twenty-seven cases of syphilitic aneurysm of the thoracic - Thorax

33 Pages·2006·8.77 MB·English

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Thorax(1950), 5, 293. : firs
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TWENTY-SEVEN CASES OF SYPHILITIC ANEURYSM d a
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OF THE THORACIC AORTA AND ITS BRANCHES 1
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BY 3
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JOHN BORRIE AND SELWYN G. GRIFFIN /th
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From the Regional Thoracic Surgery Centre, Shotley Bridge Hospital, .5
Newcastle-upon-Tyne .4
.2
(RECEIVED FOR PUBLICATION AUGUST 29, 1950) 93
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The purpose of this paper is to review the treatment of aortic aneurysms and n
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to discuss a series of 27 cases. D
An aortic aneurysm in most instances is a progressive and ultimately fatal e
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disease. Most body tissues are unable to withstand its steady encroachment. em
Pressure on the trachea or bronchus may produce obstructive and infective pul- b
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monary lesions or even necrosis and perforation with sudden death. Natural cure r 1
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may occur by clotting, especially in saccular aneurysms, but this is uncommon. 5
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Colt (1948) stated that 1,500 patients die of aneurysm each year in England . D
and Wales, and that its frequency has not been lessened by arsenical drugs. o
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Untreated patients with aneurysm have a poor expectation of life. Colt (1927) n
has shown that, at the age of 42 years, in a series of 37 cases, a quarter died loa
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four months from the time of the first symptom, half before seven months, another e
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lived more than 20 months. h
Blakemore (1945), who has studied aneurysms both from the points of view ttp
of pathology and haemodynamics, found that the blood, circulating under pres- ://th
sure through an unclotted saccular or fusiform aneurysm, created a total strain o
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on the sac wall that varied with the square root of the surface area. Doubling x
the diameter of an aneurysm by growth increased the strain upon the sac by .bm
100%. Thus, in rapidly growing aneurysms, there is a vicious circle of increased j.c
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strain upon a sac of diminishing strength. On the other hand, he stated that m
once the contents of an aneurysm had clotted, the physical laws governing solids o/
obtained, wherein the total strain is reduced from the aggregate pressure exerted n M
on the entire sac wall to that exerted on the mouth of the aneurysm alone. a
As the nutrition and strength of the aneurysmal wall largely depend on collateral rch
blood vessels from its neck, the more rapidly expanding aneurysms may outstrip 1
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their blood supply, with resulting areas of anaemic necrosis, and in certain situations , 2
rupture. 0
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HISTORICAL SURVEY b
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WIRING gu
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There is no effective medical treatment for an established aneurysm. A patient s
suffering from this disease is doomed, unless the aneurysmal growth can be checked t. P
by clotting and organization of the contents. In 1864 this was first attempted ro
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294 JOHN BORRIE and SELWYN G. GRIFFIN t p
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by Moore, who inserted fine silver wire into the sac. Various other attempts to lis
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promote clotting by inserting pieces of metal, watch springs, and other foreign ed
bodies all failed because these small foreign bodies left the sac and entered the a
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general circulation. In 1879 Filippi reported that Corradi had modified Moore's 1
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method. He inserted 40 cm. of wire into the sac, and, after connecting the free .1
end with a positive pole of a battery, placed the negative pole in the vicinity of 13
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the aneurysm. Hunner, of Baltimore, quoted by Emmert (1933), reviewed the /th
cases treated by these methods before 1900. Fourteen had been treated by x
.5
Moore's method alone, and of these eight were thoracic and six abdominal .4
aneurysms: only two (both abdominal) were cured (14%). He also collected .2
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23 cases which had been treated by the combined method, 17 thoracic and 3
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six abdominal; four (17%) of these (three thoracic and one abdominal) recovered. n
Power and Colt (1903) found three major drawbacks to Moore's method. 1 D
The surgeon punctured the aneurysm with a fine trocar and cannula from which e
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blood was often freely flowing: the length of wire introduced depended on how em
soon kinking occurred and stopped further progress. Sometimes only a few inches b
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were inserted instead of the few feet necessary. With constant handling, r 1
both by the surgeon and his assistants, it was difficult to maintain sterility. Finally, 95
the wire frequently passed into the aorta. 0. D
In 1903 they treated a patient suffering from aneurysm of the abdominal aorta, o
into which they introduced 80 in. of silver wire, with a clotting surface of 3.7 sq. in. wn
Necropsy, performed shortly afterwards, revealed that a loop of wire had lo
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passed up into the aortic arch. To avoid repeating this accident Colt later designed de
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speed and minimum risks of sepsis and haemorrhage. It was ideally suited for h
saccular aneurysms, especially those adherent to the chest wall, and could be ttp
introduced under' local anaesthesia. The apparatus consisted of a trocar and ://th
cannula, a cartridge into which was loaded a wire wisp, and a piston to discharge o
the wisp into the aneurysm (Fig. 1). Various lengths of trocar, cannula, cartridge, rax
and piston were available. .b
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The wire wisps were made in three sizes: j.c
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(a) One wisp, 21 in. long, containing 75 in. of wire, the surface area being m
1i sq. in. o/
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(b) One wisp, 31 in. long, containing 105 in. of wire, the surface area being M
21 sq. in. a
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(c) One wisp, 5 in. long, containing 150 in. of wire, the surface area being h
31 sq. in. 14
, 2
"They are of fine steel, very lissom, and are dull-gilt so as to provide a finely 0
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granular molecular surface for clotting. White thrombus, formed on this surface, 3 b
can only be removed by scraping the wire" (Colt, 1948). Electrocoagulation was y
possible with this apparatus, specially insulated cannulae being available. gu
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In 1948 Colt reported on 32 patients wired by various surgeons. One patient s
with a thoracic aneurysm lived for six and a quarter years following wiring in 1931, t. P
while another with an abdominal aneurysm wired in 1910 lived 17 years 7 months ro
completely relieved of symptoms. tec
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SYPHILITIC ANEURYSM OF THE THORACIC AORTA 295 : firs
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FIG. I.--Colt'sapparatus showing(a)wisp; (b)trocarandcannula; (c)loadedcartridgeandpiston. 9
5
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ELECTROTHERMIC COAGULATION . D
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Blakemore and King (1938) modified the methods of Moore and Corradi, and n
advocate their method of electrothermic coagulation of aneurysms. Fine (34 gauge loa
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B and G) insulated coin silver wire sterilized by autoclave was introduced through a e
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espnedcioaflwniereed.le.EaAchsu1p0p-lmyetorfe1s0e0gvmoelntstdoifrewcitrceurwraesnthewaatsedcotnone8c0t'edC.tofotrheap1r0o-tsreucdoinndg from
period, when a "tenacious clot-stimulating protein coagulum" formed on the wire. h
In 1948 Blakemore reported an analysis of 63 cases of syphilitic aneurysms ttp
of the aorta so treated. There were 54 men, with an average age of 46 years, and ://th
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nine women, with an average age of 38 years: 17, or 27%, of the 63 cases were ra
living 11 to 2 years after treatment: 15 of the 17 were working and symptom-free: x.b
two, with aortic insufficiency, had to lead restricted lives. He was impressed with m
the relief of pain, the protection against rupture, and the overall rehabilitation of j.c
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the patients. m
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CELLOPHANE FIBROSIS n
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In 1943 Harrison and Chandy reported a cure of an aneurysm of the sub- a
clavian artery from fibrosis induced by wrapping cellophane tape around the vessel. rch
In 10 months partial arterial occlusion caused the aneurysm to become smaller, 1
4
and in 19 months this process was complete. They stressed the importance of , 2
gradual occlusion of arteries, including the aorta, because in a comparable case 02
treated by ligation a residual disability of the arm occurred. 3 b
Page (1939), who wrapped the kidneys of dogs in cellophane to produce experi- y g
mental hypertension, drew attention to its irritating properties. Within two weeks u
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have stressed that some types of cellophane incite little or no foreign body reaction. rote
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: firs
296 JOHN BORRIE and SELWYN G. GRIFFIN t p
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In 1946 Poppe and De Oliveira described the results of cellophane wrapping lish
of the abdominal aorta in experimental animals. They noted that one polythene ed
variety of cellophane produced a marked fibrous tissue reaction. In one animal, as
examined two and a half months after operation, not only had the wall of the aorta 1
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been increased to six times its normal thickness, but the lumen had been reduced .1
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to one-third ofits normal diameter. 3
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While reporting the results of cellophane treatment of six syphilitic aneurysms, /th
Poppe (1948) condemned blind wiring techniques. Although it is almost impos- x.5
sible to encircle the dilatation completely without encountering other vital structures .4
or major arterial branches he had found that wrapping was most effective in fusi- .29
form aneurysms of the descending aorta. Indeed, he stated that contraindications 3 o
to surgery included bronchial obstruction or erosion of the anterior chest wall. n 1
These latter two "contraindications," however, are almost always associated in D
our experience with saccular rather than fusiform aneurysms, and we believe they ec
constitute definite indications for wiring by Colt's method. It appears to us that em
complications occurring from wiring techniques arise from faulty selection of cases. be
We believe that saccular aneurysms adherent or close to the chest wall are best r 1
treated by Colt's method, and that fusiform aneurysms are suited to cellophane 95
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wrapping. . D
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RESECTION w
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Although resection has not yet been reported for syphilitic aneurysms, it has lo
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been successfully accomplished for non-syphilitic lesions. In 1944 Alexander and d
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Byron first successfully removed an aneurysm of the thoracic aorta, measuring d
11 by 8 cm., together with a 7.5-cm. length of aorta, from a man aged 21. From fro
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clinical and radiological evidence it was assumed to arise in connexion with an h
aortic coarctation. Boerema was able to excise one which arose at the line of ttp
suture following Crafoord's operation for coarctation of the aorta (Blickman, 1949). ://th
In 1950 Monod and Meyer resected an aneurysm of the aortic arch of a woman o
aged 20 without disturbing the continuity of the aortic lumen. Because of histo- rax
logical proof of necrosis in the media of the aneurysmal wall, he suggested that it .b
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arose as a dissecting aneurysm following an embolus to a vas vasorum, or from j.c
an arteritis associated with variations in blood pressure. All these patients survived o
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operation. o/
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THE PRESENT REVIEW M
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Between September 15, 1936, and January 5, 1950, 27 patients were admitted rch
to the Northern Regional Thoracic Clinic for investigation and treatment of 1
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syphilitic aneurysms of the thoracic aorta and its branches. , 2
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2
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PATHOLOGY b
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The ages of the patients ranged from 46 to 82, with a mean of 58. As there g
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were 21 men and 6 women, men were to women in the proportion of 31 to 1. e
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The sites as diagnosed radiologically and/or by thoracotomy were as follows: t. P
Ascending aorta and transverse arch .. .. .. .. .. 20 ro
DIensnocmeinndaitneg aaorrtteary .. .... .... .... .... .... .... .... 43 tecte
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SYPHILITIC ANEURYSM OF THE THORACIC AORTA 297 : firs
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A double aneurysm was found on two occasions. In one patient both aneurysms b
were fusiform, and situated in the descending aorta; they were separated from lish
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each other by 31 cm. In the other, the proximal aneurysm was saccular and in the d
ascending aorta; the distal one, being unsuspected until necropsy, was fusiform as
and in the descending aorta. 1
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TYPE .11
3
By fluoroscopy and examination of radiographs, 21 of the aneurysms were 6
judged to be saccular and six fusiform in shape, a finding at variance with Poppe /th
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and De Oliveira's (1946) assertion that fusiform are more frequent than saccular .5
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aneurysms. Our experience does not necessarily represent a true incidence rate .2
of the two varieties of aneurysm. 93
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SYMPTOMS n 1
The onset of symptoms was usually insidious; but in two cases it was sudden. D
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One (No. 2289) complained of sudden dyspnoea, loss of voice, and tightness in c
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the neck "like a collar stud pressing on the wind pipe." After two further attacks m
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at monthly intervals, he died from bronchopneumonia. The other (No. 4817) e
experienced a sudden pain in the right infra-clavicular fossa radiating down the r 1
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inner side of the right arm. This was associated with a saccular aneurysm of the 5
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aortic arch. . D
The duration of symptoms varied from 1- to 24 months, with a mean of ow
nine months. n
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Symptoms could be readily ascribed to pressure effects of the aneurysms. a
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Cough and Dyspnoea.-This, the commonest group of symptoms, was due to d
pressure on the trachea or bronchi, with " steadily increasing dyspnoea " found in fro
16, and cough with sputum in 14 patients. Although tracheal compression alone m
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was the most common cause of chronic cough, yet in some the trachea and bronchi ttp
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pression caused collapse of the left lung and death (No. 2851). ra
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Voice Changes.-Eight patients complained of voice changes, varying from .b
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huskiness to complete loss of voice: four of these were bronchoscoped. One j.c
showed left vocal cord paralysis, and three narrowing of the trachea or bronchi. o
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Pain.-Pain variedin site, constancy, and severity. Eleven patients were affected. o/
In one pain was felt only at night. Usually it occurred night and day, and was n M
described as "burning " or "gnawing." It was often associated with "pressure a
against bone, e.g., the vertebral column, sternum, or anterior ends of ribs. rc
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Four patients had "angina pectoris." One at necropsy showed patchy fibrosis 1
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of the myocardium and well-marked patchy atheroma of the coronary arteries but , 2
no thrombus. 02
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Lump.-In three patients erosion of the chest wall produced a visible lump. b
Two are alive and well after "wiring." The other, who refused treatment, has y g
been observed for nine months. ue
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Haemoptysis.-Four complained of haemoptysis. A red tinging of sputum t. P
occurred in three, and a brisk half-pint bleed in the fourth. This last patient died ro
a month later at home, having refused treatment. Of the other three, the first te
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2982JOHN BORRIE and SELWYN G. GRIFFIN t p
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(No. 3433), a labourer, lish
aged 64, with a saccular ed
aneurysm oftheaortic arch a
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and 2 oz. of blood-stained 1
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sputum daily, died two .1
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days after admission. 3
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Necropsy showed a sac- /th
cular aneurysm arising x.5
from the aortic arch ex- .4
tending into the upper lobe .29
of the left lung. It had 3 o
eroded and ruptured into n
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the left upper lobe D
bronchus. The second e
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(No. 5062), a labourer, m
aged 47, had a fusiform be
aneurysm of the arch and r 1
descending thoracic aorta, 95
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a s sociated with cough . D
and blIood-stained o
sputum. Thoracotomy wn
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showed that the a
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aneurysm had invaded the e
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lower lobe of the left fro
lung. The third (No. 5209) m
FIG. 2.-Partial collapse of right lower lobe from bronchial a van driver, aged 57, had h
aortic aorbcshtruacstsioocniadtueedtowiatnheubrrvas-smsy(CcasoeugNho.a5n2d09)b.lood-stain~ea~d~ss~as~cp~cauutluamr.anOeunryasdmmiosfsitohne ttp://th
he had severe bronchopneumonia of the right lung caused by almost complete ora
antero-posterior compression of the trachea. As the sputum was rusty in colour, x.b
rather than bright red, it is more likely that the haemoptysis resulted from the m
severe respiratory infection or congestion than from a leaking aneurysm. In this j.c
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group of cases haemoptysis probably resulted from two causes: either from m
aneurysmal compression of bronchi or trachea producing congestion and infection, o/
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or from aneurysmal leak into a lung. M
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Loss of Weight.-Eight patients complained of loss of weight, varying from rc
a few pounds to as much as one stone in three months. h 1
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Unsuspected Aneurysms.-In a patient (No. 3319), a blacksmith, aged 55, who , 2
had a routine radiological examination following pneumonia, a fusiform aneurysm 0
2
of the aortic arch was found. He refused treatment. 3
b
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PHYSICAL SIGNS gu
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another in the left infra-clavicular fossa, and the third to the right of the sternum. rote
Precordial pulsation was present in nine other patients. c
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SYPHILITIC ANEURYSM OF THE THORACIC AORTA 299 : firs
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Respiratory System.-Signs related to aneurysmal compression of trachea can ub
be tabulated as follows: lis
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S"tBrriadosrsy cough" .... .... .... .... .. .. .. .. .. .... 44 d as
Hoarseness .. .. 2 1
TTrraacchheeaall dtiusgpla..cement.. .... .... .... .... .... .... .... 58 0.11
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Eight patients also had clinical signs of bronchial infection; one presented with 6/th
collapse of lung and one with obstructive emphysema. x
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Although "brassy cough" occurred in four patients, in only one was a left .4
vocal cord paralysis seen. Bronchoscopy, in fact, showed that the cough was due .2
9
to severe narrowing of the tracheal lumen. A similar cough is sometimes heard 3
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in patients suffering from carcinoma of the bronchus causing partial occlusion of n
the trachea ormain stem bronchi. In all four patients the aneurysms were saccular; 1 D
in three it was situated in the arch of aorta, and in one in the innominate artery. e
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Cardiovascular System.-Gross left ventricular hypertrophy and right heart m
failure were each found three times. In five cases "to and fro" murmurs were be
heard at the base of the heart or over the swelling. Mitral systolic or aortic systolic r 1
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murmurs were present on five occasions. 5
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In five patients with no evidence of right heart failure, cervical vein engorge- . D
ment suggested superior vena caval obstruction. o
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Six cases of the series showed significant changes in pulse or blood pressure. n
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In one (No. 3942), a feeble left pulse and low left arm blood pressure indicated a
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involvement oftheleft subclavian artery. (E.g., while the blood pressure inthe right e
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arm was 260/130 mm. Hg and the right pulse strong, the left arm blood pressure fro
was 130/30 mm. Hg and the left pulse weak.) m
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INVESTIGATIONS ttp
Wassermann Reaction.-The Wassermann reaction was positive in 24 cases. ://th
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Radiographs.-Both radiological and screening examination proved most help- ra
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ful in localizing the lesion accurately. Screening also proved invaluable in detecting .b
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the degree of expansile pulsation within the aneurysmal mass. Sometimes it was j.c
impossible to say whether the pulsation was expansile or transmitted from heart o
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and great vessels. Some, however, showed no pulsation. Penetrating films of o/
sternum, ribs, and spine were taken in search of bone erosion. Barium swallow n
was also used to assess the degree of oesophageal obstruction and displacement by M
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the aneurysm (Fig. 3). rc
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If there was still doubt as to the continuity of the mass with the aortic arch, 1
then, after finding the most suitable angle by screening, oblique tomograms were 4, 2
taken to demonstrate the connexion between the two. If lateral tomograms are 0
2
taken, centred on the mediastinum, one or two cuts may incidentally show the 3
amount oftracheal obstruction, a pointwellillustrated in Fig. 4. Here theaneurysm by
was causing such tracheal compression that the patient was unable to lie down gu
without becoming violently dyspnoeic. It was only when an endotracheal tube es
had been passed, under local anaesthesia, beyond the obstruction that it was possible t. P
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FIG.e4n.d-o-tRriagchhteallatertaUlbteonimnogproasmit(i1o5n.cm.d)e.mwoint-h , 2
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tstiroanti(nCgasseevNeroe.d5e2g0r9e)e. oftracheal obstruc- 23 b
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302 JOHN BORRIE and SELWYN G. GRIFFIN : first p
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to relieve the patient's distress and provide sufficient airway to allow of taking lis
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tomograms. e
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Although angiocardiography was not used during the investigation of this a
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particular series, it has proved valuable in other similar cases. 1
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.1
TABLE 1 1
3
ANALYSIS OF BRONCHoscoPIc FINDINGS 6
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SNSoerraa.l CClNini Aneurysm CVhoaincgee Finding .5.4.2
9
1 530 Saccular: aortic arch Trachea narrowed in lower third by anterior 3
compression: pulsation o
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1
2 568 Saccular: ascending R. stem bronchus narrowed below R. upper- D
aorta lobe bronchus by bulging in ofanterior and e
medialwall: pulsation c
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3 819 Saccular: aortic arch Pulsating bulge in postero-medial wall of R. b
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andL. stembronchi r 1
9
4 1175 Fusiform: descending Normalbronchialfindings 5
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aorta . D
5 2851 Saccular: aortic arch Yes Left main bronchus completely occluded by ow
extrabronchialpressurefrom"non-pulsating n
mass." Pus exuded through stenosed area. lo
Biopsyattempted; aneurysm ruptured, with ad
suddendeath e
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6 2944 Saccular: descending Leftbronchuswasdistortedandslit-like. Gross fro
aorta pulsation L. side of trachea and L. main m
bronchus h
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7 4719 Saccular: aortic arch Carpriensasifoonreshortened byantero-posteriorcom- ://th
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8 5062 Fusiform: arch and Yes Bulging, pulsating mass pushing in the left rax
descendingaorta trachealwallandinposteriorwallofL.main .b
bronchus m
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9 5209 Saccular: archofaorta Yes Antero-posterior compression oftracbea; just om
paublosvaeticnagrisnweallwienlgl,niegxhceptottaflolr)noabrsrtoruwctsleidt obny o/
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R.side M
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10 5241 Saccular: innominate Two inches below vocal- cords, trachea was rc
artery narrowedtohalfsizebyexternal swellingon h
anterior and R. lateral surfaces. No 1
4
obviouspulsation , 2
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11 5584 Saccular: archofaorta Yes Paralysed L. vocal cord. Bulging into L. 2
wlaatseraglrewaatllly obfrotardaecnheeda.abLo.vestcaerminbar,ownhchiucsh 3 by
almost completely occluded. R. stem nar- g
rowed u
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12 6135 Saccular: aortic arch Cords normal. Trachea compressed to half t. P
lsaitzeerailnaslpoewcetsr.thNirodofbrvioomusanptuelrsiaotrioannd left rote
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