POSTGRAD. MED. J. (1965), 41, 128

ANEURYSMS OF THE ABDOMINAL AORTACHARLES MARKS, M.D., M.R.C.P., F.R.C.S.

Professor of Surgery, Marquette University MedicalSchool, Wisconsin; Surgeon, Milwaukee County

General Hospital

AN ANEURYSM of the aorta irrespective of itslocation or its etiology is a serious threat tothe patient due to its tendency to enlarge andto the fact that serious complications fromrupture, dissection, pressure effects or peri-pheral embolization from a mural thrombusthreaten the life of its victim. The frequencyof death from complications has long beenknown, and Colt in 1927 collected a series of503 patients with thoracic aortic aneurysms and121 patients with aneurysms of the abdominalaorta and demonstrated that the average sur-vival of these patients was less than two yearsfrom the time of first diagnosis. Similarly,Wright (1956) made a study of 60 patients withabdominal aneurysms and found that only400/, survived two years from the time of diag-nosis whilst all the patients had died withinseven years. In a review of 101 cases by Estes(1950), 50%/, were dead after three years.The rapid development of vascular surgery,

now permits the resection of an uncomplicatedabdominal aortic aneurysm and replacementby graft with a fair degree of safety for thepatient. Since the first successful performanceof this procedure by Dubost in 1951, the workof DeBakey (1953), Robb (1953), Boyd (1957),and others have helped to standardize thesurgical technique as well as to demonstrate thesuperiority of vascular prostheses over aortichomographs. (Edwards, 1959).

Case Material

In the ten-month period, October 1963 to July 1964,the surgical service of the Milwaukee CountyGeneral Hospital admitted 14 patients for resectionof abdominal aortic aneurysms. Their ages rangedfrom 54 years to 89 years with an average age of74 years. Ten males and four female patients com-prised this series.In eleven of these patients the aortic resections

were performed on an elective basis. Abdominalpain or pain in the back was the main presentingfeature in these patients, a pulsating abdomirnal massbeing easily felt. Calcification was readily apparenton straight abdominal X-rays in three of thesepatients. Aortography was utilized in only three ofthese patients. In one case, aortography was usedto determine the state of the ilio-femoral vasculartree. In another, it was performed to relate theupper limit of the aneurysm to the renal arteries in

a patient with hypertension in whom renal arterystenosis was suspected, whilst in the third case anaortogram demonstrated a clinically unsuspectedaneurysm in a patient undergoing a vascular studyfor ilio-femoral occlusive disease. Ten of thesepatients survived the procedure, were dischargedfrom hospital, and at present all are alive and welland being followed in the clinic. The one death wasdue to a massive myocardial infarct in an 88-year-oldfemale which became apparent on the electrocardio-graphic oscilloscope at the completion of the operativeprocedure with her death soon after returning to therecovery ward.Three patients presented as emergency procedures

with rupture of the aneurysm and massive exsanguin-ation. The one survival continues to do well, whilstthe two deaths were due to myocardial infarction24 hours postoperatively in the one and death fromanuria 36 hours postoperatively in the other.

Preoperative EvaluationThe presence of a palpable pulsatile abdo-

minal mass with or without back pain orabdominal pain makes the diagnosis of ananeurysm of the abdominal aorta a fairlysimple matter. The presence of calcification ofthe aneurysm is readily apparent on a straightX-ray of the abdomen, (Figure 1) and oftenthis will indicate the relationship of the upperextent of the aneurysm to the renal arteries.This relationship can be further ascertained bythe use of intravenous pyelography and, ifconsidered necessary, by aortography. Aorto-graphy is not, in our opinion, required routinely,but is utilized to demonstrate the relationshipof the aneurysm to the renal arteries, to evalu-ate aorto-iliac arteriosclerotic occlusion orperipheral arterial inadequacy and in selectedcases of hypertension. For better detail regard-ing the patency of the arterial outflow tract inthe lower extremity, femoral arteriography maybe further indicated. An X-ray of the chest isalways performed, and it is important to ex-clude a concomitant supradiaphragmatic an-eurysm. It has been our practice to use thepercutaneous lumbar route at D1 1-D12 levelfor aortography.

Evaluation of the coronary cerebral andrenal circulations may be necessary, and thuselectrocardiography is never omitted and in thepresence of myocardial disease, it becomes

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FIG. 1.-Straight X-ray of abdomen demonstratingcalcification of aortic aneurysm.

necessary to weigh the risks of cardiac com-plications against the risk of aneurysmal rup-ture. In two of our patients with previousmyocardial infarction, aortic resection wasfollowed by an uncomplicated convalescence.

Renal function is established by carryingout a full urinalysis, estimation of blood ureaand creatinine clearance, intravenous pyelo-graphy and, where hypertension is thoughtto be due to renal artery stenosis, aortography.

Carotid and vertebral arteriography havebeen performed only where syncopal attackssuggested the possibilty of cerebral arterial im-pairment.

Preoperative PreparationA nasogastric tube is passed and an indwel-

ling urethral catheter permits measurement ofurinary output during and immediately afteroperation. A fall in urinary output to below30 ml. in any one hour prompts our use oflow molecular weight dextran and mannitol.An intravenous infusion via a polythene

catheter is arranged in the arm and not the legas it may become necessary to occlude theinferior vena cava in controlling venous hemor-rhage. Five pints of blood should always becross matched and be readily available, al-

though, in several of our patients we used aslittle as two pints. It is important to replacevolumetrically all blood lost to reduce theincidence of operative and postoperative hypo-tension. A venous catheter provides a constantmonitor of venous pressure whilst ten-minuteblood pressure readings are taken during theoperation. The oscilloscope with an operativeelectrocardiographic monitor provides immedi-ate information regarding any changes in my-ocardial status.

TechniqueEven if preoperative studies indicate patency

of the iliac and femoral arteries, access to thefemoral and on occasion to the poplitealarteries may be necessary. For this reason theentire abdomen and both thighs are preparedand appropriately draped, whilst free access tothe feet permits observation of changes in skincolor, venous filling or changes in the pedalpulses.

AnesthesiaAll patients have been induced with pentothal

and succinylcholine, were intubated and main-tained with cyclopropane and oxygen.IncisionA long midline incision from xiphoid to

pubis, skirting the umbilical cicatrix, providesadequate access for the technical maneuversrequired. A careful general abdominal explora-tion is carried out with special attention beinggiven to the stomach, gallbladder, pancreas andcolon. The superior mesenteric and renal art-eries are palpated for atherosclerotic plaques.After completion of the aortic resection, andinsertion of the graft, we have performed ap-pendicectomy in one case, and in another,cholecystectomy.

After total exteriorization of the small in-testine from the abdominal cavity, readyaccess to the aorta is provided. The retroper-itoneal portion of the duodenum is oftenclosely attached to the aorta and careful divisionof the ligament of Treitz provides a plane ofcleavage for its separation. Free exposure ofthe aorta is attained by dissecting the posteriorperitoneum from the anterosuperior surface ofthe aneurysm, and it is wise to clear that portionof the aorta proximal to the aneurysm so thatapplication of a clamp with provision ofproximal control becomes possible at an earlyphase of the operative procedure in case ofinadvertent damage to the aneurysm or to the

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FIG. 2.-Aneurysm of aorta dissected and ready forclamp control and resection.

distal vessels. A distinct anatomical gap bet-ween the aorta and inferior vena cava existsat this level providing a safety factor in thedissection (Fig. 2).

Great care needs to be taken not to injurethe left renal vein which lies immediately abovethe proximal limit of the aneurysm and may beadherent to it. In the one case where welacerated the renal vein, the rapid control ofthe structure and its partial occlusion with aSatinsky clamp permitted immediate suturerepair and subsequent pursuance of the mainoperation.The common iliac arteries are readily located,

though, they are, on occasion displaced by theaneurysm. They may also suffer aneurysmaldilatation in which case they should be excised.The common iliac veins are closely apposed tothe posterior aspect of the arteries and, toavoid their injury, it is important to stay closeto the arterial wall in their dissection. Injuryto the iliac veins or to the inferior vena cavacan be readily controlled by pressure whilstsuture repair is carried out. The ureters arereadily identified as they cross the iliac arteriesand are appropriately protected.

FIG. 3.-Aneurysm of abdominal aorta resected intoto.

With the aorta and iliac arteries cleared, theinferior mesenteric artery is dissected out andligated close to its origin, thereby permitting acollateral circulation to the colon.The aortic clamp is now occluded, and

vascular clamps are applied to the iliac arteries.10 ml. of heparin solution are injected into eachiliac artery distal to their clamps.

Removal of the AneurysmAlthough it was our initial practice to resect

the aorta with its intact aneurysm in toto,(Fig. 3) we now find it easier, faster and equallyeffective to open the aneurysm longitudinally,evacuate its contents, dissect out the intimalaortic wall and allow the posterior portion ofthe lesion to remain in situ, after transfixing theopen ositia of the lumbar arteries. This tech-nique has the added advantage of not threaten-ing the integrity of the inferior vena cava. Itis important to leave an adequate cuff of aboutone centimeter of aortic tissue proximally tofacilitate approximation of the graft. It is,on occasion, necessary to endarterectomize theproximal aortic stump.

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FIG. 4.-Tubular Dacron graft. Replacement afterresection of aneurysm.

Tailoring the GraftIn utilizing woven crimped Dacron as the

prosthesis of choice in our cases, we havefound no need to preclot the grafts. It is im-portant that the prosthesis be as near the sizeof the host vessel as possible and generallya proximal diameter of 22 mm. and an iliacdiameter of 11 mm. has proved adequate.It is important to remember that restoration ofaortic flow into the graft will elongate it witha resulting tortuous kinked distal limb andcareful attention to this aspect of tailoringtechnique is most important.

Proximal AnastomosisThis is effected by a 3-0 single layer of

mersilene commencing in the midline posterior-ly and utilizing two atraumatic vascular needleswhich pass through the graft from withoutinwards and through the aorta from withinoutwards until they meet at the midaorticpoint anteriorly where the two ends are tied.The proximal anastomosis is tested by

clamping the graft two inches from its upperend and releasing the aortic clamp. Any leaksare reinforced by appropriately placed suturesafter replacing the aortic clamp (Fig. 4).

Distal AnastomosisAppropriate tailoring of the distal end of the

tubular or bifurcation graft is carried out andbefore completing each iliac anastomosis, theiliac clamp should be removed to ensure thata free retrograde blood flow is present. Aftercompletion of the anastomosis on one side, theaortic clamp may be slowly released and withthe blood pressure stabilized, normal perfusion

FIG. 5.-Postoperative aortogram discloses site ofdistal line anastomosis as a distinct 'nick' markedby arrows.

of one limb is permitted whilst clamp controlof the opposite prosthetic limb provides con-trol for the second iliac anastomosis. We haveutilized a 4-0 mersilene double-needle suturetechnique initiated at the midpoint posteriorlyand meeting at the midpoint of the vessel an-teriorly where the two limbs of the suturesare tied (Fig. 5).

In the event that one or both iliac vesselsare irreversibly occluded, or aneurysmal, (Fig.6) the bifurcation graft is then anastomosed tothe common femoral artery in the thigh whilstin the presence of associated occlusion of thefemoral artery at the adductor canal, we haveadded a femoro popliteal by-pass graft to pro-vide good peripheral arterial flow. It cannot bestressed too often that it is important to replacevolumetrically all blood loss whilst the hypo-tensive episodes due to aortic clamp releaseshould lead to re-occlusion of the aorta withsubsequent very slow and gradual release ofthe clamps.The question whether lumbar sympathe-

tectomy should be carried out at this time isalways raised, and though we have used it inthe presence of concomitant advanced peri-pheral occlusive disease, we have not utilizedit in cases of aortic resection for aneurysmwhere peripheral pulses are not deficient. Post-operatively, we have not made use of anti-coagulants but provide a three-day course ofantibiotic therapy with penicillin and strento-mycin as the commonest antibiotics used.

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132 POSTGRADUATE MEDICAL JOURNAL March, 1965

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FIG. 6.-Aneurysm of aorta with concomitant aneurys-mal dilation of common iliac arteries demons-trated by aortography.

The Ruptured AneurysmThe surgical challenge imposed by a patient

with a ruptured abdominal aneurysm is greatindeed, and it becomes important to exertspeed in attaining proximal aortic control whichmay, in the emergency case, be applied proxi-mal to the renal arteries and with bleedingcontrolled, dissection of the infra-renal aortaand reapplication of the clamp with removalof the proximal one then becomes possible.Wound ClosureUpon completion of the operation, the post-

erior peritoneum is closed by a continuous 2-0chromic catgut suture. The anterior abdominalwall is closed in layers using a combination ofcontinuous chromic catgut reinforced by in-terrupted non-absorbable sutures of either silkor wire. We have not utilized drainage,although when considered necessary, we haveused retention sutures.

SummaryA review of 14 cases with abdominal

aortic aneurysms, indicates that with due carein ;all phases of operative management, re-section of the aneurysm and replacement by agraft is a relatively safe procedure in theunruptured case with a mortality rate of lessthan 10% despite the advanced age of thepatients.

Operative management of abdominal aorticaneurysm once it has suffered rupture intro-duces technical hazards and a high mortalityrate, further emphasizing the desirability ofresection on an elective basis.

REFERENCESBOYD, D. P., and BARTELS, C. C. (1957): SurgicalTreatment of Aneurysms of the Abdominal Aorta,Postgrad. Med., 21, 477.

COLT, C. H. (1927): The Clinical Duration of SaccularAortic Aneurysm in British-born Subjects, Quart.J. Med., 20, 331.

DEBAKEY, M. E., and COOLEY, D. E. (1953): SurgicalTreatment of Aneurysm of Abdominal Aorta byResection and Restoration of Continuity withHomograft, Surg. Gynec. Obstet., 97, 257.

DUBOST, C., ALLARY, M., and OEcONOMOS, M. (1952):Resection of an Aneurysm of the Abdominal Aorta,A.M.A. Arch. Surg., 64, 405.

EDWARDS, W. S. (1959): Progress in Synthetic GraftDevelopment, Surgery, 45, 298.

ESTES, J. E. (1950): Abdominal Aortic Aneurysms:A Study of 102 Cases, Circulation, 2, 258.

WRIGHT, I. S., VRDAVETA, E., and WRIGHT, B. (1956):Re-opening the Case of the Abdominal AorticAneurysm, Circulation, 13, 754.

AGUIRRE SILVA, R. (1942): Diverticulitis de MeckelPerforada por Cuerpo Extrano, Arch. Soc. Cir.Hosp., 12, 326.

ALHADEFF, E. (1955): Perforation of Meckel's Diver-ticulum by Foreign Body, Brit. J. Surg., 43, 555.

ASCHAN, T. (1909): A Case of Meckel's DiverticulumPerforated by a Foreign Body, Finska Lak.-Sallsk.Handl, 51, 118.

ASHE, P. (1961): Perforation of Meckel's Diverti-culum by Foreign Body, J. Irish med. Ass., 49, 103.

BEALE, L. (1852): Diverticulum from the Lower Partof the Ileum, Proc. Path. Soc. Lond., 3, 366.

BERNATZ, P. E. (1956): Unusual Conditions SimulatingAcute Appendicitis, Proc. Mayo Clin., 31, 53.

BERRY, J. A. (1927): Perforation of Meckel's Diver-ticulum, Brit. J. Surg., 15, 331.

BLANC, H. H. (1899): Note Anatomo-pathologiquesur Les inflammations du Diverticule de Meckel,Bull. Soc. Anat. Paris, p. 246.

BLOMQUIST, H. E. 1(1951): Fishbone Perforation ofMeckel's Diverticulum and the Small Intestine,Nord. Med., 46, 1045.

BOCK, H. (1933): Uber Meckel'sche Divertikel, Zbl.Chir., 60, 1715.

CHORZEWSKI, Z. (1956): Rare Complication ofMeckel's Diverticulum, Pol. Przegl. chir., 28, 1173.

DENUNCE (1851): Bull. Soc. Anat. Paris, p. 369.DONOVAN, E. J. (1937): Meckel's Diverticulum

Perforated by a Foreign Body, Ann. Surg., 106, 953.DOWSE, J. L. A. (1961): Meckel's Diverticulum,

Brit. J. Surg., 48, 392.FONTAINE, R., and BAUER, R. (1933): Aiguille Arretee

dans une Diverticule de Meckel, Rev. Chir. Paris,52, 71.

GILLETTE, W. R., and ZOLTOWSKI, P. E. (1957):Perforation of Meckel's Diverticulum by a ForeignBody, Amer. J. Surg., 94, 666.

HAGLER, F., and STEWART, J. W. (1920): AcutePerforation of Meckel's Diverticulum by a ForeignBody (Fishbone), J. Amer. med. Ass., 74, 1377.

HENRICHSEN, A. (1921): Ueber einen fall vonFremkorperdivertikulitis des Meckel'schen Diver-tikels, Munch. med. Wschr., 68, 1423.

by copyright. on 29 S

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ostgrad Med J: first published as 10.1136/pgm

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March, 1965 MARKS: Aneurysms of the Abdominal Aorta 133

HILLER, R. I., and BERNHARD, L. A. (1933):Gangrenous Meckel's Diverticulum Perforated by aTomato Peel, J. Amer. med. Ass., 101, 364.

JOHN, E. L. (1955): Perforation of Meckel's Diver-ticulum by a Pin, Brit. J. Surg., 43, 216.

KER, H. (1962): A Muckle of Meckel's, Lancet, i,617.

KOMAROV, I. A. (1959): Perforation of Meckel'sDiverticulum, Vest. Khir. Grekov., 83, 88.

LINDQUIST, S. (1926): Perforation eines Meckel'schenDivertikels, von einem Fremdkorper Beding, Zbl.Chir., 53, ii, 1756.

LONGO, T., and BROGGI, L. (1954): Di una SingolareComplicanza di un Diverticolo di Meckel, Boll.Soc. med.-chir. Varese., 9, 256.

MACFARLANE, D. A. (1948): Foreign Body Perfora-tions in Meckel's Diverticulum, Brit. J. Surg., 35,421.

MASTROSIMONE, C. (1951): Perforazione del Diverti-colo di Meckel ed Ascaridiasi, Arch. Att. Soc. It.Chir., 2, 359.

MECKEL, J. F. (1812): Handbuch der pathologischenAnatomie, Vol. 1, p. 553, Leipzig.

PERSSON, VON T. (1939): Meckel'sches Divertikel,durch einen Fremkorper Perforiert, Acta chir.scand., 82, 530.

PETERSON, E. W. (1937): Commenting on Donovan(loc. cit), Ann. Surg., 106, 954.

PIQUAND, G., and GRENET, H. (1900): Perforationd'un Diverticule Ileal par une Arete de Poisson,Bull. Soc. Anat. Paris, p. 390.

PRINCIPE, L. (1960): Perforazione da Corpo Estraneodi Diverticolo di Meckel Fibroangiomatoso, Riv.Pat. Clin., 15, 503.

RAWLINSON, J. K. M. (1956): Fishbone Perforationof Meckel's Diverticulum, Brit. J. Surg., 43, 555.

REINALDA, R. (1958): A Case of Meckel's Diverti-culum Perforated by a Fishbone, Geneesk. Gids.,36, 383.

ROESSEL, C. W. (1962): Perforation of Meckel'sDiverticulum by a Foreign Body; Case Report andReview of the Literature, Ann. Surg., 156, 972.

ROSSMAN, J. I. (1943): Fishbone Perforation ofMeckel's Diverticulum, Canad. med. Ass. J., 49, 48.

RUMORE, A. (1958): Perforation of Meckel's Diver-ticulum by Grape Seeds, Med. J. Aust., 45, 110.

RUYSCH, F. (1701): Thesaurus Anatomicus, Vol. 7,fig. 283.

SCHWENK, C., and POLLNOW, M. (1912): Fremdkorperim Meckel'schen Divertikel unter den Erscheinun-gen der Appendicitis, Berl. klin. Wschr., 49, 2228.

SEIBERT, F. M. ,(1950): Seltene Erkrankingsformd desMeckel'schen Divertikel. Fremdkorperperforationohne Begleitdiverticulitis, Artzl. Wschr., 550, 1023.

TAMRAZ, J. M. (1940): Case of Acute GangrenousDiverticulitis (Meckels) with Perforation due to aFishbone, Milit. Surg., 87, 328.

WALKLING: cited by Webb (q.v.).WARD-MCQUAID, J. N. (1950): Perforated Meckel's

Diverticulum by Tomato Skin, Lancet, i, 349.WVEBB, R. C. (1933): Meckel's Diverticulum Per-

forated Iby a Fishbone, Ann. Surg., 98, 159.WEINSTEIN, V. A. (1942): Fishbone Perforation of

Meckel's Diverticulum, J. Mt. Sinai Hosp., 9, 29.WHELAN, P. J. (1951): Fishbone Perforation of

Meckel's Diverticulum, Canad. med. Ass. J., 64, 67.WILCOX, A. E. (1932): Case Report in Minn. Med.,

15, 558.WILLIAMS, R. V. (1940): Perforation of Meckel's

Diverticulum by a Fishbone, Minn. Med., 23, 44.

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