Surgical Treatment of Aneurysms and Occlusive Disease of the Aorta MICHAEL E. DEBAKEY, DENTON A. COOLEY AND OSCAR CREECH, JR." Baylor University College of Medicine, Houston
ANEURYSMS and arteriosclerotic
thrombo-obliterative disease of the aorta constitute two of the most common and serious forms of aortic disease. Both conditions are associated with a grave prognosis, producing in most cases disabling symptoms and lethal complications. The former condition results from pressure, rupture and hemorrhage and the latter, from progressive arterial insufficiency, ischemia and gangrene. Until relatively recently, treatment of these lesions has been generally unsatisfactory and, at best, palliative. During the past few years, however, efforts have been directed toward a more effective form of therapy consisting of removal of the lesion and restoration of function either by aortic repair or by insertion of aortic homografts. To be sure, it has not been possible to apply this form of therapy in all cases encountered, but our experie n ~ e , 4 -like ~ that of '' has convinced us that it is the treatment of choice and can be employed much more frequently than previously realized. Certain f actors--particularly the nature and extent of the lesion and its location-have an important bearing on the successful application of this form of therapy. In general, aneurysms of the aorta are usually of two types, sacciform and fusiform. The former ''9
*From the Department of Surgery, Baylor University College of Medicine, and the Jefferson Davis, Veterans and Methodist Hospitals, Houston. T ~ w .
Presented before the thirtpeighth annual Assembly of the Intentate Postgraduate Medical Association at Chicago.
Aneurysms and arteriosclerotic thromboobliterative disease of the aorta constitute two of the most common and serious forms of aortic lesions for which treatment has been generdly unsatisfactory. Recently, however, a procedure has been developed wherein the lesion is extirpated and function restored by aortic repair or insertion of homografts. The gratifying results obtained by this method of therapy based on an experience with 41 cases suggests it is the most effective approach to the problem.
arise most frequently in the thoracic aorta, usually about the arch and great vessels, with syphilis being the underlying disease in most cases. Fusiform aneurysms are most commonly encountered in the abdominal aorta with arteriosclerosis as the most common underlying pathologic process. It has long been recognized' that this type of aneurysm most frequently involves the segment of abdominal aorta between the origin of the renal arteries and the bifurcation. Interestingly enough, this is also the segment of aorta most frequently involved in arteriosclerotic thrombo-obliterative disease of the aorta. The pathologic features of sacciform aneurysms of syphilitic origin include a relatively small neck and a surrounding aortic wall with a leathery consistency suitable for suture. Because of these features, excision can often b e done without encroachment upon the aortic lumen.4P7 It is accomplished by tangential occlusion of the neck of the sac with a clamp, excision of the aneurysm distal to the clamp and lateral arteriorrhaphy to repair the aortic POSTGRADUATE MEDICINE
Reprinted from February 1954 (Vol. 15, No. 2) Issue of POSTGRADUATE MEDICINE
Under these circumstances the aorta is not involved in its entire circumference by the pathologic process, and sufficient relatively normal tissue is available for satisfactory repair of the defect. A MICHAELDEBAKEY similar procedure may also be used when the aneurysm involves the major vessels of the aortic arch even though they may be fusiform in type. Because it may be necessary in such cases to sacrifice the involved vessel, it is important to determine beforehand the possible ischemic effects of occlusion of these vessels, particularly of the carotid arteries. In the resection of fusiform aneurysms of the aorta the problem is somewhat different, because such lesions usually involve the entire circumference of the aorta for a varying distance. Accordingly, extirpation of these lesions requires excision of a varying segment of the aorta itself along with the aneurysm. Under these circumstances, temporary arrest of the circulation in the aorta distal to the origin of the aneurysm must be done during aneurysmectomy, and the resulting defect in the aorta must be bridged to restore normal circulation. This may be accomplished satisfactorily by means of preserved aortic homografts. Various methods of preservation may be used for this purpose. In our early experience the homografts were preserved in nutrient media at a temperature of 0 to 4" C. More recently, however, in the last 26 cases, we have used freeze-dried aortic homografts and have been impressed with the advantages of this method of preservation. An important consideration in the performance of this procedure is the potential ischemic effects of the temporary arrest of the circulation on the tissues distal to the point of occlusion, especially in the spinal cord and kidneys. The safe period for occlusion of the aorta at this level has not been accurately determined, but, on the basis of our limited experience5*? February 1954
DENTON A. COOLEY
and that of others' with a few c rysms of the descending been found possible to occlud aorta for periods up to 58 evidence of cord or renal damage. ly, moet aneurysms requiring this arise in &e abdominal aorta below of the i d arteries, and there is cient margin of aorta between and the aneurysm to permit applica occluding clamp without flow to the kidneys. Occlusion at for periods averagin one case as long as followed by any evidence of ischemic ch in the pelvis or lower extr is of little or no import literative disease of the aorta because of the wellestablished collateral circulation. Technical considerations of the operative procedure of resection of aneurysms of the aorta with replacement by aortic homografts A left thohave been previously presented!'? racoabdominal approach through the resected bed of the ninth or tenth rib is used for aneurysms involving the lower thoracic and upper abdominal aorta. For aneurysms arising in the abdominal aorta below the origin of the renal arteries an abdominal approach through a midline incision is preferred. The application of this procedure may be illustrated by the following brief case report: Case 1-W. M., a 73 year old iceman, was admitted to the hospital on September 16, 1953, complaining of pain and a pulsating mass in the abdomen. Five years previously he was seized, while at work, with a severe abdominal pain which 121
caused him to fall to the ground. The pain lasted about 30 minutes. Shortly thereafter, the patient detected a pulsating mass in the abdomen which “felt like my heart had fallen into my belly.” For two years he had suffered from hemorrhoids and rectal prolapse. Physical examination revealed that the patient was well nourished and vigorous in appearance. Blood pressure was 140/80. The cardiorespiratory systems were normal. The abdomen was slightly protuberant, and a pulsating mass was visible in midabdomen to the left of the midline. Palpation revealed this mass to be approximately 20 by 12 cm. in size. Its superior margin extended into the epigastrium and beneath the left costal margin, and inferiorly, it extended into the suprapubic region. Pulsations were expansile. A systolic murmur was audible over the mass. Aiterial pulses were present in the lower extremities. Rectal examination disclosed external and internal hemorrhoids and a moderate rectal prolapse. Diagnoses were as follows: (1) aneurysm of the abdominal aorta; ( 2 ) hemorrhoids and rectal prolapse. Results of blood and urine examinations were normal. A roentgenogram of the abdomen showed calcification in the wall of the aneurysm and indicated that from the superior limits of the calcification the aneurysm arose below the renal arteries. On September .24, 1953, an operation was performed with the patient under general anesthesia. The abdomen was opened through a midline incision centered on the umbilicus. A. large fusiform aneurysm of the abdominal aorta was found which extended from the renal arteries distally to include the aortic bifurcation (figure 1). The posterior parietal peritoneum was incised and the ligament of Treitz divided. The aorta was freed just below the renal vessels, and both common iliac arteries were isolated. The occluded inferior mesenteric artery was divided. The aorta above and the iliac arteries below the aneurysm were occluded with vascular clamps, and the aneurysm was excised (figure 2 ) . The defect in the abdominal aorta was bridged with a freeze-dried abdominal aortic homograft. Anastomosis was accomplished with a continuous over-and-over 122
suture of 0000 arterial silk (figure 3). Total time of aortic occlusion was 78 minutes. Upon completion of the aortic transplantation, bilateral lumbar sympathectomy and appendectomy were performed. Convalescence was uneventful. Within 24 hours pedal pulses were palpable. Ambulation was begun on the second postoperative day, and the patient was discharged in good condition on October 10, 1953. We have now operated on 26 consecutive cases of aneurysms of the abdominal aorta with the intention of performing this procedure, i.e., resection with replacement by aortic homograft. It was possible to perform the procedure in all but one case. This single exception concerned a patient whose fusiform aneurysm involved virtually the entire abdominal aorta. Under these circumstances aneurysmectomy would have necessitated interruption of all visceral blood supply and, accordingly, was considered impractical. In this series of 25 cases of aneurysmectomy, the majority of patients were men in the seventh decade, and 4 were over 70 years of age. The aneurysms were arteriosclerotic in origin in all but 1 case in which syphilis was considered the causative factor. The bifurcation was involved, requiring excision and the use of a bifurcation homograft in all but 3 cases. In 2 patients the aneurysm had ruptured, producing severe hemorrhage and shock, and the operations were performed as emergency procedures. Hypertension of moderate to severe degree was present in 7 patients. All 25 patients showed varying degrees of atheromatous changes and roentgenologic evidence of calcification in the aorta. On the basis of experience from this series the impression has been gained that none of the factors mentioned necessarily constitute a contraindication to operation and that major contraindications are concerned with severe impairment of vital functions, involving cardiopulmonary and renal organs. The operation itself seemed to be well tolerated by all the patients, although 5 died subsequently-2 from severe coronary disease, 2 from renal failure and progressive uremia, and 1 from pulmonary embolism. AIl of POSTGRADUATE MEDICINE
the other patients have been lieved of their sympto conditions have shorn ment. Of particular si that most of them se ment in circulation in the lower The operative procedure d aneurysms of the abdominal aort which has been termed Leriche's syndrome, or insidious thrombosis of the aortic bifurcation, apparently develops on the basis of arteriosclerotic changes with atheromatous plaques and calcified ulcerated areas in the intima leading to thrombus formation. These changes ultimately produce stenosis and as a result of the superimposed thrombotic process lead to complete occlusion of the lumen. Not infrequently, as observed by Leriche,ls*l4 these artericmclerotic changes begin in the iliac arteries near the bifurcation with progressive thrombus formation propagating upward to occlude completely the aortic lumen. In some instances, this obliterative process progressively extends up as high as and even above the origin of the renal arteries, resulting in death from hypertensive cardiovascular disease and uremia. The disease is characterized by an insidious. and slowly progressive development with symptoms of intermittent claudication, pain, easy fatigability particularly in the hips and legs, and sexual impotency. Physical findings include manifestations of arterial ins&ci in the lower extremities with absence of sations and usually a systolic murmur in the
1 (top). Photograph taken during operation in case 1, showing huge aneurysm of abdominal aorta after it had been freed from surrounding structures. Umbilical tapes are shown encircling the aorta above the aneurysm and the common iliac arteries below.
(center). Photograph of aneurysm of abdominal aorta after excision in case 1, showing stumps of iliac arteries on left and additional segment of excised aorta on right, and revealing extensive atheromatous changes.
3 (bottom). Photograph made at operation in case 1 after resection of aneurysm of abdominal aorta and completed anastomosis of bifurcation aortic homograft to aorta proximally and iliac arteries distally.
abdomen. The diagnosis may be readily confirmed by aortography (figure 4). Although the condition is slowly progressive, sometimes over a period of 5 or 10 years, the ultimate prognosis is grave with most patients dying of the complications of the disease. Until relatively recently, treatment has not been satisfactory and, at best, is palliative. It consists essentially of lumb tomy?*10*14,16*1' Thrombo-en designed to remove the disea restore a normal arterial lumen better results in some instance perience, however, mural chan ally been so extensive about the to preclude the use of this pro these circumstances. For this re tion of the diseased segment. of continuity by aortic homograft, as originally proposed by Leriche, is believed to provide a more effective therape the problem. The successful ap procedure is illustrated by the case report: Case 2--5. M.,a 58 year was admitted to the hospital 1953, complaining of abdo stools, and cramping pain in the lower extremities. The patient had been under medical treatment for a duodenal ulcer since 1937 and had been hospitalized several times for intractable pain. In recent months he had noted tarr stools on several occasions. In 19443, cramping *
Urinalysis and hemogram were within normal limits. Barium study of the upper gastro124
intestinal tract revealed a duodenal ulcer. Translumbar aortography showed occlusion of the abdominal aorta and common iliac arteries from a point just below the renal arteries (figure 4 ) . On October 15, 1953, an operation was performed under continuous spinal anesthesia. The peritoneal cavity was entered through a midline incision extending from just below the xiphoid to well below the umbilicus. The preoperative diagnoses of duodenal ulcer and aortic thrombosis were confirmed. A 70 per cent gastric resection and a Billroth I gastroduodenostomy were performed first. The posterior parietal peritoneum was then incised, the ligament of Treitz divided, and the aorta and iliac arteries mobilized. The occluded inferior mesenteric artery was divided between ligatures. Clamps were applied to the aorta slightly below the renal arteries and to the common iliac arteries, and the aorta and bifurcation were removed (figures 5 and 6).
4. Aortogram in case 2, showing complete occluaorta beginning just below the sion of the origin of the renal arteries. FIGURE
5. Photograph taken during operation in cam 2, showing mobilized abdominal aorta with umbilical tapes encircling iliac arteries below and aorta above, immediately below overlying left renal vein. Note roughened irregular surface of aorta and dense periaortic fibrosis.
FIGURE 6. Photograph of excised segment of abdominal aorta and bifurcation in case 2, showing complete occlusion of lumen and additional segment of organized thrombus projecting above level of divided aorta and removed from proximal aortic stump.
7. Photograph made at oparation in case 2 after resection of obliterated segment of aorta and replacement with aortic homograft. FIGURE
The proximal aortic lumen was found to be partially occluded by an atheromatous plaque and a soft thrombus. Therefore, a clamp was applied above the renal arteries, the atheroma and thrombus removed, the lumen flushed with saline solution, and a clamp reapplied below the renal arteries; then the clamp abovc the renal arteries was removed. The lumens of the iliac arteries were occluded by organized thrombi. They were stripped out of the lumen distally to the iliac bifurcations where vigorous back flow was encountered. A reconstituted, freeze-dried homologous aortic Y graft was inserted into the defect, using a continuous over-and-over suture of 0000 arterial silk (figure 7 ) . The total time of aortic occlusion was one hour. Following removal of the 126
clamD. Dulsations were detectable in both femoral arteries. Bilateral lumbar sympathectomy - dectomy were performed following the completion of the aortic graft. Within 24 hours after operation bounding pedal pulses were present. Convalescence was uneventful except for a moderate degree of postural hypotension which was relieved by compression bandages applied to the lower extremities. We have now employed this procedure in 11 cases of arteriosclerotic thrombo-obliterative disease of the aorta. In one of the patients the obliterative process was located in the lower thoracic and upper abdominal aorta, and in the remainder of the patients it inI
volved the terminal portion of the aorta and bifurcation. All of these patients recovered; most of them showed striking improvement in circulation of the lower extremiti pulses and disap of arterial insufEc these 36 cases of ease of the abdormn tion and replacement wi aortic homografts, we have used this proce-
3. This procedure of e
s series. All of the other patients ing improvement or complete relief of symptoms. ’ 4. Although further experience and longer ns are required for final
racic aorta. Two of these patients
1. Aneurysms and arteriosclerotic thromboobliterative disease of the aorta constitute serious disorders that ultimately produce disabling symptoms and lethal complications for which treatment has been generally unsatisfactory and, at best, palliative. The recent development, however, of a procedure directed toward extirpation of the lesion and restoration of function by aortic repair or insertion of aortic homografts is believed to provide a more effective form of therapy. 2. The successful application of this form of therapy is dependent primarily on the type, extent and location of the lesion. Sacciform aneurysms, for example, which usually involve the thoracic aorta and in which the neck is relatively small and the surrounding aortic wall is suitable for suture, may be excised by tangential occlusion of the neck and lateral aortorrhaphy. Fusiform aneurysms, on the other hand, because of their tendency to involve the entire circumference of the aorta for a varying distance, usually necessitate excision of a segment of the aorta itself with replacement by aortic homograft to restore normal circulation. A similar procedure may also be employed in thrombo-obliterative disease of the aorta.
6. 7. 8.
10. 11. 12.
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