The treatment of aneurysm of the aorta - Thorax - BMJ Journals

16 Pages·2004·4.86 MB·English

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The surgical treatment of acquired h
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aneurysm of the thoracic aorta s 1
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C. N. BARNARD AND V. SCHRIRE 6
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From the Departments ofSurgery and Medicine, University of Cape Town, Council for Scientific and Industrial x
Research Cardiopulmonary Group, and the Cardiac Clinic, Groote Schuur Hospital, Cape Town, South Africa .18
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The surgical treatment of an aneurysm of the Atthisstagetheclinicalpictureofsuperiormediastinal 01
abdominal aorta is a well-established procedure obstruction was present, and a continuous murmur was o
with fairly clear-cut indications and limitations. audible in the right parastemal and aortic areas. Treat- n 1
Treatment of an aneurysm of the thoracic aorta, ment with iodide, mercury, penicillin, and mercurial J
on the other hand, is a more hazardous procedure diuretics was begun. When he continued to deteriorate un
hewasreferredtothecardiacclinic. e
thhyaptotrheeqrumiirae,s peairtthiearl moordetortaatlecaorrdiparcofboyupnads,s wwiitthh necOkn, uepxpaemrintartuinokn, haendwausppaelrmolsimtbsmowreirbeunvde.ryToheedefamcae-, 196
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arteries, and the three major vessels supplying the arms was equal, 165/80 mm. Hg. There was no cardio- w
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head, neck, and upperlimbs arefrequentlyinvolved megaly and no valve murmurs. In the right lower neck lo
by the disease. In consequence, special perfusion and intraclavicular area acontinuous thrill andmurmur ad
techniques are required to maintain adequate indicative of an arterio-venous fistula was present. ed
cardiac, brain, and spinal cord function during a gMrodaemrsahtoewheedparitgohmtegveanltyriwcualsarnodtieldat.atTihoneaenledctornocraarddiioo-- fro
prolonged procedure lasting several hours. m
In this paper we describe the surgical results in graphy (Fig. IA) the superior mediastinal shadow was h
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varying degrees of associated aortic incompetence immediate surgery advised. The serology was positive o
in two, erosion of the sternum and ribs in two, for syphilis, the sedimentation rate was 52 mm./hour rax
involvement of the innominate artery in one, and the leucocyte count was 24,000 per c.mm. .b
m
poebrsftorruacttiioonn ionftothtehepuslumpeorniaorryvaerntaercyavaandinriognhet,vaennd- steErmneortgoemnycywitbhilamteedrailanthstoerrancoottoommyy farnodm tthreanssuvperras-e j.co
tricleinone. Infour,varyinglengthsofthedescend- sternal notch to the third intercostal space was per- m
ing aorta were involved, the proximal aorta being formed. The pericardium was opened and both atrial o/
appendages exposed. After systemic heparinization, n
affected in three ofthe four patients, with involve- 90 mg./m.2 body area, bypass and cooling was begun. M
mTewnot ooff tthheesleunpgatainendt/sorhtahdorancoicavsesrotceibatreade ianoratlilc. Adinameatneeru,rywsams foofuntdh.e Iatscheanddirnugptauorretda,inatbooutthe8sucpme.rioinr arch
incompetence. vena cava, the opening being about 1 cm. in diameter. 1
1
CASE REPORTS hMeaarrktefdailuvree,noaunsdbciolantgeersatliopnl,euraclonesfifduesriaobnslewerrieghptre-sseindte.d , 20
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Resection ofthe aortic aneurysm and ofthe superior 3
CASE 1 V.M.,acolouredmanof44years,wasadmitted vena cava was performed, continuity of both vessels b
y
on2 May 1961 inseveredistress. Mildinconstantcentral beingrestoredwithTeflongrafts.Profoundhypothermia g
chest pain, radiating to the shoulders, and dysphagia was used and complete cessation of circulation for u
e
hadcommencedfairlyacutelyonemonthbefore. Onthe severalperiodswasnecessary.Attheendoftheprocedure s
dayhissymptoms began his wife noticed swelling ofhis the heart took over with good beat and good pressure t. P
face andthe rightside ofhisneck, followedbybilateral after defibrillation, but there was considerable oozing ro
jugular venous distension. Severe effort dyspnoea and from veins so that much time was lost in controlling te
poaritnhoapnnodeadydsepvhealgoipaedhardapdiidslayppaenadredp.ersSiesvteerdeabfitleartetrhael theThbeleepdoisntg-.opTehreatilveengtchouorfseperwfaussiosntowramys,21t9hemipnauttieesn.t cted
shoulder pain then recurred, requiring admission else- never really recovering consciousness. A tracheostomy b
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where and pethidine administration. was necessary and respiration was maintained with a c
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FIG. 1. Antero-posterior viewsfrom (A) case I and (B) case 4. (C and D) Pre- and post-operative radiographs gu
from case 3. es
t. P
Bird respirator. Poor peripheral circulation, peripheral Comment A man of44 presented with an illnessro
gangrene, and renal tubular necrosis developed, the of abrupt onset resulting in superior mediastinalte
patient dying two weeks after surgery. The histology compression, a fistulous murmur, and acute rightcte
showed atherosclerosis with pronounced adventitious d
responseconsistent withsyphilis butequally compatible heart failure. The diagnosis of ruptured aortic b
with dissection of the aorta. aneurysm intothesuperiorvenacavawasconfirmedy c
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The suirgical treatment of acquired aneurysm of the thoracic aorta 103 ra
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vateneamecarvgaenwceyresurregseercyt.ablTeh.eThaenepurroylsomngeadndprsoucpeedruiroer riandvioollvoignigcatlhaeppaesacreanndciensgweaorrettahoasnedofaarcdhi,ffuwsietahnecaurrayisom- : first pu
urensduelrtedcaridniacirbryevpearsssiblaenddipfrfousfeountdisshuyepodtahmeargmei.a mseedgiamleyn.taTthieonserraotleowgyasw2a5smpmos.i/thioveu,r.and the erythrocyte blish
Surgerywasnotadvisedinviewofthedegreeofaortic e
Syphilis was the probable cause ofthe aneurysm. d
incompetence. However, when he deteriorated rapidly, a
anemergencybilateralthoracotomywasperformed,with s
caCbrhdaAeedmSgsiiEatatn,tt2eewaddhiytMwceo.iahMttrh.hp,earafotrgaeitrrgwehBsottsa-hiynaeveteraulamrypmpsaietannaondcrrryaeloneaofgcsf.eeadsDbowyiofesnulplttsihninezo4gee5.saowLyfeeowlatlcarhiassnel,gmrpiiwaalganidhsdn,t pAthaerfyntatpdneeosnrtvcaheeser.hcsreeeTpmnahidsreaitinenawgirnazneasoatutoirboroyetmngsay,umnaw.chnaaadsrAddmieiflardoaclourigdnenebde,dyapsntapwheslieuisttrshtyeiwsnciagmotonarhodtsficaiptnnrhodicefnatoscaheuorinmcr1d-hd. 10.1136/th
of six months' duration; dysphagia was absent. There x
waOsna setxoraymionfatuinotrneattheed spyapthiileinstmlaonoykeydearvserpyreviillousalnyd. ctohsetaalnceaurrtyilsamgeistarnudptpuarretd.ofTthheesatoerrtnaumw.asWhcirloessd-iscsleacmtpiendg .18.2
distressed with a large bulge, pulsating, fluctuating, and bothproximal and distal to the aneurysm and a carotid .1
arteryperfusedthroughanadditionalcatheter. Theneck 0
hot, the size of an orange to the right ofthe sternum. 1
Theswellingclearlywasproducedbyananeurysmerod- oftheaneurysmwasresectedandtheexcesswallremoved. o
The aorta was reconstructed by means of a graft. The n
siunpgertfhicrioaulghtistshuee c(hFiegs.t2w)a.llT,hceovpeurlesdesownelryebayllskpirneseanntd, heartwasdefibrillated but itsoon becameclear that the 1 J
aorticincompetence wassevere. Theheartwasunableto u
equal and of large volume, with a blood pressure of n
maintain circulation when bypass was discontinued so e
130/60mm.Hg.Theapexwasleftventricularintypeand that the patient died on the table afteralmostsix hours 1
displaced outwards inthesixth space in themid-axillary 9
bypass.Themacroscopicappearancewasthatofsyphilis. 6
line. Loud murmurs ofaorticincompetencewerepresent 3
over the front ofthe chest to the right and left ofthe Comment A desperately ill man of45 years was . D
sternum. The electrocardiogram showed extensive T admitted with aneurysm of the arch and ascending o
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wave inversion in the left ventricular surface leads. The aorta, erodingthrough thechest andpointingunder n
theskin. Althoughresectionwastechnicallypossible loa
the prolonged procedure and severe valve incom- de
ptoetbeenctehelecdatuosedeoaftthheonantehuertyasbml.e. Syphilis appeared d fro
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CASE 3 P.P., a coloured man of 46 years, developed ttp
sfeovlelroewetdrabnysiaenstweplaliinnginwhtihcehraigphpteaurpepderonsetewrenaelkrbeegfioorne, ://th
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attendance at the cardiac clinic. For two years he had ra
noticedhoarseness. Hehadnocardiacdisabilityandwas x
able to carry heavy sacks weighing 200 lb. without .bm
discomfort. Sarcomaofthesternumhadbeensuspected. j.c
On examination he had a smallbrachial pulse (blood o
pressure 120/100 mm. Hg), a diminutive right carotid m
pulse,collapsingleftcarotid,leftbrachial(bloodpressure o/
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160/80 mm. Hg), and femoral arteries. A pulsatile M
swelling in the right upperchestjust below the clavicle, a
lifting up the sternum, was present. The apex beat was rc
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left ventricular, thrusting in type but not displaced. A 1
short early diastolic murmur was audible, virtually only 1
to the right ofthe sternum and in the aortic area. Else- , 2
where a loud aortic ejection click was present. There 02
were no murmurs in the neck and no signs of superior 3
mediastinal obstruction. 1he electrocardiogram was by
normal. An aneurysm ofthearchandinnominate artery g
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was diagnosed, with moderate aortic incompetence. e
dRiaadginoolsoigsi.caAl10i-ndvaesytcigoautrisoenof(Ftiwgo.miIlCl)ionsuunpiptosrpteendiciltlhiins st. P
daily was advised, the serology being positive. ro
Two months laterthe patientwas admitted for aorto- te
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graphy prior to surgery. The sedimentation rate was te
FtIhGr.ou2g.h thCeassete2r.numThaendapnreoudruycsimngcaanswbeellisnegeninptrhoetrcueanitnrge 2o2uslmym.u/shionugr.thteheSealodrintgoegrratmec(hFniig.que3),, sdhonoewepderacutlaanreg-e d by
ofthechest, coveredonlybytheskinstructures. saccular aneurysm ofthe ascending aorta near the arch c
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FIG. 3. Case 3. A-P and lateral angiocardiograms outlining the aneurysm of the ascending aorta which consists 9
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ofalarge major sacfrom which a second large pouch arises. 3
. D
and an additional false aneurysm arising from the main CASE 4 D.R., a coloured man of 34 years, was wello
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sac. The three major vessels ofthe aorta were normally until two months before admission, apart from mildn
opacified distal to the aneurysm. epigastric discomfort. His illness commenced acutelylo
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A bilateral thoracotomy with transverse sternotomy withupperabdominal pain followedbyorthopnoea andd
was performed on 14 September 1961. A saccular severe effort dyspnoea. At the same time his abdomened
earnoeduirnygsmthoefsttheemausmcenadnidngthaeorsteacoanndd aanrcdhtwhairsdfcoousntda,l bGeengearnaltiozesdweloleadnedmahisfanielicnkgvteoinsresstpooonddouttoltikreeactomrednst. from
cartilages on the right. No aortic incompetence was soonappeared. h
noted at operation. The innominate artery was partly On examination he was in congestive cardiac failurettp
tadhhreormebnocseedt.oBseucraruosunedoifngthsetreurcotsuiroesntohfetahneesutreyrsnmumcoaunldd wabiltehvheenpoautsomdeigstaelnys,iona,ntdricouesdpeimdai.ncAompceotlelnacpes,incgonspiudlesre-,://th
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not be dissected. After systemic heparinization, bypass equal in all limbs, with a blood pressure of 160/55 mm.ra
with profound hypothermia was begun. During dis- Hg was present. Therightventricle wasenlarged with ax
section the aneurysm ruptured. Bypass was temporarily systolic thrill in the pulmonary area and a continuous.b
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bdiustcocinrtciunluaetdi,onthteobrtahienraesntdohfeatrhtewbeordeypewrafsussetdospeppeadr.atTehley mpeutremncuerwaatstphreesseanmteastitteh.eTfhoeurmtuhrlemfutrspoafcea.ortic incom-j.co
neck of the aneurysm was dissected free and resected. The electrocardiogram showed left atrial hypertrophym
The innominate artery was partially obliterated and the andbiventricularenlargement,andonscreeningtheright o/
portion of the aneurysm involving this vessel was left atriumwasmarkedlyenlargedwith pulsation oftheleftn M
intact. The defect in the aortic arch was reconstructed upper cardiac border. The radiograph (Fig. IB) showed
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with a Teflon patch. The heart was defibrillated and pulmonaryoligaemiawithcardiomegalyandaprominentrc
ifumsmieodniawtaesly14t6oomkinouvteers.function. The duration of per- laenfgtioucpapredriocgarradpihacyabsorddeesrc.riCbeadrdeilascewchaetrheet(eSrcihrziartei,onBeacnkd,h 11
Thepost-operative course was complicated by a right and Bamard, in preparation) showed aneurysmal, 2
upper lobe consolidation which responded to treatment. dilatationoftheascendingaortacompressingtheoutflow0
2
The histology showed the condition was probably tract of the right ventricle and pulmonary artery, pro-3
syphilitic. Sixmonthslaterthepatientwasasymptomatic, ducing extreme pulmonary stenosis. The serology was b
y
the pulses were normal and radiography (Fig. ID) positive for syphilis. g
showed marked improvement. A median stemotomy was performed and a saccularu
e
aneCuormymsemntof Athemaasnceonfdi4n4gyeaaorrstapreersoednitnegdtwhirtohuagnh eaxnteeunrdyisnmg toof tthhee lreofottanodf tchoemparsecsesnidnigngthaeorptualmfoonuanrdy,st. P
the sternum and ribs. The aneurysm was resected arteryandoutflowtractoftherightventricle. Moderatero
psuoctceenscsefuwlalyswmiitnhimcaolm,pnloetteberiencgovoebrsye.rvAeodrtaitcsuirngceormy-. wbaoiyrtpthaiscsainatcnaopdme,pceottohelenicnpegawtbiaeesgnutpnr.ewsaeTsnhte.heTaphoaerrtiaanoirzwteaadswaatnshdeennccaicrrrdcoilsasec-dtected
Syphilis was considered to be the cause of the clamped above the aneurysm and the pericardium b
aneurysm. packedwithicedsaline. Afteropeningtheaneurysm,they c
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The surgical treatment of acquired aneurysm of the thoracic aorta 105 ra
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sac was resected and the incision in the aorta repaired. histology showed laminated blood clot but no recog- : firs
The heart was defibrillated and perfusion discontinued nizable wall. Nine months later he was asymptomatic t p
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after abouttwo hours. andback at work. b
rtthuhrpeTetheemeda,wrpebokeesekitdsn-gopraaeefsrststaeortricicivstaeuitroecgndoeruwoyrif,stehfclwouaimadpmssla.esstsHmeioelvoyetwdhwaieuslarlensddiaissnucdndhieanswrtpigeiterthd-e pofroCtdohumecmidenengstcseenvdAeirnnegbaaanocerkutraa,ynsedmrrooodfoittnhgpeatiphnre,ovxieinrmtaaelbcropaloeorutarineoddn lished as
minimal signs ofaortic incompetence. The histology of man of58. The aneurysm displaced the heart to the 1
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the aneurysm was compatible withsyphilis. left, producing apparent cardiomegaly, only slight .1
Comment Acolouredman of34yearspresented aortic incompetence being present. Successful 13
wriigthhtavceuntterirciuglhatrhoeuatrftlfoawilburye aduseypthoiliotbisctrauncetiuornystmo eSxycpihisliiosnwoafstthheeamnoesutrypsrombawbiltehccauursee.was achieved. 6/thx
of the ascending aorta. The aneurysm was success- .18
fully resected with immediate restoration ofnormal CASE6 A.B., acolouredman of38 years,was admitted .2
haemodynamics and cure ofthe patient. in May 1956 forsurgicalrepair ofasubacuteperforated .1
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peptic ulcer. There were no cardiac symptoms at the 1
CASE 5 J.A., acoloured man of58 years, was admitted time; theheartwasnormal in size,but abloodpressure on
on5July 1961 withafour-yearhistory oflowbackache. of 160/70 mm. Hg was found in the right arm and the 1
Atthistimehewasabletowork,butoften thepainwas murmurs of aortic incompetence were heard. Radiolo- J
u
so severe that he had to take to his bed for a week or gically an aortic aneurysm was present. The electro- n
two at a time. The pain was worse during the day and cardiogram was normal. A course ofpenicillin therapy e 1
was aggravated by sitting for any length oftime in the wasgiven,theserologybeingpositiveforsyphilis. 9
6
sameposition orbywalkingalot. Foreightmonths the In 1960 he had to stop working because of effort 3
pain had radiated to the left upper quadrant. A root dyspnoea which progressed but never to the stage of . D
pain was diagnosed and malignancy suspected. Slight orthopnoea or paroxysmal cardiac dyspnoea. Early in ow
effortintolerancewastheonlycardiacsymptompresent. February 1962 he had a small haemoptysis and a few n
Onexaminationtherewasnoevidenceofheartfailure, days before admission he coughed up 'about a gallon' lo
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but a disparity between the peripheral pulses and the of blood. Thereafter the cough continued with blood- d
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cardiac apex was apparent. The pulses were equal and streaking ofthesputum. d
anpoerxmableawtitwhasa btlhrouosdtipnrgesisnurteypoef, 1s2i0t/u8at0edmmi.n tHhge.sTixhteh preOsnentexwaimtihnaati'odnrumm-oldieker'atseecaoonrdticsouinndc,omtpheetemnucremuwrass from
spaceintheanterioraxillaryline,suggestingconsiderable and altered A2 being best heard to the right of the h
leftventricularenlargement. Theearlydiastolicmurmur sternum. The blood pressure in the right arm was ttp
swatsemaulmsoanadtyopinclayl,prebseeinntgatautdhieblaepext.oAtnheaorritgihctejoefcttihoen e1l5e5c/t7r0ocmamrd.ioHgrgamawnadsinnorthmealleafntd1a40r/a6d0iomgmr.aphHgs.hoTwheed ://th
clickwaswidelyheardoverthefrontoftheleftchest. alargeaneurysmwithcalcification ofthewall ofthesac ora
Radiological examination (Fig. 4A) resolved the (Fig. 4B). During thefollowing weekhehad three more x
paradox by showing marked displacement ofa normal haemoptyses, a 'basin-full' at a time, and steadily .bm
spiazretdhoefartthetodtehsecleenfdtibnygaaloarrtgae,anwehiucrhysmwaosftehreopdrionxgimtahle detHeeriowraatseda,dmliostitnegd1f1orlb.st(u4dy99akngd.)hiandwaeighhate.moglobin j.co
vertebrae. Theaorticincompetence was thoughtto have of 10 g./100 ml. Retrograde arterial catheterization of m
little haemodynamic significance. Retrograde aorto- the right brachial artery was performed and dye was o/
graphy(Fig. 5)throughtherightbrachialarteryrevealed injected into the ascending aorta. Moderate aortic n M
a saccular aneurysm of the descending thoracic aorta incompetence was present, with dilated aortic sinuses a
with mild aortic regurgitation. The electrocardiogram and normal coronary arteries. A saccular aneurysm of rc
sonhloyweabdnoUrmwalaivtey.inTvheerssieornoloovgeyrwtahseploesftitvievnetrfiocrlesypahsiltihs.e jtuhset aboerytoandwatsheshloefwtn,subicnlvaovlivianngarttheeryd,esecxetnednidnigngapoorst-a h 11
Elective surgery using aleft thoracotomy through the teriorly and laterally (Fig. 6). Four hours after this , 2
bedofthesixthrib wasperformed. Afterheparinization procedure the patient had another haemoptysis, which 02
a left atrial/left femoral artery bypass was established. heregardedasnomorethanusual,andonmeasurement 3
An aneurysm of the descending thoracic aorta, about he was found to have lost2,000 ml. blood. Transfusion by
12 cm. in diameter, extending from just above the was immediately begun and he was referred for emer- g
diaphragm to immediately below the ligamentum gency surgery. ue
abretheirnidostuhme,hewaarstafonudndh.adItereoxdteedndtehdreeinvteorttehberaele.ftThleurneg waAs pleefrtftohrmoerda.coTthomeystehgrmoeungthotfhethbeedaoorftathiemfmoeudritahterliyb st. P
was a large blood clot in the aneurysm. The aneurysm proximaltotheaneurysmwasdissectedfreeandencircled ro
was partially resected and the remainder of the sac with a tape. A left atrial/left femoral artery bypass with te
closed. Aortic continuity was restored with a Teflon moderate hypothermia was started after heparinization, cte
graft. The length of perfusion was 180 minutes. sincethe aneurysm was tom while attempting to dissect d
The post-operative course was uneventful, the patient it free from the left lung. The aneurysm involved the by
being discharged well three weeks after surgery. The descending aorta immediately below the origin of the c
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FIG.4. Antero-posteriorviewsfiom(A)case5,(B)case6,(C) case 7, and(D) case 8. s
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l9efctm.subicnldaivaimaentearr.terTyh.eIltefwtalsunagbwoauts a1d2hecrme.ntloonvgeratnhde toIcmomnetdrioaltealymaasfsteirvesurhgaeermyotrhrehcahgeestfhraodmtoanbeirnet-erocpoesnteadl rotec
aneurysm and at one point the aneurysm had actually vessel. te
rcounpttiunrueidtyinotfotthheealourngt.aTrehsetoarneedubryysamTweafslornesgercatfte.dTahned cerTehberalpopsoti-onpteroaftivvieew,cotuhresepatwiaesntstcoarmmey.roFurnodmfrtohme d by
proceduretook223 minutes. the anaesthesia satisfactorily. Tracheotomy withassisted c
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The surgical treatment of acquired aneurysm of the thoracic aorta 107 ra
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FIG. 5. Case 5. A-P andlateral h
e
angiograms showing the large, d
saccular aneurysm ofthedescend- as
ing aorta eroding the vertebrae 1
anddisplacing the heart forwards 0.1
andto the left. 1
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FIG. 6. Case 6. A-P and lateral 63
angiograms showing the large, . D
saccular aneurysm of the de- o
scending aorta with partial w
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extravasation of the dye beyond lo
the sac. The aneurysm is eroding ad
the left lungandmoderate aortic e
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incompetence ispresent. fro
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respiration became necessary two days later because of Comment A coloured man of38 years presented m
pulmonary complications, due to the pre-operative with repeated massive haemoptyses due to an j.c
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haemoptyses. Oliguria and renal shut-down then devel- aneurysmoftheproximaldescendingaortarupturing m
oped. The usual regime ofrestricted fluids and reduced into the leftlung. Minimal aortic incompetence was o/
caloric intake was introduced, and the patient appeared n
to be making good progress. On the fifth day post- present. Emergency resection of the aneurysm was M
roepseirnastiwveerlye itnhterosdeucreudm, aplotthaosusgihumthheapdatriiesnetnsaenedmedortaol sduucecestsofuplublumtonthaeryposatn-doperreantailvecopmeprliiocdatwiaosnss.toTrhmey arch
be making good progress and was perfectly satisfactory patient died, apparently from hypoglycaemic coma 1
1
from the haemodynamic and circulatory points ofview. due to excessive sensitivity to insulin. , 2
Insulin, in doses of 2-5 units at two to three-hourly 0
intervals for six doses over 15 hours, was given. During CASE 7 K.S., a coloured man of 59 years, had no 23
the early hours of the morning the patient became complaints until February 1962, when he suddenly had b
comatose and could not be roused. After 50% dextrose a haemoptysis, coughing up about 500 ml. ofblood. A y g
he promptlyregained consciousness and was completely week laterhe coughedup twice as much blood. He was u
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rational. Twohourslaterheagainlapsedintocomaand admitted elsewhere, found to have radiological evidence s
died before help could be obtained. At necropsy the of aortic aneurysm (Fig. 4C) with a 'collapse' of the t. P
pituitary and other endocrine glands appeared to be left upper lobe, and was referred to the cardiac clinic. ro
normal, the aneurysm had been satisfactorily repaired Onexamination therewere no abnormal findingsexcept te
and the kidneys showed the changes of acute tubular forthealtered qualityoftheaorticsecondsound, which c
necrosis in the stage of regeneration. The histology of wastambour-like,especially to therightofthesternum. ted
the aorta showed a moderate degree of atherosclerosis There was no tracheal tug. The blood pressure in both b
and features consistent with syphilis. armswas 140/85 mm. Hgandtheelectrocardiogramwas y c
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FIG. 7. Case 7. A-P and lateral 1
0
angiograms showing theaneurysm .1
of the descending aorta with a 1
3
small 'daughter' aneurysm pro- 6
trudingfrom themain sacintothe /th
left lung. The ectatic innominate x.1
artery is outlined. 8
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npeonrimcailll.inTthheeraspeyrowlaosgygivweans. positive for syphilis and Ageosrtteidcaisntchoempmeotsetncliekewlyascauasbes.ent. Syphilis is sug- 3. Do
The patient was admitted for retrograde catheteriza- w
tion, andalargesaccularaneurysm withaslightpedicle CASE 8 W.E., a coloured man of61 years, complained nlo
attachedtothedescendingaorta,belowtheoriginofthe of stabbing intermittent pain in the back between the a
left subclavian, was demonstrated, with a smaller false scapulae,worseonlyingdown,forsevenyears.Forthree de
aEcnteausriyasmofltahteerarlighttoitnhneomipnraitmearyartaenryeuwrayssmno(tFeidg,. b7u)t. yneuamrsbtahnedpapiarnaehsatdhertaidc.iaNteudmbdnoewsnsboofththaerrmisg,htwhaircmhwfaelst d fro
there wasno aorticincompetence. aggravated by lying on the right side and the left arm m
larWgheihlaeeamwoapittyisnegs,sumragekriyngthseuprgaitciaelntinhtaedrvseenvteiroanlufrugretnhte.r wbaescamafefeacftfeedctwehdebnuthenoltaythoenthtuhmebsle.ft.HeAllsutbhseeqfuienngtelrys http
Othnef1i5ftMharribchwa1s96p2erafloerfmtetdh,oraancdotthoemyaotrhtraouengchirtchleebdewditohf dbeavcekloppaiend,puanirneliantbeodtthoseifdfeosrtofatnhdencohtestr,elsiiemvieldarbytoretshte. ://tho
atapeproximalanddistaltotheaneurysm.Theaneurysm Foroneyearheexperiencedlowerbackacheonstanding, ra
was about 10 cm. in diameter, starting immediately associated with a cramp-like pain in the thighs and x.b
belowtheleftsubclavian andextending about 14cm. to calves, relieved by exercise. In 1954 the Wassermann m
about 4 cm. above the diaphragm. The aneurysm had reaction was doubtful and the Kahn positive. In 1961 j.c
eroded three of the thoracic vertebral bodies and also thesetestswerenegative. om
extAefntderedheipntaoritnhiezalteifotnl,unag.left atrial/left femoral artery preOsnsureexawmaisna1t3i0o/n90amllmp.ulHsge.sTwheerreeewqausalnoancadrdtiheombelgoaolyd on/
bypass under moderate hypothermia was begun. The and no heart murmurs. The electrocardiogram was M
aneurysm was partially resected, the sac which had normal. Radiological examination showed a dilated a
burrowed into thelung beingleft behind and oversewn. aorticknuckle with a rim ofcalcification (Fig. 4D) and rch
Aortic continuity was restored by insertion ofa Teflon in the lateral viewerosion ofthe dorsal vertebrae could 1
graPfots.t-Tohpeerpaetrifvuelsyiotnhetipmaetiwenatsg1a5v7enmionuttreosu.bleandmade beRseeterno.grade angiographic investigation through the 1, 2
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a smooth recovery. Histological examination of the right brachial artery with injection of dye into the 2
3
aortic aneurysm specimen showed laminated thrombus ascending aorta showed a fusiform aneurysm of the b
and degenerative changes but no recognizable arterial aorta just below the left subclavian (Fig. 8). There y
wall structure. Syphilis was suggested as the cause, appeared to be clot in the aneurysm. No aortic incom- gu
although a dissecting aneurysm or arteriosclerosis could petence was present. Surgical excision was advised. e
s
notCboemmexecnlutded.A coloured man of59 presented with eonfcOitnrhcel2e2dfiMwftaihtrhcrhicbo1t9tw6oa2nsltepafpetertfhaoorbrmoaevdce.otaonTmdhyebtehalronoweu,ugrhaynstdhmeawfbtaeesdr t. Pro
roefptehaetepdrmoaxsismiavledheasecmeonpditnygseasordtuaeetroodainnganientuorytshme hweiptahrinmiozdaetrioantea hlyefptotahtreiraml/ilaeftwfaesmorcaolmmaerntecreyd.bypTahses tecte
alenfetulruynsgmanwidthverctoembpralee.teSurcceecsosvfeurly ewxcaissioanchoiefvetdh.e saunbeculravyisamn,exthteenddieadmeftoerrabbeoiuntg a1b0ouctm.6 cbme.loTwhetrhee wlaefst d by
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The surgical treatment of acquired aneurysm of the thoracic aorta 109 ora
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FIG. 8. Case 8. A-P and lateral .1
angiograms showing a fusiform 1
3
aneurysm involving theproximal 6
part ofthe descending aorta and /th
erodingthe vertebrae. x.1
8
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slight erosion ofthree ofthe thoracic vertebral bodies. vertebrae, massive haemoptysis, and obstruction to 3
Theaneurysmwasresectedandaorticcontinuityrestored the pulmonary artery. . D
by means ofaTeflon graft. The duration ofbypass was Involvement of the aortic valves is common and ow
w1a2l5lmaidnhuetseiso.ns,Thwehriechwagsavseomrieseopoozsitn-gopefrraotmivetlhyetcoheasnt aortic incompetence ofvarying degrees was present nlo
in four of the eight patients. In the presence of a
effusion, but apart from this recovery was smooth. d
haemodynamically significant aortic incompetence, e
Back pain immediately disappeared. Histological exam- d
iannadtitohneoffeatthuereasneoufraytshemrosshcolewreodsisc.alcification atone end sinusrugfifciaclienrte.paRiardiooflogtihcealanaenudryasnmgioaglroanpehicmaiynvebse- from
Comment Acoloured man of61 years presented tigation is helpful in the localization of the lesion h
with root pain due to an aneurysm ofthe proximal and outlining the disturbed anatomy. Retrograde ttp
dSuecscceesnsdfiunlgeaxocristiaoneroofditnhgetahnreeuertyhsomrawciitchvcerotmepblreate.e abrytedriiroegcrtapehyx,poesiutrheerobfyathveespseerlcuwtiatnheoiunsjercotuiotne oorf ://tho
radio-opaque material (70% Hypaque in our ra
recovery was achieved. Aortic incompetence was x
absent. Syphilisorarteriosclerosiscouldberegarded patients)andbi-planeradiography, gavesatisfactory .b
results. m
astheprobablecauseoftheaneurysm. The indications for surgery were clear-cut in all j.c
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thepatients. The aneurysm waseither an immediate m
DISCUSSION threat to life, producing compression of vital o/
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Aneurysm ofthe thoracic aorta, particularly that of structures or massive haemorrhage, or was respon- M
the ascending aorta, is usually syphilitic in origin. sible for intractable vertebral or root pain. a
Whereas this condition is becoming infrequent in Despitetheremarkableadvancesincardiovascular rch
western countries, in South Africa and the develop- surgery, the treatment of aneurysm of the thoracic 1
1
ing areas it still presents a major and formidable aorta remains a difficult problem. Treatments such , 2
complication of the disease. In this series it was asligation(Gordon-Taylor, 1950; Greenough, 1929; 0
2
probably responsible for theprocess in seven ofthe Lane and Peirce, 1951; Lilienthal, 1915; Matas, 3
eight patients. 1914; Rundle, 1937; Shumacker, 1947), the intro- by
The disease produces its effects by compression duction of foreign material to promote clotting g
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and erosion of neighbouring structures, often (Colt, 1927; Corradi, 1914; Moore and Murchison, e
s
roMefossutlhtteiondfgitsheieanscepoearmrfemooreaxnteimaopnnldifouirendcmaoisnmstmihoviesnschmoaamelpmlloisrcerrahitaeisgoeno.sf (118A96b54b1)o;,ttDw,era1Tp9ap4ki9an;tgsCtoaownldsetyRi,emyunSlloaotlaedns,,pera1in9-4adr7t;eSruMilailledndfbliebrergmoesarin,s t. Prote
psautpieernitosr. Tmheudsiatshteincalliniccaolmpprreessseinotna,tionarwtearsiotvheantouosf a1n93d9D;rePyea,rs1e9,51;19H4a0r;riPsoopnpea,nd1C94h8a;ndPyo,pp19e43a;nPdagDee, cted
fistula formation, erosion ofthe sternum, ribs, and Oliveira, 1946; Yeager and Cowley, 1948), and by
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endo-aneurysmorrhaphy (Matas, 1888) have largely used by Lilienthal (1915), Dunhill (1922), and: firs
been abandoned. It isgenerally agreed thatexcision Churchill, Sweet, Soutter, and Scannell(1950). Thet p
of the aneurysm with restoration of normal blood exposureofthebloodvesselsinthesuperioranteriorub
flow is the most effective method of surgical mediastinum hasbeenfully describedbyShumackerlis
h
treatment. (1948), Elkin (1945, 1946), and Wilson and Carre
d
The success of this radical approach depends (1948). a
largely on six factors, namely adequate exposure, It has been the general experience that the bests 1
control of the circulation through the aneurysm, exposure of the ascending aorta and proximal0
prevention of tissue damage, restoration ofnormal portion of the arch is the vertical sternal-splitting.11
blood flow after resection, meticulous attention to incision. If the aneurysm is unusually large, with36
haemostasis, and prevention ofinfection. erosion of the chest wall (Fig. 2), vertical splitting/th
x
of the sternum is dangerous until the circulation.1
EXPOSURE The difficulty of finding a single ade- through the aneurysm has been controlled. In such8
.2
quate approach to the ascending aorta, arch, and patientsarightanteriorthoracotomyforcirculatory.1
descending aorta lies in the fact that the arch does control is performed first, and the incision is then0
1
not only pass from right to left, but also from in extended. Either a median sternotomy extending o
n
front at the manubrium backwards to the level of cephalad, atransverse sternotomy oracombination 1
the fourth thoracic vertebra. The ascending aorta ofthe two, will give adequate exposure. J
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andthebeginningofthearcharethusbetterexposed In four of our patients the aneurysm either in-n
e
through an anterior incision, whereas the distal volved theascending aorta, the ascending aorta and 1
portion of the arch and the descending aorta are arch, or the arch alone (Table 1). In cases 1 and 296
betBtaerrdaepnphreouaecrhe(d18t85h)r,ouKgohcaheprost(e1r9i1o1r),inacinsdionS.auer- faoubritlhatreirbalantdhoaramceodtioamnysttehrrnooutgohmythceombbeidneodfwitthhe3. D
o
bruch andSchumacker(1911) describedanapproach a vertical sternotomy was used for exposure. Inw
n
to the anterior mediastinum. Milton (1901) des- case 3 a bilateral thoracotomy with transverselo
cribed the longitudinal splitting approach to the sternotomy, and in case 4 a vertical sternotomyad
anterior mediastinum and this was subsequently alone, proved safe and gave adequate exposure. ed
fro
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Case ASegxeand Incision Lesion CCiorncturloaltioofn PTriesvseuentDioanmaogfe RCeosnttiorrueidty CoPopomesrptal-tii-ve Result://th
cations ora
1. V.M. M 44 Bilateral thor- Ascending aorta, Profoundhypothermia, Profoundhypothermia 2Teflongrafts Cerebral Died x
acotomy,trans- rupturedinto extracorporeal circula- (aortaand damage .b
versesterno- S.V.C. tion,bypass S.v.C.) m
mtoemdyi,ancespthearlnaodtomy discontinued j.c
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2. M.M. M 45 Bilateral thor- Ascendingaorta, Profoundhypothermia, Profoundhypothermia, Teflongraft Aortic Died m
vaecrosteomsyt,ertnroa-ns- ainncdoamrpcehte+nacoertic etxiotnr,acdoirsptoalreaanldcircula- pbeordfyusuipontoodfisbtraalicnlaanmdp itennccoempe- on/
tstoemryn,omteomdyian proximalclamps M
a
3. P.P. M 46 Bilateralthor- Sacculartype, Profoundhypothermia, Profoundhypothermia, Teflon None Curedrc
acotomy, archand extracorporeal perfusionofbrainand patch h
transverse innominateartery circulation, bypass myocardium 1
sternotomy discontinued 1
4. D.R. M 34 Median Sacculartype, Profoundhypothermia, Profoundhypothermia, Direct3-0 None Cured, 2
sternotomy a+sacoerntdiicngaorta, ecixrtcrualcaotripono,rebaylpass hiecaerht,yppoetrhfeursimoinatoof rmeaitntfroerscsedsuwtiutrhes 023
incompetence discontinued distalclamp continuoussuture b
5. J.A. M 58 tLehfotracotomy D+easocretnidcingaorta, Pcrloaxmipmsalanddistal mLo.Ad.e/rFa.tAe.hbyyppoatshse,rmia gTreafflton None Curedy g
incompetence ue
s
6. A.B. M 38 tLehfotracotomy rDuepstcuerneddinigntaoolretfat, Pcrloaxmipmsalanddistal mLo.Ad.er/aF.tAe.hbyyppoatshs,ermia Tgreafflton tRuebnuallar Died t. P
liunncgom+petaeorntciec necrosis ro
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7. K.S. M 59 Left Descendingaorta, Proximalanddistal L.A./F.A.bypass, Teflon None Curedc
thoracotomy leaking,involving clamps moderatehypothermia graft te
leftlung d
b
8. W.E. M 61 Left Descendingaorta Proximalanddistal L.A./F.A.bypass, Teflon None Curedy
thoracotomy clamps moderatehypothermia graft c
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