A Method for Resection of Aortic Arch Aneurysms'

WVILLIA.m H. MULLER, JR., M.D., (F.A.C.S.), W. DEAN WARREN, M.D.,FRANK S. BLANTON, JR., M.D.

From the Department of Surgery, University of Virginia School of Medicine,Charlottesville, Virginia

THE DEVELOPMENT of methods for replac-ing arterial segments has made excision andinsertion of a graft or prosthesis the pro-cedure of choice for the treatment of ar-terial aneurysms. Aneurysms in the abdom-inal aorta do not usually present a problemsince they generally occur below the renalarteries, and the aorta in this area can beoccluded for a relatively long period oftime without detrimental effects on thespinal cord or the adjacent abdominal vis-cera. The surgeon is thus able to resect theaneurysm and re-establish arterial continu-ity in a precise and accurate manner. Aneu-rysms of the descending thoracic aorta,however, present a greater problem be-cause of the likelihood of spinal cord dam-age or of cardiac failure with prolongedaortic occlusion. Aortic arch aneurysms in-volve even more difficulties because ac-commodation must be made for cardiacoutput, and circulation to the brain mustbe maintained during the period of excisionand replacement.

Early investigations of methods for aorticarch replacement were reported by Hardin,Schafer and their associates.4 In a num-ber of animals, they successfully employedtemporary polyethylene bypass shunts per-mitting arch resection. They applied thistechnic to one patient who died shortlyafter insertion of the aortic homograft.Their investigations demonstrated the feasi-bility of aortic arch resection. Also, Strana-han et al. used shunts for resection of ananeurysm of the aortic arclh in a patientwlho did not survive.

* Suibmitted for pulblication MIay 25, 1959.

In 1955, Cooley and associates 1 reporteda patient who survived six days followingresection of an arch aneurysm and replace-ment with homograft, utilizing hypothermiaand temporary shunts. More recently theyhave used extracorporeal circulation to per-fuse the brain and maintain blood flowthrough the descending aorta.2 Two of tenpatients were living and well at the time ofreporting.Gwathmey, Pierpoint and Blades 3 dis-

cussed their series of aortic arch proceduresand described three technics for maintain-ing circulation. They employed hypother-mia in the first group, segmental occlusionwith hypothermia in the second, and extra-corporeal circulation in the third. Four oftheir patients survived, two of whom hadaneurysmorrhaphy and two, segmental re-sections.Hypothermia and a temporary shunt

were used for our first resection of theaortic arch but, because of certain disad-vantages associated with this method, itwas decided that it should be abandonedfor the second patient. An extracorporealapparatus was available at the time of op-eration but we were reluctant to use it b-cause of the additional risk it imposed andthe possibility of hemorrhage of heparin-ized blood through the knitted prosthesis.Therefore, a technic was successfully em-ployed which does not require the extra-corporeal system and wlhich permits resec-tion of the aneurysm and insertion of theprosthetic arclh in a relatively normal an-atomic relationslhip.

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MULLER, WVARREN AND BLANTON Annals of SurgeryFebruary 1960

FIG. 1. Drawing of alarge aneuirysm of the en-tire aortic arch. The als-cending and descendingaorta and great vesselslhave been dissected freeand isolated.

Operative Procedure

The patient is placed in the supine posi-tion and a transsternal incision is madethrough the right third and left fourth inter-costal spaces. The incision is carried fartherposteriorly on the left so that adequateexposure of the descending aorta may beobtained. The ascending aorta is freed fromthe pulmonary artery, and two centimetersof aorta not directly involved in the aneu-

rysm should be present; if not, a procedureutilizing the pump oxygenator must be em-

ployed. The descending aorta immediatelydistal to the aneurysm is likewise freed fora distance of several centimeters and theinnominate, left carotid and left subclavianarteries are exposed and dissected free fromsurrounding tissue (Fig. 1). An approx-

imate measurement is then made for theprosthesis which is fashioned to size andpre-soakedc with the patient's blood. Twocturved arterial clamps are placed on theproximal aorta occluding about two-thirdsof its diameter and excluding a semicircularporticn of its wvall (Fig. 2). An incision ismade into the excluded segment beginningnear the proxiimcal cliamp aind extendingdliagonallv and superiorly towx,ard the dlistalclamp, partially transsectinc the aorta. Thedistal opening is close(d with a continuLousatrauimatic sutture. The proximal end of the

graft is tailored on a bias so that when itis fitted to the proximal opening into theaorta it will assume a normal position in thechest. It is anastomosed to the proximal endof the aorta in the usual fashion. A clampis placed across the prosthesis just proximalto its first limb and the curved clamps on

the aorta are slowly released. An end-to-side anastomosis of the first limb of thegraft to an isolated segment of the innom-inate artery is performed after which theclamp on the prosthesis is advanced to a

point distal to the origin of this limb. Anend-to-end or end-to-side anastomosis iscarried out between the remaining limbsof the prosthesis and the left carotid andsubclavian arteries (Fig. 3). Finally, thedescending aorta is clamped and divided,and an anastomosis is carried out betweenthe prosthesis and the distal aorta. Thisshould be accomplished in less than _0 to25 minutes, and the anastomosis can usuallvbe performed in a much shorter time.Clamps are then placed across the base ofthe aneurysm just beyond the proximal an-

astomosis and the aorta is divided. Theseclamps should be placed so that the prox-

imial aorta is tapered towvard the prosthesis.The aortic stulmp is closed and the aneu-

rysm, noNw isolated from the circtulation, can

be excised (Fig. 4). The pericardium is

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FIG. 2. (a) Curvedclamps partially occludethe ascending aorta andan incision has been madeinto it to receive theprosthesis. (b) A crimpedTeflon aortic arch graftis tailored to fit the aorticincision. (c) The anasto-mosis is shown betweenthe end of the prosthesisand the aortic incision.(d) An end-to-side anas-tomosis is made betweenthe limb of the prosthesisand the innominate artery.

RESECTION OF AORTIC ARCH ANEURYSMIS

closed loosely over the aortic anastomosisand a posterior inferior dependent drainageopening is made in it on the left. The elec-tric cautery and gelatin foam soaked inthrombin solution are helpful in controllingbleeding from the raw oozing bed of theaneurysm. Drainage catheters are placed inboth sides of the chest in the posterior axil-lary line in the seventh or eighth intercostalspace. The chest is closed in layers in theroutine fashion.

Case PresentationsK. G., UVH #437629. This 51-year-old white

male was admitted to the University Hosp-tal onDecember 2, 1957. Five months prior to his ad-mission, he had a cough, progressive weight lossof 15 pounds, anorexia and weakness. Three weeksbefore admission he had hemoptysis and incre-sedseverity of his cough and hoarseness. His past his-tory, family history and system's review were non-contributory to the present illness.

Physical examination revealed a blood pressureof 160/90 in the right arm and decreased pulsesin the left arm. There was exophthalmos and ptosison the right, and the right pupil was larger thanthe left. A left vocal chord paralysis was present.The neck veins were not distended but a bruit washeard over the right comml-on carotid artery andpulsations were diminished on the left. A loudsystolic murmur was heard in the aortic area and

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in the neck. The aortic second sound was distinctand equal to pulmonary second sound. The liverwas palpable at the right costal margin.

Roentgenologic examination demonstrated apulsating mcss in the midmediastinum. Wassermannand Kline tests were 4 plus positive. Bronchoscopyshowed extreme narrowing of the left mainstembronchus and biopsy at this site was reported aschronic inflammation with squamous metaplasia.Angiocardiography demonstrated an aneurysm in-volving the aortic arch.

The patient was placed on antileutic therapyand was discharged to return in one month. Onre-admission his condition was essentially un-changed. He was taken to the operating roomwhere his temperature was lowered to 320 C.,and a posterolateral thoracotomy was performedthrough the bed of the fourth rib. A large aneurysminvolving the arch of the aorta and extending sev-eral centimeters distal to the left subelavian arterywas visualized. A tape was passed about the aortaproximal to the aneurysm where 3 centimeters ofnormal aorta was present. The innominate and leftcommon carotid arteries were patent, but the leftsubclavian artery was found to be nearly occluded.A compressed polyvinyl sponge shunt with in-nominate and carotid branches terminating in rigidpolyethylene cannulae was then sutured to theaorta proximally and distal to the aneurysm. Bloadflow through the shunt was adequate and the limbs,"ere then attaclhed to the innominate and carotidvessels by insertion of the polyethylene cannulaethrough longitudinal incisions and tightening tour-

228 MULLER, WARREN AND BLANTON

niquet ligatures previously placed about these ves-sels. The aneurysm was then isolated with clampsand excised. Dense attachments to esophagus andtrachea were present. There was a thrombosedcommunication between the aneurysm and the leftmain stem bronchus, and the bronchial openingwas closed with interrupted fine silk sutures. Ahomologous arterial graft was then sutured to thedistal end of the aorta and to the left common

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Annals of SurgeryFebruary 1960

FIG. 3. (a), (b) Theprosthesis is inserted end-to-side between a limbof the prosthesis and theinnominate artery, andend-to-end between thesecond limb of the pros-thesis and the left carotidartery. (c) An end-to-end anastomosis betweenthe distal end of theprosthesis and descend-ing aorta is shown. (d)All anastomoses are com-pleted.

carotid artery and blood permitted to flow retro-grade through this channel to the left carotid. Thegraft was then anastomosed to the innominate ar-tery and both polyethylene cannulae removed. Theprocedure was completed by suture of the prox-imal end of the graft to the ascending aorta. Whenthe shunt was removed, the blood pressure waslow, and the temperature was 28° C. The heartbeat was adequate, but pressure could not be

FIG. 4. Drawing ofthe arch prosthesis illus-trating completion of theanastomoses and resec-tion of the aneurysm.

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FIG. 5. Photographshowing the aortic archprosthesis in place.

RESECTION OF AORTIC ARCH ANEURYSMS

maintained in spite of administration of calciumchloride and additional blood. Considerable oozingof blood occurred throughout the procedure inspite of careful hemostasis. The chest was closed,and the patient was treated with massive trans-fuisions and vasopressors buit he remained unre-sponsive and continued to decline. Ventricularfibrillation and death ensued. Postmortem examina-tion revealed the graft to be intact. Ltuetic changesextended to the aortic valves, and both coronaryostia were markedly narrowed by this process.

G. W. R., UVH #448110. This 49-year-oldwhite male laborer was admitted to the Universityof Virginia Hospital on July 8, 1958, with a six-months' history of pain in the right side of hischest radiating to the right arm and neck, dys-phagia, hoarseness and gradually progressive dys-pnea and orthopnea. Two and one-half years priorto this admission, a thoracic aortic aneturysm hadbeen demonstrated on routine chest x-ray buttreatment had been declined. A history of syphilistreated 30 years previously was obtained. Twoyears before this admission he was found to havepositive serology and spinal fluid and was ade-quiately treated with penicillin.

Physical examination showed that he was hoarseand mildly dyspneic. Blood pressure was 144/80 inthe right arm and 124/80 in the left. The tracheawas moderately deviated to the right and therewas a soft systolic murmtir along the left sternalborder. Pulses were palpable and equal in all ex-tremities. Wassermann was 4 pltus and Kline 2plus. Spinal fluid was negative.

Retrograde aortogram performed through theright brachial artery showed an aneurysm involv-ing the transverse and descending portions of thearch.

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The patient was treated with penicillin for 12days and digitalized after which he was takento the operating room where a bilateral thoracot-omy was performed through the left fourth andright third intercostal spaces. A huge saccularaneurysm was seen to involve the entire aorticarch. The pericardium was opened and the prox-imal 3 centimeters of the aorta was dilated butnot involved in the aneurysm. The aorta again be-came normal at the level of the sixth thoracicvertebra. A pump oxygenator was available but forreasons already mentioned was not employed. Themethod of progressively inserting the prosthesisas described above was employed (Fig. 5). Hisimmediate postoperative course was uncomplicatedexcept for accumulation of left pleural fluid neces-sitating multiple thoracenteses. On the twelfthpostoperative day, he experienced onset of severeepigastric pain and lapsed into shock. The ab-domen was diffusely tender with spasm and re-bound tenderness in the right upper quadrant.Laparotomy revealed a ruptured spleen attributedto subcapsular hematoma as a complication ofthoracentesis. The remainder of his postoperativecourse was not remarkable, and he was dischargedon the thirty-fourth day after operation. He hascontinued to do well through the intervening 11months.

DiscussionAt this time when there is such a great

tendency to apply the pump oxygenator toprocedures of this type and magnitude,one might consider a more conservativemethod of aortic arch resection inadequate.On the other hand, there are a number ofdefinite advantages to recommend a pro-

230 MULLER, WVARREN AND BLANTON Annals of Surgery

cedure which does not employ an extra-corporeal apparatus. First of all, less timeis required and less operating is involved.The risk of using the pump itself is avoidedeven though this risk has become smallwith present-day systems in the hands ofexperienced operators. Of great importanceis the absence of necessity for hepariniza-tion. It is true that one can operate uponthe heparinized patient 'without difficultyand use a fabric prosthesis if the intersticesare small; however, bleeding is more diffi-cult to control if the procedure is of greatmagnitude and especially if large raw sur-faces such as the bed of the aneurysm areexposed. In such cases such as these, then,it is much easier if heparin is not needed.

In order to utilize the method herein de-scribed, it is necessary that at least a shortproximal segment of the ascending aortanot be involved with the aneurysm. Dilata-tion of the proximal aorta occurs in mostinstances and indeed is helpful because itenables one to occlude this vessel partiallyfor application of the proximal end of thegraft and at the same time allows adequateblood flow through the remaining aorta.Anastomoses to the innominate and leftcommon carotid arteries may be performedend-to-end if they can be carried out rap-idly. If an unusually long time is necessaryto perform the anastomosis, end-to-side su-ture may be done by partially occludingthese vessels. End-to-side suture is espe-cially applicable to the larger innominateartery. Although it has long been knownthat the left subclavian artery may beligated in its first portion without producingclinically significant changes in the nutri-tion of the left upper extremity, it is advis-able to anastomose this vessel to the graftbecause it serves as a source of collateralblood supply to the brain and is the originof the vertebral artery. This vessel may behelpful in supplying blood to the brain ifthe carotid artery is partially occluded byarteriosclerosis or thrombus from the aneu-rysm.

Hypothermia, though not necessary, may

be of value in prolonging the time one may,safely occlude the great vessels of the aorticarch. The dangers inherent in hypothermiaitself may be prevented by avoiding ex-tremely low body temperatures.

SummaryThe evolution of methods to replace the

aortic arch has been reviewed. Two patientsare reported in whom large aneurysms in-volving the entire arch of the aorta were ex-cised. In one, hypothermia and a temporaryshunt method were employed without sur-vival. In another, a method of progressivelyinserting the prosthesis without extracor-poreal circulation or a shunt was success-fully utilized. This latter method is de-scribed in detail.When the aneurysm arises at the origin

of the aorta an extracorporeal apparatusmust be used. If two or three centimetersof proximal aorta are available, the methoddescribed can be used to advantage.

Bibliography1. Cooley, D. A. and MI. E. DeBakey: Total Exci-

sion of the Aortic Arch for Aneurysm. Surg.,Gynec. & Obst., 101:667, 1955.

2. DeBakey, NI. E., E. S. Crawford, D. A. Cooleyand G. C. Morris: Stuccessful Resection ofFusiform Aneurysm of the Aortic Arch withReplacement by Homograft. Surg., Gynec. &Obst., 105:657, 1957.

3. Gwathmey, O., H. C. Pierpont and B. Blades:Clinical Experiences with the Surgical Treat-ment of Acquired Aortic Vascular Diseases.Surg., Gynec., & Obst., 107:205, 1958.

4. Hardin, C. A., T. L. Batchelder and P. W.Schafer: Temporary Use of PolyethyleneShunts in the Resection and HomologousGraft Replacement of the Aortic Arch in theDog. Surg., 32:219, 1952.

5. Schafer, P. W. and C. A. Hardin: The Use ofTemporary Polyethylene Shunts to PermitOcclusion, Resection and Frozen HomologousGraft Replacement of Vital Vessel Segments.Surg., 31:186, 1952.

6. Spencer, F. C.: Aneurysm of the CommonCarotid Artery Treated by Excision and Pri-mary Anastomosis. Ann. Surg., 145:254, 1957.

7. Stranahan, A., R. D. Alley, W. H. Sewell andH. W. Kavesel: Aortic Arch Resection andGrafting for Aneurysm Employing an Ex-ternal Shunt. J. Thor. Surg., 29:54, 1955.