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Aneurysm of the bifurcation of the innominate artery
.,__^_
CASE REPORTS-*
Aneurysm SUCCESSFUL
of the Bifurcation Innominate Artery
EXCISION
HAROLDA.ZINTEL,M.D.
AND RESTORATION AND
of the
OF THE
EARLC.RISBECK,M.D.,
CAROTID
New York,New
ARTERY York
From the Surgical Service, St. Luke’s Hospital, New York, New York.
tion of blood Aow in the carotid artery in a lesion of the bifurcation of the innominate artery.
NEURYSMS of the innominate artery occur infrequently. In 1950, Gordon-TayIor reviewed the literature and reported on a tota of fifty-two patients with aneurysms of the innominate artery treated by surgery [I]. Only twenty-six of these patients had lesions similar to that of the patient we are reporting on herein, these patients having had aneurysms of the distaI end or bifurcation of the innominate artery. The patients reported on by GordonTaylor were all treated by Iigation of the major vessel or vesseIs. In two patients, the aneurysm was divided also. Almost half the patients reported on died during the immediate postoperative period. Death was usually the result of cerebra1 ischemia or rupture of the aneurysm. Three survivors had puIsating Iesions immediately postoperatively. It is interesting to note that of the several surviving patients in whom recurrent lesions were known to have developed late, evidence of recurrence in one patient did not develop until ten years postoperatively. Modern medical thinking dictates that ideal therapy for these lesions should be by methods which excise the diseased arterial tissue and restore adequate bIood ffow to the head and upper extremity. ExceIIent resuIts have been reported in a few patients folIowing such therapy in Iesions of the innominate, subcIavian and carotid arteries. We have not found a report of successful resu1t.s in restora-
CASE REPORT
A
D. J. S. (No 314-568),a fifty year oId Negro man, was admitted to St. Luke’s HospitaI on August 18, 1956, with the compIaint of weakness and numbness of the Ieft arm, and weakness of the Ieft Ieg of three days’ duration. For the same period of time he had had miId, but constant, frontal headache. Initially, the weakness was suffcient to prevent waIking and grasping objects with the Ieft hand. At the time of admission he could waIk without assistance. The numbness in the arm had disappeared compIeteIy, and he couId hold objects in his Ieft hand. The patient stated that he had been in good health unti1 eight years prior to admission when he noted a painless mass the size of a goIf bal1 on the right side of the neck. (Fig. I.) This mass remained stationary in size unti1 four months before admission when it had rapidIy become larger associated with some IocaI pain. For several years the patient had noted progressive hoarseness and Iack of sweating on the right side of the face. The patient denied venereal disease but stated he had had a course of injections at another hospital some years ago. He denied dysphagia, weight loss, or respiratory diffIcuIty. On admission physical examination revealed the patient to be we11 nourished and deveIoped. BIood pressure was 160/80 mm. Hg in the left arm and 120/80 mm. Hg in the right. Pulse, respirations and temperature were within norma Iimits. In the right supracIavicuIar area a mass measuring 20 by 13 cm. was noted. This mass was puIsatiIe in the IateraI as we11 as anteroposterior axis, and a
929
Amrricon Journal of Surgery. Volume gg. June.
Ig6o
ZinteI and Risbeck Laboratory examination revealed that the hemogIobin IeveI, red bIood ceI1 count, differentia1 white bIood ceI1 count, bIood sugar and bIood urea nitrogen were within norma limits. UrinaIysis showed a trace of aIbumin and 15 to 20 white blood ceIIs per high power fieId. BIood voIume was normal was 4,800 cc. The 4,400 cc.9 caIcuIated resuIts of the seroIogic tests for syphiIis were as foIIows: Mazzini, 3 pIus; Kahn, 3 PIUS; and KoImer, 4 plus. SpinaI fluid by lumbar puncture demonstrated no ceIIs. The spinal fluid contained 61 mg. per cent sugar; 197 mg per cent protein; 122 mg. per cent chloride. The resuIt of the Wasserman test was 4 pIus. An electrocardiogram showed deviation of the Ieft axis and non-specific myocardia1 changes. X-ray examination of the chest revealed the Iung fieIds to be cIear and the cardiac siIhouette enIarged with prominence of the Ieft ventricle and a soft tissue mass to the right of the trachea, deflecting this structure to the left. An x-ray fiIm of the neck demonstrated some caIcification of the lateral aspect of the soft tissue mass on the right side of the neck. Prior to operation the patient was given 12,000,000 units of peniciIIin for syphiIis over a period of seven days, and the bIood voiume was restored to norma by transfusion. SeveraI IyophiIized homografts and Tapp grafts were avaiIabIe to bridge the defect foIlowing excision of the aneurysm or to bypass the Iesion either temporariIy or permanentIy. On September 13, 1956, with the patient under endotrachea1 ether anesthesia an L-shaped incision was made on the right side of the neck and chest. (Fig. 2.) The upper limb of the incision was made aIong the media1 border of the sternocIeidomastoid muscle from the mastoid process to the IeveI of the third intercosta1 space. The Iower Iimb extended IateraIIy aIong the level of the third intercostal space to the nippIe Iine. The manubrium and upper sternum were spIit, and the third intercostal space entered. The insertions of the right strap muscles and sternocIeidomastoid muscle were divided. This aIIowed the cIavicIe and first and second ribs to be retracted IateraIIy, providing access to the structures in the upper right superior mediastinum and base of the neck. The anterior surface of the Iesion was exposed by sharp and bIunt dissection. The appearance of the Iesion on exposure is shown in Figure 2. Tapes to be used as tourniquets were IooseIy applied around the innominate and common carotid artery above and below the lesion. The interna juguIar vein was divided and Iigated above and beIow the aneurysm because it was denseIy adherent to the IateraI aspect of the aneurysmal sac. During the course of dissection the aneurysm ruptured, and the previously placed tapes were tightened to contro1 the hemorrhage. A cIamp was pIaced across the subclavian artery as it emerged
FIG. I. Mass on right side of neck first noted eight years before patient’s admission to hospital.
bruit was audibIe over the media1 aspect. The mass extended from beneath the right cIavicIe upward beneath the sternocIeidomastoid muscIe deflecting this muscle IateraIIy. The mass deflected the trachea to the Ieft, and rotated the anterior aspect of the Iarynx approximately 45 degrees to the Ieft. The externa1 juguIar vein on the right side was quite distended when the patient was in the sitting position. There was no paIpabIe cervica1 Iymphadenopathy. Examination of the chest reveaIed the lungs to be cIear except for some diminished breath sounds at the right apex. The heart appeared to be enIarged to the Ieft with the point of maximum impuIse in the sixth intercosta1 space, z cm. IateraI to the nippIe Iine. NeuroIogic examination reveaIed a Horner’s syndrome of the right eye with a fixed smaI1 pupil and ptosis of the lid. There was a Ieft homonymous hemianopsia. There was partial sensory Ioss, most marked in the Ieft arm but also present in the Ieft Ieg, and slight weakness of a11 muscIe groups on this side. Hyperreffexia was present on the Ieft side of the body. There was a Ioss of abduction of the right voca1 cord. Examination of the abdomen reveaIed no abnorma1 findings. PeripheraI puIses were paIpabIe and equa1 in both upper and Iower extremities. On the right anterior chest waI1, extending in from the right upper arm, was a Iarge, tortuous, diIated vein. AI1 veins of the right arm were prominent and did not empty normaIIy when the arm was eIevated.
930
Aneurysm
of Bifurcation
of Innominate
Artery
FIG. 2. Artist’s drawing of Iesion on exposure.
cyanotic. Within tweIve hours the arm was warm aIthough no pulse was paIpabIe. FoIIowing the administration of PriscoIine,@ normal skin color and a weak brachia1 puIse were restored. Sensory and motor functions of the right arm were normal. There was no progression of the preoperative neuroIogic changes of the left extremities. For two weeks moderate amounts of serosanguinous fluid were drained from the patient’s neck. StaphyIococcus albus organisms were curtured from the fluid that was drained. AIbamycin” therapy was instituted and continued for severa days until excessive drainage ceased. The patient was discharged from the hospital on October 27, 1956, with a heaIed wound. Subsequent examinations in the SurgicaI FoIIowup Clinics over a period of three years revealed no recurrence of the mass in the neck. There has been no appreciabIe change in the neuroIogic deficit the patient had presented immediateIy preoperatively.
from the aneurysm, and the aneurysm was excised except for a 3 cm. diameter portion of the densely adherent posterior waII which was Ieft in place. Because of the great eIongation of the common carotid artery as it was stretched out over the anterior surfaces of the aneurysma sac, this vesse1 could be brought down to the divided innominate artery and anastomosed to it end to end without tension. The difference in size of the two vesseIs was not dificuIt to manage. The proxima1 end of the subcIavian artery was Iigated. IdeaIIy, bIood Aow in the subcIavian artery shouId also have been restored. However, in this aIready seriousIy iI patient, we believed that to attempt to restore the function of this vesse1 might produce further cerebra1 damage. The Iength of time required to compIete the anastomosis and restore circuIation to the common carotid artery after the tape ligatures had been tightened was twenty-four minutes. A catheter was placed in the eighth intercostal space and connected to underwater drainage. The general area of the aneurysm sac was drained with a cigarette drain pIaced we11 above the site of the anastomosis and exteriorized through the stab wound in the anteroIatera1 aspect of the neck. ImmediateIy after cIosure of the wound, the skin of the patient’s right arm was cool and’sIightIy
COMMENTS
Aneurysms of the common innominate arteries are reIativeIy cases previousIy reported, over were syphilitic in origin [I].
93’
carotid and rare. Of the go per cent
In untreated
Zintel and Risbeck patients the major comphcation was usuaIIy hemipIegia and/or spontaneous rupture. HemipIegia may resuIt from emboIi or possibIe tota occIusion of the carotid artery. In the past, methods of treatment have incIuded: (I) simpIe Iigation of the artery above and beIow the Iesion, either simuItaneousIy or in stages; (2) partia1 occIusion of the proxima1 artery; (3) dista1 ligation of the interna and externa1 carotid arteries; (4) excision of the aneurysms foIIowing Iigation above and beIow the Iesion; and (5) wrapping the aneurysm with various substances such as ceIIophane. In a11 these methods the incidence of postoperative neuroIogic compIications or subsequent rupture of the aneurysm is high. The incidence of hemipIegia foIIowing Iigation of the common carotid artery varies from 70 per cent as reported by Watson and SiIverstone i’n studies performed of patients with cancer of the head and neck [2] to 15 to 25 per cent as described by Brackett [3]. Because of this high incidence of hemiplegia it is apparent that some method of predicting this disastrous compIication would be of great heIp to the surgeon if Iigation of the carotid artery seemed necessary. SeveraI rather simpIe tests have been devised to determine the abiIity of the patient to toIerate Iigation or temporary occIusion of the common carotid artery. Apparently, none of them are compIeteIy reIiabIe inasmuch as the patient may have permanent cerebra1 damage despite the fact that the resuIts of a test indicate that the circuIation of the carotid artery couId be temporarily or permanentIy occIuded. The abiIity of patients to toIerate temporary or permanent OccIusion, of course, varies from patient to patient. One method of evaIuating the abiIity of the patient to withstand Iigation of the common carotid artery is described by Johnson [4]. This method consists of pressure readings in the interna carotid artery before and after temporary occlusion of the common carotid artery. FolIowing occIusion of the common carotid artery eIeven patients showing a faI1 in pressure of less than 60 per cent in the internal carotid artery had no hemiplegia foIIowing ligation of the common carotid artery. Three of five patients who had a faI1 of more than 60 per cent in the pressure in the internal carotid artery had hemipIegia folIowing Iigation of the common carotid artery. Spencer [5] suggested a method of occIusion of the common carotid artery for not more than
932
forty minutes, with the patient under IocaI anesthesia which appears to be appIicabIe to those cases in which reconstitution of bIood flow in the carotid artery by means of graft or primary anastomosis is anticipated. If neuroIogic signs appear in Iess than forty minutes, the bIood ffow is immediateIy restored. If no neuroIogic signs deveIop in forty minutes it is unIikeIy that they wouId develop during a Ionger period of occlusion. This test wouId aid in determining whether or not the patient will toIerate occlusion of the artery for sufficient time to compIete the anastomosis. Hemiplegia does not seem to develop as a Iate compIication if the bIood ffow is adequateIy restored. If transient hemipIegia deveIops folIowing occIusion of the common carotid artery, since by Spencer’s test the anastomosis must be compIeted in Iess time than that required to produce transient hemiplegia, then a shunt bypass technic described by Mahorner and Spencer [a may be used. The danger of embolic phenomena in patients with aneurysms of the carotid artery is iIIustrated we11 by the case we have reported herein. Left hemiparesis which actuaIIy necessitated hospitaIization was due probably to an embolus or emboIi entering the right hemisphere from the aneurysm. This compIication is worthwhiIe remembering when deciding how soon a lesion shouId be operated upon. Another feature iIIustrated by the case reported herein is that the common carotid artery may become eIongated by being stretched out over the aneurysm so that interposition of a graft may not be necessary to restore continuity once the aneurysm is excised. In this case the aneurysm had dissected beneath the common carotid artery, elevating and eIongating it so its proxima1 end couId easiIy be brought down to the innominate artery for primary anastomosis. AIso iIIustrated by this case is the fact that a Iong norma segment of artery may be buried within the substance of the faIse aneurysm giving the erroneous impression of being invoIved in a rather Iong fusiform aneurysm. Spencer [4] has indicated this possibiIity and suggests opening the aneurysm prior to proximal and distal transection to determine the extent of the Iesion and prevent unnecessary sacrifice of norma artery. Obviously, preservation of this Iength may permit primary anastomosis without the use of a graft, and reduce the
Iength of operating time, period of occIusion of
Aneurysm
of Bifurcation
bIood flow and, of course, danger of permanent cerebral damage. In the treatment of vascular tumors of intracranial vessels and cancer of the head and neck technics of graduaI occlusion of the common carotid artery have been used with a reduction of neurologic comphcations. This same technic could be tried in the treatment of an aneurysm of the common carotid artery if primary anastomosis or grafting cannot be performed. In our patient, the location and angutation of the carotid artery dista1 to the aneurysm and its compression by the aneurysm would suggest that bIood flow through this vesse1 might have been diminished preoperatively. Such diminution of ffow on the affected side usuahy leads to development of colIatera1 ffow from the opposite side through the external carotid and intracerebrai pathways. This factor may we11account for the lack of progression of neurologic findings during the period of surgica1 occlusion in our patient as we11 as in other patients with partial occIusion due to a disease process.
of Innominate
Artery
minutes of occIusion. The subcIavian artery was sacriliced. The complication of hemipIegia following ligation of the common carotid artery is discussed. Methods of evaluating the likelihood of the deveIopment of hemipIegia are also briefly discussed. Early operative intervention is advocated to prevent cerebral damage from emboh. Early intervention is also easier when the lesion is smaI1 and has not greatly distorted the vesse1 and its surrounding structures. Attention is directed again to the advisability of entering the aneurysm prior to its excision to determine the limits of the diseased vesseI and prevent unnecessary resection of normal artery, thus reducing the chance of primary anastomosis. REFERENCES
GORDON-TAYLOR, G. The surgery of the innominate artery with special reference to aneurysm. &it. J. Surg., 148: 25, xg5o. 2. WATSON, W. L. and SILVERSTONE,S. M. Ligature of the common carotid artery in cancer of the head and neck. Ann. Surg., dog: I, 1939. 3. BIUCKE~, C. E. The complication of carotid artery ligation in the neck. J. Neurosurg., IO: gr, 1953. 4. JOHNSON,A. C. CervicaI intracarotid pressure studies. Their significance in management of intracranial aneurysm. Surgery, 33: 537, 1953. SPENCER, F. C. Aneurysm of the common carotid artery treated by excision and primary anastomosis. Ann. Surg., ‘45: 254. 1957. 6. MAHORNER, H. and SPENCER, R. Shunt grafts. Ann. Surg., 139: 439, 1954. I.
SUMMARY
A case of syphilitic aneurysm of bifurcation of the innominate artery is presented. The aneurysm was resected, and primary anastomosis of the common carotid to the innominate artery was performed during twenty-four
933
CASE REPORTS-*
Aneurysm SUCCESSFUL
of the Bifurcation Innominate Artery
EXCISION
HAROLDA.ZINTEL,M.D.
AND RESTORATION AND
of the
OF THE
EARLC.RISBECK,M.D.,
CAROTID
New York,New
ARTERY York
From the Surgical Service, St. Luke’s Hospital, New York, New York.
tion of blood Aow in the carotid artery in a lesion of the bifurcation of the innominate artery.
NEURYSMS of the innominate artery occur infrequently. In 1950, Gordon-TayIor reviewed the literature and reported on a tota of fifty-two patients with aneurysms of the innominate artery treated by surgery [I]. Only twenty-six of these patients had lesions similar to that of the patient we are reporting on herein, these patients having had aneurysms of the distaI end or bifurcation of the innominate artery. The patients reported on by GordonTaylor were all treated by Iigation of the major vessel or vesseIs. In two patients, the aneurysm was divided also. Almost half the patients reported on died during the immediate postoperative period. Death was usually the result of cerebra1 ischemia or rupture of the aneurysm. Three survivors had puIsating Iesions immediately postoperatively. It is interesting to note that of the several surviving patients in whom recurrent lesions were known to have developed late, evidence of recurrence in one patient did not develop until ten years postoperatively. Modern medical thinking dictates that ideal therapy for these lesions should be by methods which excise the diseased arterial tissue and restore adequate bIood ffow to the head and upper extremity. ExceIIent resuIts have been reported in a few patients folIowing such therapy in Iesions of the innominate, subcIavian and carotid arteries. We have not found a report of successful resu1t.s in restora-
CASE REPORT
A
D. J. S. (No 314-568),a fifty year oId Negro man, was admitted to St. Luke’s HospitaI on August 18, 1956, with the compIaint of weakness and numbness of the Ieft arm, and weakness of the Ieft Ieg of three days’ duration. For the same period of time he had had miId, but constant, frontal headache. Initially, the weakness was suffcient to prevent waIking and grasping objects with the Ieft hand. At the time of admission he could waIk without assistance. The numbness in the arm had disappeared compIeteIy, and he couId hold objects in his Ieft hand. The patient stated that he had been in good health unti1 eight years prior to admission when he noted a painless mass the size of a goIf bal1 on the right side of the neck. (Fig. I.) This mass remained stationary in size unti1 four months before admission when it had rapidIy become larger associated with some IocaI pain. For several years the patient had noted progressive hoarseness and Iack of sweating on the right side of the face. The patient denied venereal disease but stated he had had a course of injections at another hospital some years ago. He denied dysphagia, weight loss, or respiratory diffIcuIty. On admission physical examination revealed the patient to be we11 nourished and deveIoped. BIood pressure was 160/80 mm. Hg in the left arm and 120/80 mm. Hg in the right. Pulse, respirations and temperature were within norma Iimits. In the right supracIavicuIar area a mass measuring 20 by 13 cm. was noted. This mass was puIsatiIe in the IateraI as we11 as anteroposterior axis, and a
929
Amrricon Journal of Surgery. Volume gg. June.
Ig6o
ZinteI and Risbeck Laboratory examination revealed that the hemogIobin IeveI, red bIood ceI1 count, differentia1 white bIood ceI1 count, bIood sugar and bIood urea nitrogen were within norma limits. UrinaIysis showed a trace of aIbumin and 15 to 20 white blood ceIIs per high power fieId. BIood voIume was normal was 4,800 cc. The 4,400 cc.9 caIcuIated resuIts of the seroIogic tests for syphiIis were as foIIows: Mazzini, 3 pIus; Kahn, 3 PIUS; and KoImer, 4 plus. SpinaI fluid by lumbar puncture demonstrated no ceIIs. The spinal fluid contained 61 mg. per cent sugar; 197 mg per cent protein; 122 mg. per cent chloride. The resuIt of the Wasserman test was 4 pIus. An electrocardiogram showed deviation of the Ieft axis and non-specific myocardia1 changes. X-ray examination of the chest revealed the Iung fieIds to be cIear and the cardiac siIhouette enIarged with prominence of the Ieft ventricle and a soft tissue mass to the right of the trachea, deflecting this structure to the left. An x-ray fiIm of the neck demonstrated some caIcification of the lateral aspect of the soft tissue mass on the right side of the neck. Prior to operation the patient was given 12,000,000 units of peniciIIin for syphiIis over a period of seven days, and the bIood voiume was restored to norma by transfusion. SeveraI IyophiIized homografts and Tapp grafts were avaiIabIe to bridge the defect foIlowing excision of the aneurysm or to bypass the Iesion either temporariIy or permanentIy. On September 13, 1956, with the patient under endotrachea1 ether anesthesia an L-shaped incision was made on the right side of the neck and chest. (Fig. 2.) The upper limb of the incision was made aIong the media1 border of the sternocIeidomastoid muscle from the mastoid process to the IeveI of the third intercosta1 space. The Iower Iimb extended IateraIIy aIong the level of the third intercostal space to the nippIe Iine. The manubrium and upper sternum were spIit, and the third intercostal space entered. The insertions of the right strap muscles and sternocIeidomastoid muscle were divided. This aIIowed the cIavicIe and first and second ribs to be retracted IateraIIy, providing access to the structures in the upper right superior mediastinum and base of the neck. The anterior surface of the Iesion was exposed by sharp and bIunt dissection. The appearance of the Iesion on exposure is shown in Figure 2. Tapes to be used as tourniquets were IooseIy applied around the innominate and common carotid artery above and below the lesion. The interna juguIar vein was divided and Iigated above and beIow the aneurysm because it was denseIy adherent to the IateraI aspect of the aneurysmal sac. During the course of dissection the aneurysm ruptured, and the previously placed tapes were tightened to contro1 the hemorrhage. A cIamp was pIaced across the subclavian artery as it emerged
FIG. I. Mass on right side of neck first noted eight years before patient’s admission to hospital.
bruit was audibIe over the media1 aspect. The mass extended from beneath the right cIavicIe upward beneath the sternocIeidomastoid muscIe deflecting this muscle IateraIIy. The mass deflected the trachea to the Ieft, and rotated the anterior aspect of the Iarynx approximately 45 degrees to the Ieft. The externa1 juguIar vein on the right side was quite distended when the patient was in the sitting position. There was no paIpabIe cervica1 Iymphadenopathy. Examination of the chest reveaIed the lungs to be cIear except for some diminished breath sounds at the right apex. The heart appeared to be enIarged to the Ieft with the point of maximum impuIse in the sixth intercosta1 space, z cm. IateraI to the nippIe Iine. NeuroIogic examination reveaIed a Horner’s syndrome of the right eye with a fixed smaI1 pupil and ptosis of the lid. There was a Ieft homonymous hemianopsia. There was partial sensory Ioss, most marked in the Ieft arm but also present in the Ieft Ieg, and slight weakness of a11 muscIe groups on this side. Hyperreffexia was present on the Ieft side of the body. There was a Ioss of abduction of the right voca1 cord. Examination of the abdomen reveaIed no abnorma1 findings. PeripheraI puIses were paIpabIe and equa1 in both upper and Iower extremities. On the right anterior chest waI1, extending in from the right upper arm, was a Iarge, tortuous, diIated vein. AI1 veins of the right arm were prominent and did not empty normaIIy when the arm was eIevated.
930
Aneurysm
of Bifurcation
of Innominate
Artery
FIG. 2. Artist’s drawing of Iesion on exposure.
cyanotic. Within tweIve hours the arm was warm aIthough no pulse was paIpabIe. FoIIowing the administration of PriscoIine,@ normal skin color and a weak brachia1 puIse were restored. Sensory and motor functions of the right arm were normal. There was no progression of the preoperative neuroIogic changes of the left extremities. For two weeks moderate amounts of serosanguinous fluid were drained from the patient’s neck. StaphyIococcus albus organisms were curtured from the fluid that was drained. AIbamycin” therapy was instituted and continued for severa days until excessive drainage ceased. The patient was discharged from the hospital on October 27, 1956, with a heaIed wound. Subsequent examinations in the SurgicaI FoIIowup Clinics over a period of three years revealed no recurrence of the mass in the neck. There has been no appreciabIe change in the neuroIogic deficit the patient had presented immediateIy preoperatively.
from the aneurysm, and the aneurysm was excised except for a 3 cm. diameter portion of the densely adherent posterior waII which was Ieft in place. Because of the great eIongation of the common carotid artery as it was stretched out over the anterior surfaces of the aneurysma sac, this vesse1 could be brought down to the divided innominate artery and anastomosed to it end to end without tension. The difference in size of the two vesseIs was not dificuIt to manage. The proxima1 end of the subcIavian artery was Iigated. IdeaIIy, bIood Aow in the subcIavian artery shouId also have been restored. However, in this aIready seriousIy iI patient, we believed that to attempt to restore the function of this vesse1 might produce further cerebra1 damage. The Iength of time required to compIete the anastomosis and restore circuIation to the common carotid artery after the tape ligatures had been tightened was twenty-four minutes. A catheter was placed in the eighth intercostal space and connected to underwater drainage. The general area of the aneurysm sac was drained with a cigarette drain pIaced we11 above the site of the anastomosis and exteriorized through the stab wound in the anteroIatera1 aspect of the neck. ImmediateIy after cIosure of the wound, the skin of the patient’s right arm was cool and’sIightIy
COMMENTS
Aneurysms of the common innominate arteries are reIativeIy cases previousIy reported, over were syphilitic in origin [I].
93’
carotid and rare. Of the go per cent
In untreated
Zintel and Risbeck patients the major comphcation was usuaIIy hemipIegia and/or spontaneous rupture. HemipIegia may resuIt from emboIi or possibIe tota occIusion of the carotid artery. In the past, methods of treatment have incIuded: (I) simpIe Iigation of the artery above and beIow the Iesion, either simuItaneousIy or in stages; (2) partia1 occIusion of the proxima1 artery; (3) dista1 ligation of the interna and externa1 carotid arteries; (4) excision of the aneurysms foIIowing Iigation above and beIow the Iesion; and (5) wrapping the aneurysm with various substances such as ceIIophane. In a11 these methods the incidence of postoperative neuroIogic compIications or subsequent rupture of the aneurysm is high. The incidence of hemipIegia foIIowing Iigation of the common carotid artery varies from 70 per cent as reported by Watson and SiIverstone i’n studies performed of patients with cancer of the head and neck [2] to 15 to 25 per cent as described by Brackett [3]. Because of this high incidence of hemiplegia it is apparent that some method of predicting this disastrous compIication would be of great heIp to the surgeon if Iigation of the carotid artery seemed necessary. SeveraI rather simpIe tests have been devised to determine the abiIity of the patient to toIerate Iigation or temporary occIusion of the common carotid artery. Apparently, none of them are compIeteIy reIiabIe inasmuch as the patient may have permanent cerebra1 damage despite the fact that the resuIts of a test indicate that the circuIation of the carotid artery couId be temporarily or permanentIy occIuded. The abiIity of patients to toIerate temporary or permanent OccIusion, of course, varies from patient to patient. One method of evaIuating the abiIity of the patient to withstand Iigation of the common carotid artery is described by Johnson [4]. This method consists of pressure readings in the interna carotid artery before and after temporary occlusion of the common carotid artery. FolIowing occIusion of the common carotid artery eIeven patients showing a faI1 in pressure of less than 60 per cent in the internal carotid artery had no hemiplegia foIIowing ligation of the common carotid artery. Three of five patients who had a faI1 of more than 60 per cent in the pressure in the internal carotid artery had hemipIegia folIowing Iigation of the common carotid artery. Spencer [5] suggested a method of occIusion of the common carotid artery for not more than
932
forty minutes, with the patient under IocaI anesthesia which appears to be appIicabIe to those cases in which reconstitution of bIood flow in the carotid artery by means of graft or primary anastomosis is anticipated. If neuroIogic signs appear in Iess than forty minutes, the bIood ffow is immediateIy restored. If no neuroIogic signs deveIop in forty minutes it is unIikeIy that they wouId develop during a Ionger period of occlusion. This test wouId aid in determining whether or not the patient will toIerate occlusion of the artery for sufficient time to compIete the anastomosis. Hemiplegia does not seem to develop as a Iate compIication if the bIood ffow is adequateIy restored. If transient hemipIegia deveIops folIowing occIusion of the common carotid artery, since by Spencer’s test the anastomosis must be compIeted in Iess time than that required to produce transient hemiplegia, then a shunt bypass technic described by Mahorner and Spencer [a may be used. The danger of embolic phenomena in patients with aneurysms of the carotid artery is iIIustrated we11 by the case we have reported herein. Left hemiparesis which actuaIIy necessitated hospitaIization was due probably to an embolus or emboIi entering the right hemisphere from the aneurysm. This compIication is worthwhiIe remembering when deciding how soon a lesion shouId be operated upon. Another feature iIIustrated by the case reported herein is that the common carotid artery may become eIongated by being stretched out over the aneurysm so that interposition of a graft may not be necessary to restore continuity once the aneurysm is excised. In this case the aneurysm had dissected beneath the common carotid artery, elevating and eIongating it so its proxima1 end couId easiIy be brought down to the innominate artery for primary anastomosis. AIso iIIustrated by this case is the fact that a Iong norma segment of artery may be buried within the substance of the faIse aneurysm giving the erroneous impression of being invoIved in a rather Iong fusiform aneurysm. Spencer [4] has indicated this possibiIity and suggests opening the aneurysm prior to proximal and distal transection to determine the extent of the Iesion and prevent unnecessary sacrifice of norma artery. Obviously, preservation of this Iength may permit primary anastomosis without the use of a graft, and reduce the
Iength of operating time, period of occIusion of
Aneurysm
of Bifurcation
bIood flow and, of course, danger of permanent cerebral damage. In the treatment of vascular tumors of intracranial vessels and cancer of the head and neck technics of graduaI occlusion of the common carotid artery have been used with a reduction of neurologic comphcations. This same technic could be tried in the treatment of an aneurysm of the common carotid artery if primary anastomosis or grafting cannot be performed. In our patient, the location and angutation of the carotid artery dista1 to the aneurysm and its compression by the aneurysm would suggest that bIood flow through this vesse1 might have been diminished preoperatively. Such diminution of ffow on the affected side usuahy leads to development of colIatera1 ffow from the opposite side through the external carotid and intracerebrai pathways. This factor may we11account for the lack of progression of neurologic findings during the period of surgica1 occlusion in our patient as we11 as in other patients with partial occIusion due to a disease process.
of Innominate
Artery
minutes of occIusion. The subcIavian artery was sacriliced. The complication of hemipIegia following ligation of the common carotid artery is discussed. Methods of evaluating the likelihood of the deveIopment of hemipIegia are also briefly discussed. Early operative intervention is advocated to prevent cerebral damage from emboh. Early intervention is also easier when the lesion is smaI1 and has not greatly distorted the vesse1 and its surrounding structures. Attention is directed again to the advisability of entering the aneurysm prior to its excision to determine the limits of the diseased vesseI and prevent unnecessary resection of normal artery, thus reducing the chance of primary anastomosis. REFERENCES
GORDON-TAYLOR, G. The surgery of the innominate artery with special reference to aneurysm. &it. J. Surg., 148: 25, xg5o. 2. WATSON, W. L. and SILVERSTONE,S. M. Ligature of the common carotid artery in cancer of the head and neck. Ann. Surg., dog: I, 1939. 3. BIUCKE~, C. E. The complication of carotid artery ligation in the neck. J. Neurosurg., IO: gr, 1953. 4. JOHNSON,A. C. CervicaI intracarotid pressure studies. Their significance in management of intracranial aneurysm. Surgery, 33: 537, 1953. SPENCER, F. C. Aneurysm of the common carotid artery treated by excision and primary anastomosis. Ann. Surg., ‘45: 254. 1957. 6. MAHORNER, H. and SPENCER, R. Shunt grafts. Ann. Surg., 139: 439, 1954. I.
SUMMARY
A case of syphilitic aneurysm of bifurcation of the innominate artery is presented. The aneurysm was resected, and primary anastomosis of the common carotid to the innominate artery was performed during twenty-four
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