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Pathologic confirmation of the principles of the thromboexclusion operation for descending aortic dissection
448
JOURNALOF VASCULARSURGERY February 1993
Letters to the Editors
intrahepatic leiomyosarcoma of the inferior vena cava (IVC) 2 that illustrates several interesting points in the management of this condition. A 54-year-old man was referred to our unit from a neighboring hospital with a 3-week history of bilateral leg edema and a mass related to his IVC that was shown on computed tomography. Inferior vena cavography revealed a lobulated mass in the IVC at the level of the renal veins, which exhibited reduced flow on duplex scanning. A transluminal biopsy of the mass performed during cavography revealed thrombus only. Superior vena cavography showed that the mass extended into the right atrium, and a transluminal biopsy obtained during this investigation suggested the presence of a smooth-muscle tumor. During laparotomy, involvement of the portal nodes was noted and these were histologically demonstrated to contain leiomyosarcoma. It was decided that the most effective palliation would be obtained by debulking the tumor without IVC resection. This was achieved by the use of extracorporeal circulation and hypothermic circulatory arrest, which allowed dissection of most of the tumor from the IVC wall via a right atriotomy and inferior vena cavotomy. The patient recovered well and received postoperative radiotherapy. This case illustrates the use of percutaneous transluminal biopsy in the preoperative diagnosis of rare venous tumors, which may allow more effective intraoperative treatment. The use of extracorporeal circulation with circulatory arrest is a well-documented technique for facilitating resection of tumors that extend into the right atrium 3 and was invaluable in this case. Finally, the role of surgery in palliation of leiomyosarcoma of the venous system should not he forgotten, especially if there is imminent danger of hepatic venous occlusion. Surgical palliation may be successful because of the slow-growing nature of these tumors.
extending into the heart via the inferior vena cava. Surgery 1981;89:604-11. 24/41/41178
Pathologic confirmation of the principles o f the thromboexclusion operation for descending aortic dissection To the Editors:
The thromboexclusion approach to descending aortic dissection has evolved out of the dissatisfaction with currently accepted surgical techniques that interpose a prosthetic graft in the region of the intimal tear. 1,2 The standard operation does not exclude aortic blood flow from the involved descending aorta and requires administration of heparin and aortic cross-clamping. The concept of thromboexclusion as developed by Carpentier proposes a rerouting of blood from the ascending aorta to the
21/I. M. Thompson R. K. Firmin A. A. Bolia T. R. Graham P. I~ F. Bell
Department of Surgery Clinical Sciences Building Leicester Royal Infirmary Leicester LE2 7LX United Kingdom
REFERENCES 1. Dzsinich C, GloviczkiP, van Heerden JA, et al. Primary venous leimyosarcoma: a rare but lethal disease. J VAsc SURG 1992;15:595-603. 2. Thompson MM, Graham TR, Bolia AA, Firmin RK, Bell PRF. Intrahepatic leimyosarcoma of the inferior vena cava with extension into the right atrium-case report and review of the literature. Eur J Vasc Surg (in press). 3. Kaku K, Kawashima Y, Kitamura S, et aL Resection of leiomyosarcoma originating in the internal iliac vein and
Fig. 1. Representation of thromboexclusion operation. (Reprinted with permission from Elefteriades JA, Hartleroad J, Gusberg RJ, et al. Ann Thorac Surg 1992;53:1121)~
JOURNAL OF VASCULARSURGERY Volume 17, Number 2
Letters to the Editors
449
Fig. 2. Photograph of postmortem specimen of aorta depicts abdominal portion of prosthetic graft and discrete edge of organized thrombns within descending thoracic aorta. Metal probe reveals intimal tear in abdominal aortic dissection. abdominal aorta via an extraanatomic bypass graft (Fig. 1). This achieves reversal of blood tow'in the descending aorta with stagnation of blood from an absence of runoff that results in "therapeutic" thrombosis. Perfusion to those aortic branches with significant runoff, especially the low intercostal branches and abdominal visceral branches, is preserved. Little information, especially pathologic data, exists in the literature on the long-term changes after thromboexclusion of the descending aorta. A case is presented that, on postmortem examination, confirms a number of the postulates of the thromboexclusion operation. We report the case of a 59-year-old man with a long
history of hypertension who was diagnosed with descending thoracic aortic dissection by computed tomography and angiography. Because of progressive symptoms and radiographically documented enlargement of the dissection, the patient underwent a thromboexclusion procedure with permanent stapling of the distal aortic arch and creation of an extraanatomic graft between the ascending aorta and the abdominal aorta as shown in Fig. 1. Thirty months after surgery he was admitted to the emergency department with severe back pain and hypotension. The patient's hemodynamic status deteriorated rapidly and he died shortly thereafter. Postmortem examination revealed an intimal tear of the
450
JOURNALOF VASCULARSURGERY February 1993
Letters to the Editors
abdominal aorta posteriorly, opposite the site of the infrarenal distal anastomosis of the extraanatomic graft (Fig. 2). There was retrograde dissection of the aorta with an external adventitial tear within the lower mediastinumand rupture into the left pleural space. Inspection of the aorta revealed organized intraluminal thrombus from the staple line to a discrete point just above the lower intercostal arteries. These low intercostal arteries were patent, as were all visceral vessels, including the celiac trunk, superior and inferior mesenteric arteries, and renal arteries (Fig. 2). Because clinical experience with the thromboexclusion operation remains limited, the postulated effects of this operation are, in some measure, speculative. 1,2 The case presented provides direct pathologic verification of several postulates regarding the thromboexclusion procedure. First, the pathologic data confirm complete thrombosis of the descending aorta with exclusion of the diseased segment from the circulation. This exclusion was effective in arresting progression of the thoracic aortic enlargement. In addition, sustained long-term patency of the low intercostal and visceral arterial branches is confirmed. Although the occurrence of abdominal aortic dissection seen in this case was unexpected, "primary" abdominal aortic dissection is a recognized, although rare, phenomenon. The location of the intimal tear in a review of these primary abdominal dissections was uniformly below the renal arteries and above the inferior mesenteric artery as in this case. 3 In all cases in this review as well as in the case presented, retrograde dissection occurred. Robiscek4 has recommended that thromboexclusion be supplemented by stapled occlusion of the lower descending aorta at a later date to ensure complete exclusion rather than relying on spontaneous thrombosiS. Had this been done in this case, retrograde extension of the abdominal aortic dissection could have been prevented. These pathologic data after the thromboexclusion operation are presented to add to the clinical information available on this evolving alternative surgical approach to descending aortic dissection. Juan A. Sanchez, MD, Richard J. Gusberg, MD Graeme L. Hammond, MD John A. Elefleriades,MD Sections of Cardiothoracic and Vascular Surgery Yale University School of Medicine FMB 121 333 Cedar St. New Haven, CT 06510
REFERENCES 1. Carpentier AF, Deloche A, Fabiani JN, et al. New Surgical approach to aortic dissection: flow reversal and thromboexclusion. J Thorac Cardiovasc Surg 1981;81:659-68. 2. Elefteriades JA, Hartleroad 1, Gusberg RJ, et al. Long-term experience with descending aortic dissection: the complicationspecific approach. Ann Thorac Surg 1992;53:11-21.
3. Becquemin JP, Deleuze P, Watelet 1, et al. Acute and chronic dissections of the abdominal aorta: clinical features and treatment. J VAsc SURG 1990;11:397-402. 4. Robiscek F. Discussion in: Elefteriades JA, Harderoad J, Gusberg RJ, et al. Long-term experiencewith descending aortic dissection: the complication-specific approach. Ann Thorac Surg 1992;53:11-21. 24/41/41151
Pulmonary embolism caused by venous compression ultrasound examination To the Editors: In the June issue of the JoukNAL oF VASCULAR SURGERY, William B. Schroder and John F. Bealer I state that theirs is the first reported instance of pulmonary embolism (PE) caused directly by a thrombus dislodged from the femoral vein during venous compression ultrasonography. In fact, there are at least two other reports of such a complication. In one case, 2 an asymptomatic, pulmonary embolus cieveloped in the patient and was documented with a ventilation-perfusion scan after a femoral vein clot was dislodged by compression with the ultrasonography probe. In the other report, 3 a thrombus in the proximal superficial femoral vein was observed with use of sonography to migrate out of the field of view during the compression maneuver. Dyspnea and hypoxia developed in the patient over the next several hours, and the patient underwent a ventilation-perfusion scan 8 hours after the ultrasound examination, which showed a high probability of PE. This citation of two additional instances of PE caused by venous compression ultrasonography serves to emphasize the common message of all three reports; that is, this complication may be more common than appreciated, and probe compression should be done with as little force as needed to establish a diagnoses. Robert Fdd, M_D Department of Radiology-Imaging Mount Sinai Hospital 500 Blue Hills Ave. Hartford, CT 06112
REFERENCES 1. Schroder WB, Bealer JF. Venous duplex ultrasonography~ causing acute pulmonary embolism: a brief report. JOURNALOF VASCULARSURGERY1992; 15:1082-3. 2. YedlickaJW, Hunter DW, Letourneau JG. Pulmonary embolism after femoral vein compression during sonography: case report. Semin Interventional Radiol 1990;7:24-6. 3. Perlin SL Pulmonary embolism during compression US of the lower extremity. Radiology 1992; 184:165-6. 24/41/41528
JOURNALOF VASCULARSURGERY February 1993
Letters to the Editors
intrahepatic leiomyosarcoma of the inferior vena cava (IVC) 2 that illustrates several interesting points in the management of this condition. A 54-year-old man was referred to our unit from a neighboring hospital with a 3-week history of bilateral leg edema and a mass related to his IVC that was shown on computed tomography. Inferior vena cavography revealed a lobulated mass in the IVC at the level of the renal veins, which exhibited reduced flow on duplex scanning. A transluminal biopsy of the mass performed during cavography revealed thrombus only. Superior vena cavography showed that the mass extended into the right atrium, and a transluminal biopsy obtained during this investigation suggested the presence of a smooth-muscle tumor. During laparotomy, involvement of the portal nodes was noted and these were histologically demonstrated to contain leiomyosarcoma. It was decided that the most effective palliation would be obtained by debulking the tumor without IVC resection. This was achieved by the use of extracorporeal circulation and hypothermic circulatory arrest, which allowed dissection of most of the tumor from the IVC wall via a right atriotomy and inferior vena cavotomy. The patient recovered well and received postoperative radiotherapy. This case illustrates the use of percutaneous transluminal biopsy in the preoperative diagnosis of rare venous tumors, which may allow more effective intraoperative treatment. The use of extracorporeal circulation with circulatory arrest is a well-documented technique for facilitating resection of tumors that extend into the right atrium 3 and was invaluable in this case. Finally, the role of surgery in palliation of leiomyosarcoma of the venous system should not he forgotten, especially if there is imminent danger of hepatic venous occlusion. Surgical palliation may be successful because of the slow-growing nature of these tumors.
extending into the heart via the inferior vena cava. Surgery 1981;89:604-11. 24/41/41178
Pathologic confirmation of the principles o f the thromboexclusion operation for descending aortic dissection To the Editors:
The thromboexclusion approach to descending aortic dissection has evolved out of the dissatisfaction with currently accepted surgical techniques that interpose a prosthetic graft in the region of the intimal tear. 1,2 The standard operation does not exclude aortic blood flow from the involved descending aorta and requires administration of heparin and aortic cross-clamping. The concept of thromboexclusion as developed by Carpentier proposes a rerouting of blood from the ascending aorta to the
21/I. M. Thompson R. K. Firmin A. A. Bolia T. R. Graham P. I~ F. Bell
Department of Surgery Clinical Sciences Building Leicester Royal Infirmary Leicester LE2 7LX United Kingdom
REFERENCES 1. Dzsinich C, GloviczkiP, van Heerden JA, et al. Primary venous leimyosarcoma: a rare but lethal disease. J VAsc SURG 1992;15:595-603. 2. Thompson MM, Graham TR, Bolia AA, Firmin RK, Bell PRF. Intrahepatic leimyosarcoma of the inferior vena cava with extension into the right atrium-case report and review of the literature. Eur J Vasc Surg (in press). 3. Kaku K, Kawashima Y, Kitamura S, et aL Resection of leiomyosarcoma originating in the internal iliac vein and
Fig. 1. Representation of thromboexclusion operation. (Reprinted with permission from Elefteriades JA, Hartleroad J, Gusberg RJ, et al. Ann Thorac Surg 1992;53:1121)~
JOURNAL OF VASCULARSURGERY Volume 17, Number 2
Letters to the Editors
449
Fig. 2. Photograph of postmortem specimen of aorta depicts abdominal portion of prosthetic graft and discrete edge of organized thrombns within descending thoracic aorta. Metal probe reveals intimal tear in abdominal aortic dissection. abdominal aorta via an extraanatomic bypass graft (Fig. 1). This achieves reversal of blood tow'in the descending aorta with stagnation of blood from an absence of runoff that results in "therapeutic" thrombosis. Perfusion to those aortic branches with significant runoff, especially the low intercostal branches and abdominal visceral branches, is preserved. Little information, especially pathologic data, exists in the literature on the long-term changes after thromboexclusion of the descending aorta. A case is presented that, on postmortem examination, confirms a number of the postulates of the thromboexclusion operation. We report the case of a 59-year-old man with a long
history of hypertension who was diagnosed with descending thoracic aortic dissection by computed tomography and angiography. Because of progressive symptoms and radiographically documented enlargement of the dissection, the patient underwent a thromboexclusion procedure with permanent stapling of the distal aortic arch and creation of an extraanatomic graft between the ascending aorta and the abdominal aorta as shown in Fig. 1. Thirty months after surgery he was admitted to the emergency department with severe back pain and hypotension. The patient's hemodynamic status deteriorated rapidly and he died shortly thereafter. Postmortem examination revealed an intimal tear of the
450
JOURNALOF VASCULARSURGERY February 1993
Letters to the Editors
abdominal aorta posteriorly, opposite the site of the infrarenal distal anastomosis of the extraanatomic graft (Fig. 2). There was retrograde dissection of the aorta with an external adventitial tear within the lower mediastinumand rupture into the left pleural space. Inspection of the aorta revealed organized intraluminal thrombus from the staple line to a discrete point just above the lower intercostal arteries. These low intercostal arteries were patent, as were all visceral vessels, including the celiac trunk, superior and inferior mesenteric arteries, and renal arteries (Fig. 2). Because clinical experience with the thromboexclusion operation remains limited, the postulated effects of this operation are, in some measure, speculative. 1,2 The case presented provides direct pathologic verification of several postulates regarding the thromboexclusion procedure. First, the pathologic data confirm complete thrombosis of the descending aorta with exclusion of the diseased segment from the circulation. This exclusion was effective in arresting progression of the thoracic aortic enlargement. In addition, sustained long-term patency of the low intercostal and visceral arterial branches is confirmed. Although the occurrence of abdominal aortic dissection seen in this case was unexpected, "primary" abdominal aortic dissection is a recognized, although rare, phenomenon. The location of the intimal tear in a review of these primary abdominal dissections was uniformly below the renal arteries and above the inferior mesenteric artery as in this case. 3 In all cases in this review as well as in the case presented, retrograde dissection occurred. Robiscek4 has recommended that thromboexclusion be supplemented by stapled occlusion of the lower descending aorta at a later date to ensure complete exclusion rather than relying on spontaneous thrombosiS. Had this been done in this case, retrograde extension of the abdominal aortic dissection could have been prevented. These pathologic data after the thromboexclusion operation are presented to add to the clinical information available on this evolving alternative surgical approach to descending aortic dissection. Juan A. Sanchez, MD, Richard J. Gusberg, MD Graeme L. Hammond, MD John A. Elefleriades,MD Sections of Cardiothoracic and Vascular Surgery Yale University School of Medicine FMB 121 333 Cedar St. New Haven, CT 06510
REFERENCES 1. Carpentier AF, Deloche A, Fabiani JN, et al. New Surgical approach to aortic dissection: flow reversal and thromboexclusion. J Thorac Cardiovasc Surg 1981;81:659-68. 2. Elefteriades JA, Hartleroad 1, Gusberg RJ, et al. Long-term experience with descending aortic dissection: the complicationspecific approach. Ann Thorac Surg 1992;53:11-21.
3. Becquemin JP, Deleuze P, Watelet 1, et al. Acute and chronic dissections of the abdominal aorta: clinical features and treatment. J VAsc SURG 1990;11:397-402. 4. Robiscek F. Discussion in: Elefteriades JA, Harderoad J, Gusberg RJ, et al. Long-term experiencewith descending aortic dissection: the complication-specific approach. Ann Thorac Surg 1992;53:11-21. 24/41/41151
Pulmonary embolism caused by venous compression ultrasound examination To the Editors: In the June issue of the JoukNAL oF VASCULAR SURGERY, William B. Schroder and John F. Bealer I state that theirs is the first reported instance of pulmonary embolism (PE) caused directly by a thrombus dislodged from the femoral vein during venous compression ultrasonography. In fact, there are at least two other reports of such a complication. In one case, 2 an asymptomatic, pulmonary embolus cieveloped in the patient and was documented with a ventilation-perfusion scan after a femoral vein clot was dislodged by compression with the ultrasonography probe. In the other report, 3 a thrombus in the proximal superficial femoral vein was observed with use of sonography to migrate out of the field of view during the compression maneuver. Dyspnea and hypoxia developed in the patient over the next several hours, and the patient underwent a ventilation-perfusion scan 8 hours after the ultrasound examination, which showed a high probability of PE. This citation of two additional instances of PE caused by venous compression ultrasonography serves to emphasize the common message of all three reports; that is, this complication may be more common than appreciated, and probe compression should be done with as little force as needed to establish a diagnoses. Robert Fdd, M_D Department of Radiology-Imaging Mount Sinai Hospital 500 Blue Hills Ave. Hartford, CT 06112
REFERENCES 1. Schroder WB, Bealer JF. Venous duplex ultrasonography~ causing acute pulmonary embolism: a brief report. JOURNALOF VASCULARSURGERY1992; 15:1082-3. 2. YedlickaJW, Hunter DW, Letourneau JG. Pulmonary embolism after femoral vein compression during sonography: case report. Semin Interventional Radiol 1990;7:24-6. 3. Perlin SL Pulmonary embolism during compression US of the lower extremity. Radiology 1992; 184:165-6. 24/41/41528