM OF THE ASCENDING AORTA 833
Number 6
FIG. 3. L. A.: Lateral
views of Films 7, 11.
Note large size of saccu-
lar aneurysm, contraction
of true aortic lumen in
upper descending thorac-
ic aorta and reflux from
site of re-entry window
into false lumen. Does
not suggest decompres-
sion of the dissection at
re-entry site.
(Fig. 2, 3). There was also reflux of the contrast tear which involved about 50 per cent of the cir-
medium from the site of the previous DeBakey cumference of the vessel. The noncoronary cusp of
procedure upward into the false lumen. The true the aortic valve was somewhat deformed and
lumen through the transverse aortic arch was con- shortened, although the commissure was not dis-
siderably narrowed. sected away from the wall. Bicuspidization was
Operation was carried out on February 1, not carried out because of the wide fixation of
1963. A double lumen was encountered at the the enlarged aortic root to the surrounding struc-
site of cannulation in the external iliac artery. A tures, including the right atrium. The noncoronary
large saccular aneurysm measuring about eight to cusp was excised and replaced with a Teflon leaf-
ten centimeters in diameter arose from the ascend- let. Under continuous coronary perfusion the heart
ing aorta (Fig. 4). On extracorporeal circulation
remained beating throughout the procedure. The
the aneurysmal sac was incised and found to com-
municate with the true lumen of the aorta several aneurysm was excised, leaving the posterior wall
millimeters distal to the aortic annulus through a intact and the aneurism adherent to the right
FIG. 4. L. A.: Transverse intimal tear near
aortic valve. Dilatation of annulus as well as
shortening ofnoncoronary cusp. Location of ostium
of left coronary artery is in error and should have
been depicted close to commissure between left FIG. 5. L. A.: Reconstructed ascending aorta.
and noncoronary leaflets. Note wide fixation of Aneurysm wall adherent to right atrium and supe-
aortic root to surrounding tissues. rior vena cava left in situ.
834 BOSHER, BROOIKS AND POIS Annals of Surgery
June 1964
false lumen of the abdominal aorta, which was
fed by a defect in the left renal artery. A small
re-entry point was also noted in the external iliac
artery.
At the site of the previous DeBakey procedure
contracture of the internal wall had reduced the
true lumen so that only an index finger could be
admitted (Fig. 6). The diameter of the dissection
through the transverse aortic arch was limited to
about 1 cm.
Case 2 (E. T.). A white woman, 54 years of
age, a known hypertensive, on May 6, 1962 sud-
denly developed substernal chest pain penetrating
to the back. The pulse disappeared from the right
FIG. 6. L. A.: Postmortem specimen of aorta
showing arch and upper descending thoracic aorta. arm. She later exhibited signs of pericarditis.
Arrow 1 indicates true aortic lumen at level of left After one week the pain subsided and she was
subclavian artery; arrow 2 points into small false discharged five weeks after admission. Thereafter
lumen through aortic arch; arrow 3 points into she remained relatively asymptomatic although
true lumen at level of re-entry window; arrow 4
indicates old anastomotic line. during the ensuing nine months there was a pro-
gressive enlargement of the ascending aorta (Fig.
7).
atrium. A Teflon graft, 2.5 cm. in diameter, was
She was first admitted to the Medical College
inserted (Fig. 5).
of Virginia Hospital on March 9, 1963. A retro-
After coming off bypass the blood pressure was
grade aortogram showed a dissecting aneurysm of
140/100 and cardiac action seemed reasonably
the ascending aorta with a saccular dilatation of
good. Bleeding from several suture holes in the
the false lumen (Fig. 8). The dissection extended
friable proximal cuff of the aorta was difficult to
below the diaphragm. There was no aortic in-
control. One-half hour after bypass the heart went
sufficiency.
into ventricular tachycardia and shortly there-
Operation was carried out on March 19, 1963.
after into ventricular fibrillation. Heroic efforts
at resuscitation, including re-institution of cardio- A double lumen presented at the site of the ar-
pulmonary bypass, failed. terial cannulation in the iliac artery. A large aneu-
Postmortem examination showed a severe cor- rysmal sac consisting of the outer wall of the
onary atherosclerosis with secondary myocardial dissection was encountered with a transverse split
fibrosis and isolated small fresh areas of infarction. 2 cm. in length in the inner wall at the midportion
There was thrombus, both old and recent, in the of the ascending aorta (Fig. 9).
*:X. 5^X2 - &C;
FIG. 7. E. T.: Series (4/21/62, 5/22/62, 2/23/63) of chest roentgenograms beginning just
prior to onset of dissection in ascending aorta, showing development of saccular aneurysm.
Volume 159 DISSECTING ANEURYSM OF THE ASCENDING AORTA 835
Number 6
FIG. 8. E. T.: Retro-
grade aortogram, show-
ing leak in midportion of
ascending aorta into sac-
cular aneurysm. Aortic
valve competent. Note
narrowed true lumen of
descending thoracic aorta
and opacification of false
lumen in region of distal
aortic arch.
Initially an attempt was made to reconstruct examination the blood pressure was 125/55. The
the inner and outer walls of the aneurysm by heart was considerably enlarged, and there was
means of a plastic procedure. Sutures cut through a Grade II, systolic murmur over the base with
the friable inner wall causing leakage into the
plane of the dissection. Ultimately the ascending
aorta was resected and replaced with a Teflon
graft (Fig. 10). Cystic medial necrosis was not
observed in the specimen. Later in her course
postoperatively, digitalization was carried out be-
cause of persistent tachycardia. Serosanguineous
fluid was aspirated from the right pleural space
on one occasion and about five days postopera-
tively she developed a mild jaundice with a bili-
rubin of 3 mg.% which subsided promptly. She
has remained in excellent health during the suc-
ceeding eight months.
Case 3 (H. S.). This 45-year-old white man
was admitted to the Medical College Hospital in
January 1958. He had first become aware of heart
disease six years previously, but serious shortness
of breath and anginal pain did not occur until
the year prior to admission. There was a ques- FiG. 9. E. T.: Saccular aneurysm of ascending
tionable history of rheumatic fever at age 20. On aorta atsite oftransverseintimaltear.
836 BOSHER, BROOKS AND POIS Annals of Surgery
June 1964
In April 1961 hewas in reasonably goodhealth.
The blood pressure in the left arm was 160/0 and
in the lower extremities 135/75. In the fall of
1961 he developed severe pain in the chest and
was admitted to another hospital where "heart
attack" was diagnosed. From that time he suffered
occasional anterior chest pain.
In November 1962 deterioration was apparent
with increasing fatigue and shortness of breath.
He had recently been admitted to another hospital
with a diagnosis of embolus to the leg. The left
pedal pulse was found to be somewhat weaker
than the right.
In January 1963 he was admitted to the Medi-
cal College Hospital in marked congestive failure
FIG. 10. E. T.: Technic of Teflon (woven)
graft insertion. Proximal anterior suture line com- which was controlled by bedrest, diuresis and
pleted last. Continuous everting mattress suture regulation of digitalis. Cardiac catheterization
of 3-0 Mersilene reinforced by running over-and- showed a pulmonary artery pressure of 35/25 and
over suture.
a cardiac index of 1.4 L/M2.
On admission for operation in March 1963
a Grade II, decrescendo, diastolic murmur at the electrocardiogram revealed first degree A-V block,
aortic area and along the left sternal border. antero-lateral peri-infarction block and left ven-
Peripheral signs of aortic insufficiency were pres- tricular strain. By roentgenographic study the
ent. Electrocardiogram showed first degree A-V heart had enlarged further since 1958 (Fig. 11,
block and left ventricular strain. The serology was 12). The BUN was elevated to 32. Unexpectedly,
negative and it was thought that the aortic in- at surgery, a large aneurysm of the ascending
sufficiency might be associated with rheumatoid aorta, 10 cm. in diameter, was encountered (Fig.
spondylitis. 13). Arterial cannulation for extracorporeal circu-
On January 9, 1958 a No. 3 Hufnagel valve lation was carried out into the right subelavian
was inserted into the descending thoracic aorta. artery above the clavicle. Upon opening the aneu-
A specimen of the aorta showed cystic medial ne- rysm a circumferential split in the inner wall was
crosis. His postoperative course was complicated seen with a dissection extending proximally to the
by the development of a coagulase positive staphy- aortic annulus and distally beyond the innomi-
lococci right lower lobe pneumonia and by a nate artery. It displaced the right atrium far
staphylococci wound infection. He was treated towards the diaphragm. There was a marked dila-
with chloromycetin and erythromycin and recov- tation of the aortic annulus which measured 5 cm.
ered without developing endocarditis. in diameter. The leaflets were widely separated,
FIG. 11. H. S.: Com-
parative chest roentgeno-
grams showing left ven-
tricular enlargement due
to aortic insufficiency
prior to insertion of old
Hufnagel valve in 1958
and again in 1963 with
progressive cardiomegaly.
3%2'. (.3
-
Li ILI
smftvfl.
1.
Volume 159 DISSECTING ANEURYSM OF THE ASCENDING AORTA 837
Number 6
the free edges thickened and rolled. Bicuspidiza-
tion was carried out with moderate difficulty, but
this procedure seemed inadequate to control the
incompetence. Accordingly, the two cusps were
excised and replaced with 40 millimeter Teflon
leaflets (Fig. 14 a, b). The right coronary artery
was noted to be markedly thickened and calcified,
possibly due to a previous dissecting hematoma.
The aneurysm was excised and replaced with a
woven Teflon prosthesis. Coronary perfusion was
used throughout and the heart continued beating.
A one and a quarter inch Teflon graft was sutured
I Fri:
into the defect after resection of the aneurysm.
A considerable portion of the posterior wall of FIG. 13. H. S.: Opened aneurysm showing cir-
the aneurysm was left in situ. cumferential disruption of inner wall. Dissection
His postoperative course was complicated by continues into arch. Aortic annulus is dilated to
a gradual rise in BUN to a maximum of 105 with 5 cm.
a creatinine of 2.7. On the fifth postoperative day
the blood pressure dropped to 90 mm. systolic and
the peripheral circulation seemed poor. This was
believed due to myocardial insufficiency and ac-
cordingly he was treated with a dilute mixture of
norepinephrine intravenously for several days,
after which his circulation stabilized and he grad-
ually improved. Digitalis was increased during
this period. However, this led to the onset of
FIG. 14 a, b. H. S.: Bicuspidization of aortic
valve is shown with 40 millimeter Teflon leaflet
replacement to assure valve competency. Aneurysm
has been excised but adherent floor remains.
FIG. 12. H. S.: Left anterior oblique view suggests FIG. 14b.
presenceoffusiformaneurysmofascendingaorta.
838 BOSHER, BROOKS AND POIS Annals of Surgery
June 1964
FIG. 15. B. M.: Se-
ries of chest roentgeno-
(9/4/57, 5/16/61,
grams
9/12/62, and 3/30/63).
Wideningofmediastinum
becomes definitely path-
ological in September
1962 film.
syncopal attacks due to complete heart block heard at the apex and the base of the heart. No
which was controlled with isuprel sublingually and diastolic murmurs were heard. Chest roentgeno-
which cleared after reduction in digitalis. grams showed mild cardiomegaly with some wid-
Since that time he has continued to improve ening of the mediastinum (Fig. 15). A compari-
progressively although exhibiting residual exercise son with previous roentgenograms showed the
intolerance. A rasping, aortic systolic murmur is widening to have been present as early as Sep-
still present, but no diastolic murmurs are heard. tember 12, 1962. On the retrograde aortogram
The blood pressure is 120/80. a segmentation was seen in the ascending aorta
losafhteteaCnrgaoest,peearddt4epvaoe(ifBln.oshpeieMrnd.)tf.ihcfeotAnhrgiepcgsrhotetliogvarneneatdnefcrawiyioolrumartacehnew,dshtui.r3ci2Shnegyvteeiatrmrhaesle wod(ihcFliciaglct.uahdt1ie6wod)na.snoeTfaihrnettheirtersipgrhoaertotiregctdiaanr.oaitsnTidhaetarhrdeetiesrwusyapecspwteairasnlgscpoooarmfntpueilsuoeirntfyeoslromymf
the descending thoracic aorta.
months after delivery she was admitted to a hos-
pfaiitlaulreo.nSJhaenuiarmypr2o1v,ed19a6f3tewritdhigistyalmipztatoimosn,ofbuhteaornt A moOpdeerraattieonsizweadsacnaerurriyedsmouotf tohne Aapsrcielnd1i2n,g1a9o6r3t.a
February 8 went into mild shock and the radial was encountered with a circumferential split and
pulse was found to be absent in the right arm. dissection in the wall about 2 cm. distal to the
She recovered in a few days and was discharged. aortic valve, extending two-thirds around its cir-
She was first admitted to the Medical College cumference (Fig. 17). A false lumen could not
of Virginia Hospital on March 28, 1963. The be identified distally. Considerable scarring was
blood pressure in the right arm was 95/85 and encountered posteriorly near the angle of reflec-
in the left arm 160/85. The right brachial pulse tion between inner and outer walls. The ascend-
was barely palpable. The right carotid pulse was ing aorta was resected and a Teflon woven graft
absent. There was a fairly loud systolic murmur inserted. A moderate bleeding dyscrasia post-