The Surgical Treatment of Acquired Aneurysm of the Thoracic Aorta

Abstract

The surgical treatment of an aneurysm of the abdominal aorta is a well-established procedure with fairly clear-cut indications and limitations. Treatment of an aneurysm of the thoracic aorta, on the other hand, is a more hazardous procedure that requires partial or total cardiac bypass with hypothermia, either moderate or profound, with or without local cooling of the heart. The reason for this is that the aortic valves, the coronary arteries, and the three major vessels supplying the head, neck, and upper limbs are frequently involved by the disease. In consequence, special perfusion techniques are required to maintain adequate cardiac, brain, and spinal cord function during a prolonged procedure lasting several hours.In this paper we describe the surgical results in eight consecutive patients with aortic aneurysm. In four of these the ascending aorta was involved with varying degrees of associated aortic incompetence in two, erosion of the sternum and ribs in two, involvement of the innominate artery in one, perforation into the superior vena cava in one, and obstruction of the pulmonary artery and right ventricle in one. In four, varying lengths of the descending aorta were involved, the proximal aorta being affected in three of the four patients, with involvement of the lung and/or thoracic vertebrae in all. Two of these patients had no associated aortic incompetence.CASE REPORTS CASE 1 V.M., a coloured man of 44 years, was admitted on 2 May 1961 in severe distress. Mild inconstant central chest pain, radiating to the shoulders, and dysphagia had commenced fairly acutely one month before. On the day his symptoms began his wife noticed swelling of his face and the right side of his neck, followed by bilateral jugular venous distension. Severe effort dyspnoea and orthopnoea developed rapidly and persisted after the pain and dysphagia had disappeared. Severe bilateral shoulder pain then recurred, requiring admission elsewhere and pethidine administration.At this stage the clinical picture of superior mediastinal obstruction was present, and a continuous murmur was audible in the right parastemal and aortic areas. Treatment with iodide, mercury, penicillin, and mercurial diuretics was begun. When he continued to deteriorate he was referred to the cardiac clinic.On examination he was almost moribund. The face, neck, upper trunk, and upper limbs were very oedematous. The veins draining into the superior vena cava were dilated and non-pulsatile. The blood pressure in both arms was equal, 165/80 mm. Hg. There was no cardiomegaly and no valve murmurs. In the right lower neck and intraclavicular area a continuous thrill and murmur indicative of an arterio-venous fistula was present.Moderate hepatomegaly was noted. The electrocardiogram showed right ventricular dilatation and on radiography (Fig. IA) the superior mediastinal shadow was widened.The diagnosis of ruptured aortic aneurysm into the superior vena cava or innominate vein was made and immediate surgery advised. The serology was positive for syphilis, the sedim...

History of reconstructive surgery of aorta and aortic valve

“…Впер-вые для резекции мешковидной аневризмы 14 сентяб-ря 1961 г. этот метод применили Christiaan Neethling Barnard и Velva Schrire [54]. Чрездвуплевральным досту-пом обнажена дуга аорты с аневризмой.…”

Thoracic aneurysms

“….. shunts, cardiopulmonary bypass, perhaps with profound hypothermia in order to maintain cerebral, cardiac and renal viability whilst the aorta is. excised and a graft sutured in position (Barnard & Schrire, 1963).…”

Retrograde cerebral perfusion for brain protection in aortic aneurysm surgery

“…After the introduction of deep hypothermic circulatory arrest (DHCA) for surgical correction of complex lesions of ascending aorta and arch of aorta in 1963, DHCA became the main modality of cerebral protection in these cases [1]. Despite the use of DHCA, the incidence of neurological events continued to be prohibitively high.…”

“…Use of retrograde cerebral perfusion (RCP) may provide additional protection for brain viability. RCP is supposed to uniformly cool the brain, provide metabolic support, remove particulate matter and reduce the incidence of air emboli [1,2].…”