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Repair of Aortic Dissections
CORRESPONDENCE
Repair of Aortic Dissections To t h e Editor: We were interested to read the recent report of Dr. Berger, “A Simplified Plastic Repair for Aortic Dissections” (Ann Thorac Surg 25:250, 1978) and would appreciate the opportunity to draw to the attention of your readers our experience with an almost identical technique that was reported some 16 years ago [4]. Further experience with this technique was reported subsequently [l-31. I think you will agree the illustrations in these references show a very similar technique.
lustrations do not accurately depict the procedure described by the authors. It is of note that subsequent papers and textbooks citing the same references as those listed by Morris and Lawrie refer to classic repair and do not mention the one I have reported.
Robert L. Berger, M . D . Department of Cardiothoracic Surgery Boston University Medical Center 75 E Newton S t Boston, M A 02228
George C . Morris, J r . , M . D . Gerald M . Lawrie, M . D . Cora and W e b b Mading Department of Surgery Baylor College of Medicine Texas Medical Center Houston, T X 77030
References DeBakey ME, Henly WS, Cooley DA, et al: Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 49:134, 1965 DeBakey ME, Henly WS, Cooley DA, et al: Surgical management of dissecting aneurysm involving the ascending aorta. J Cardiovasc Surg (Torino) 5:200, 1966 Lawrie GM, Morris GC Jr: 15 year follow-up of emergency operation for acute dissecting aneurysm of the aorta with aortic insufficiency (letter to the editor). JAMA 239:724, 1978 Morris GC Jr, Henly WS, DeBakey ME: Correction of acute dissecting aneurysm of aorta with valvular insufficiency. JAMA 184:63, 1963
Reply To the Editor: I welcome the implied endorsement of the simplified repair for aortic dissections that I described in my paper. As usual, it is moot to engage in the battle of who was first. Nevertheless, it is fair to point out that although the illustrations in the references cited by Drs. Morris and Lawrie are similar to those in my paper, the texts describe the procedure as transection of the dissected aorta, excision of the aortic segment containing the intimal tear, and end-to-end anastomosis of the two aortic ends, with or without graft interposition. None of those papers state that the excision of the aorta is limited to the anterior wall and that the posterior wall is left intact. Thus, all four articles advocate the conventional repair of aortic dissections and in no way refer to the simpler technique 1 described. I have to conclude that the il-
Bronchial Artery Embolization To t h e Editor: 1 read with considerable interest the report by Dr. Sehhat and associates, “Massive Pulmonary Hemorrhage: Surgical Approach as Choice of Treatment” (Ann Thorac Surg 25:12, 1978). Their data leave no doubt that prompt localization of the bleeding site with subsequent surgical excision of abnormal lung represents the treatment of choice. However, patients who refuse operation or who are not suitable for operation because of poor respiratory function or bilateral lung disease or because of the surgeon’s inability to localize the site of hemorrhage remain a therapeutic problem and have a high mortality. Several recent reports [1-3] have stressed the value of bronchial arteriography with transcatheter embolization of bronchial arteries in the treatment of patients with massive, life-threatening, or repeated hemoptysis who have a temporary or permanent contraindication to operation. Remy and colleagues [2] treated 104 patients with hemoptysis by embolization of bronchial and nonbronchial arteries supplying diseased areas of lung. As in the series of Sehhat and associates, tuberculosis and bronchiectasis were most often responsible. Among 49 patients treated by embolization during an episode of acute bleeding, 41 experienced immediate cessation of hemoptysis; 6 of these 41 had recurrence 2 to 7 months after embolization, but 35 had no further bleeding during a follow-up of 2 to 30 months. It must be emphasized that all of these 41 patients survived the acute episode of hemorrhage. Although the fate of the other 8 patients who were treated without cessation of hemoptysis remains unclear, certainly the survival of these 49 patients far exceeds the 15% 25-day survival reported by Sehhat and associates for nonoperable patients. Others [l, 31 have reported similar success in treating patients with massive hemoptysis who were not suitable for operation. Among the 104 patients seen by Remy and colleagues [21, complications have been limited to necrosis of the small bowel (1 patient), brief epigastric pain (1 patient), and substernal chest pain and fever of two or three days du-
Repair of Aortic Dissections To t h e Editor: We were interested to read the recent report of Dr. Berger, “A Simplified Plastic Repair for Aortic Dissections” (Ann Thorac Surg 25:250, 1978) and would appreciate the opportunity to draw to the attention of your readers our experience with an almost identical technique that was reported some 16 years ago [4]. Further experience with this technique was reported subsequently [l-31. I think you will agree the illustrations in these references show a very similar technique.
lustrations do not accurately depict the procedure described by the authors. It is of note that subsequent papers and textbooks citing the same references as those listed by Morris and Lawrie refer to classic repair and do not mention the one I have reported.
Robert L. Berger, M . D . Department of Cardiothoracic Surgery Boston University Medical Center 75 E Newton S t Boston, M A 02228
George C . Morris, J r . , M . D . Gerald M . Lawrie, M . D . Cora and W e b b Mading Department of Surgery Baylor College of Medicine Texas Medical Center Houston, T X 77030
References DeBakey ME, Henly WS, Cooley DA, et al: Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 49:134, 1965 DeBakey ME, Henly WS, Cooley DA, et al: Surgical management of dissecting aneurysm involving the ascending aorta. J Cardiovasc Surg (Torino) 5:200, 1966 Lawrie GM, Morris GC Jr: 15 year follow-up of emergency operation for acute dissecting aneurysm of the aorta with aortic insufficiency (letter to the editor). JAMA 239:724, 1978 Morris GC Jr, Henly WS, DeBakey ME: Correction of acute dissecting aneurysm of aorta with valvular insufficiency. JAMA 184:63, 1963
Reply To the Editor: I welcome the implied endorsement of the simplified repair for aortic dissections that I described in my paper. As usual, it is moot to engage in the battle of who was first. Nevertheless, it is fair to point out that although the illustrations in the references cited by Drs. Morris and Lawrie are similar to those in my paper, the texts describe the procedure as transection of the dissected aorta, excision of the aortic segment containing the intimal tear, and end-to-end anastomosis of the two aortic ends, with or without graft interposition. None of those papers state that the excision of the aorta is limited to the anterior wall and that the posterior wall is left intact. Thus, all four articles advocate the conventional repair of aortic dissections and in no way refer to the simpler technique 1 described. I have to conclude that the il-
Bronchial Artery Embolization To t h e Editor: 1 read with considerable interest the report by Dr. Sehhat and associates, “Massive Pulmonary Hemorrhage: Surgical Approach as Choice of Treatment” (Ann Thorac Surg 25:12, 1978). Their data leave no doubt that prompt localization of the bleeding site with subsequent surgical excision of abnormal lung represents the treatment of choice. However, patients who refuse operation or who are not suitable for operation because of poor respiratory function or bilateral lung disease or because of the surgeon’s inability to localize the site of hemorrhage remain a therapeutic problem and have a high mortality. Several recent reports [1-3] have stressed the value of bronchial arteriography with transcatheter embolization of bronchial arteries in the treatment of patients with massive, life-threatening, or repeated hemoptysis who have a temporary or permanent contraindication to operation. Remy and colleagues [2] treated 104 patients with hemoptysis by embolization of bronchial and nonbronchial arteries supplying diseased areas of lung. As in the series of Sehhat and associates, tuberculosis and bronchiectasis were most often responsible. Among 49 patients treated by embolization during an episode of acute bleeding, 41 experienced immediate cessation of hemoptysis; 6 of these 41 had recurrence 2 to 7 months after embolization, but 35 had no further bleeding during a follow-up of 2 to 30 months. It must be emphasized that all of these 41 patients survived the acute episode of hemorrhage. Although the fate of the other 8 patients who were treated without cessation of hemoptysis remains unclear, certainly the survival of these 49 patients far exceeds the 15% 25-day survival reported by Sehhat and associates for nonoperable patients. Others [l, 31 have reported similar success in treating patients with massive hemoptysis who were not suitable for operation. Among the 104 patients seen by Remy and colleagues [21, complications have been limited to necrosis of the small bowel (1 patient), brief epigastric pain (1 patient), and substernal chest pain and fever of two or three days du-