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Traumatic aneurysm of the internal mammary artery
TRAUMATIC
ANEURYSM OF THE INTERNAL ARTERY * EDWARD
MAMMARY
0. FINESTONE, M.D.
New York, New York
T
HE literature is repIete with reports of a11types of aneurysms incIuding puIsating hematoma, false aneurysm and arteriovenous f%tuIa. These invoIve the aorta and periphera1 vesseIs. In spite of the great number of war injuries reported, especiaIly those that concern the chest, there is no report of any aneurysms involving the internal mammary A careful search of the literature artery. for the past twenty years faiIs to disclose any case similar to the one described in this articIe. The nearest approach to it in similarity is the case of a traumatic spurious aneurysm invoIving the intercosta1 artery. This case was reported by Guardascione3 who described a severe contusion of the thorax in a man who was found to suffer fractures of the right second and third ribs near their costovertebral angles. He deveIoped traumatic pleurisy and subcutaneous emphysema for a short time folIowing his injury. He resumed work after six weeks and died suddenIy five months foIIowing his injury. At the time of death he had a profound hemoptysis. Autopsy revealed an aneurysma sac which had penetrated into the right Iung and had perforated into the bronchotracheal tree. The aneurysm was derived from the interCosta1 artery at the site of the healed fracture of the second rib. AIthough severa Iarge series of war injuries involving the chest have been reported,1,2f416 onIy casua1 mention is made of any involvement of the internal mammary artery. This structure has been the site of injury in 4 per cent of a11 penetrating chest wounds during the war.4 The foIlowing case report derives interest from the fact that the diagnosis of traumatic aneurysm was made preoperatively. It aIso shows the various types of treatment indicated in three phases of the case, nameIy, (I) immediate treatment at the time of injury, (2) definitive treatment for the aneurysm and (3) *
subsequent decortication and treatment of the empyema. The patient was a twenty-eight year oId colored male who entered the Sydenham Hospital on October I, 1948, in a state of shock with muItipIe Iacerations invoIving his face, arms, right kidney region and chest. AI1 the lacerations were superficial, with the exception of the Iast. This Iaceration measured I 35 inches in length and extended obIiqueIy over the interna end of the right fifth costal cartilage. There was not much bIeeding from the wound. There was no sucking or subcutaneous emphysema. Examination of the chest reveaIed considerable duIIness and flatness indicative of a hemothorax. This was confirmed by x-rays of the chest which revealed a hemopneumothorax occupying about haIf of the right chest cavity with a shift of the mediastinum to the Ieft. The patient was in obvious shock, with a systolic bIood pressure of 80. Diastolic pressure was not obtained. He presented minima1 After administration of respiratory distress. 500 cc. of plasma folIowed with 2,000 cc. of 3 per cent gIucose in saIine intravenousIy, his genera1 condition improved; his bIood pressure rose to 90/60. There was some sIight rigidity in the right upper quadrant of the abdomen. The impression was that the patient had suffered a penetrating stab wound of the right chest with hemopneumothorax incident to invoIvement of the intercosta1 vessels, the interna mammary vesseIs or the lung. The signs in the right upper quadrant of the abdomen were deemed to be due to minima1 trauma to the diaphragm or Iiver. The attending surgeon beIieved that conservative treatment was indicated since the respiratory and cardiovascular functions were not seriously disturbed and since the patient’s genera1 condition improved and became we11 stabilized folIowing supportive treatment on admission. Four days after admission check-up x-rays
From the Surgical Service of the Sydenham Hospital, New York, N. Y. 824
American
Journal
of Surgery
Finestone-Aneurysm
of Internal
reveaIed a disappearance of the pneumothorax, but the fluid &II occupied the lower half of the right chest. The Iung was clear. The patient was feeling well. He suffered no pain, respiratory distress or fever. During the course of the lirst week aspiration of the right chest yieIded only IOO cc. of blood, most of which had clotted. One week following admission the patient arose from bed without permission and went to the lavatory. While straining at stool he suddenly went into shock, with respiratory distress, rapid p&e and Iow bIood pressure. Examination of the chest now reveaIed an increase in the pleural effusion. This was confirmed by x-ray. There was a to and fro machinery murmur localized directly over the wound which had now healed. The patient was again given supportive therapy by means of intravenous tluids and a transfusion so that he recovered from shock after a period of a few hours. He now appeared pale with more rapid pulse and respiration, eIevated temperature and the signs of increased fluid in the right chest. The impression was that he had suffered a secondary hemorrhage from a ruptured aneurysm of the interna mammary vesseIs, with increased pIeural effusion. Because of this red signa it was deemed imperative to subject him to expIoration rather than to continue to support him with transfusions and perform repeated tappings of the pleural cavity. Accordingly, on October 8, 1948, an operation was performed for the ligation of an aneurysm of the right internal mammary artery. Since the genera1 condition of the patient was precarious and because further bleeding was anticipated, genera1 anesthesia was not used. Under local anesthesia a vertical incision was made over the right rectus in the paramedian Iine. The rectus muscle was retracted and the deep epigastric vesseIs ligated as high up as possibIe. The wound was then closed, except for the upper portion of the skin incision. Another incision was made vertically in the right parasterna1 line, beginning over the third costal cartilage, continuing it down almost to the wound. The third and fourth costal cartilages were removed and the interna mammary vessels ligated as Iow as possibIe. By this procedure (of Iigating the deep epigastric vesseIs in the abdomen and the internal mammary vessels above the Iaceration of the chest) the danger of hemorrhage from the aneurysm June,
1952
Mammary
Artery
825
an was recluced to a minimum. Thereupon, incision was made over the original laceration, connecting both upper and lower preliminary incisions. Here, a clot representing the spurious aneurysm was found. It was traced down to and underneath the right fifth Costa1 cartilage which was resected over a distance of about 3 inches. Up to this point the operation had been conducted under local anesthesia, without entering the right pleural cavity. Now because the clot was traced through the pleura the Iatter was entered and a huge gush of bIood was expehed. Between 1,300 and 2,000 cc. of old fluid bIood were removed. When the wound was entireIy dry, bleeding could now be seen coming from the internal mammary vessels beneath the margin of the sternum. The bleeding was not very active and this was ascribed to the preliminary ligations. The vessel above and below the bleeding site was secured by sutures taken through the intercostal structures above and beIow the fifth costal cartilage where it joined the sternum. The latter part of the operation was conducted under a small amount of genera1 anesthesia. There was no unusual respiratory distress, the mediastinum being stabilized by traction on the Iung. After compIete evacuation of bIood cIots from the chest the lung was sutured into the margins of the wound which was compIeteIy closed. A stab wound was made in the right axiIlary line at the IeveI of the eighth intercostal space and a Pezzer catheter introduced for underwater drainage. The patient made an uneventful recovery without respiratory distress. After daily instiIlation of penicillin through the Pezzer catheter, it was removed on the sixth postoperative day. X-rays made a week following the operation showed a smaII amount of fluid with the Iung clearing. The wound healed by primary intention and the sutures were removed one week postoperatively. At this time only 30 cc. of blood could be obtained by aspiration of the chest. In spite of antibiotics the fever persisted and after two weeks was septic in type. Three weeks postoperatively only 20 cc. of bIood could be obtained by aspiration and it was deemed advisable to explore the chest. This was not carried out because the surgeon could not find any localized accumulation in the operating room and he did not think it wise to perform thoracotomy without a thorough IocaIization of an accumulation of pus or blood.
826
Finestone-Aneurysm
of Internal
One month following operation the patient was still running a septic course. S-ra,vs sho~~al fIuid completely enveloping the right upper and lower fobes with a large loculated effusion cxtending from the fourth rib to the diaphragm posteriorIy. A week Iater a compIete decortication of the right Iung was performed followed with underwater drainage. CuItures had been uniformly sterile except for one msde at operation which showed StaphyIococcus aureus. The patient did we11 foIlowing the decortication but a small residual empyema cavity developed which was drained on December 3, 1948, eight weeks foIIowing the origina thoracotomy. FoIlowing this Iast operation the wound healed promptly and his respiratory function was completely restored. SUMMARY
AND
Arteq-
vessels follows in 4 per cent ol’ penetrating \vountls 01 the chest, no similar case has been rccoi-dcd. 3. The case reported herein is of interest because a diagnosis was made preoperativeIy at the time of the secondary hemorrhage from the aneurysm. 4. The various types of treatment indicated in the three phases of the case are described. REFERENCES I.
2. 3.
CONCLUSIONS
A case of traumatic aneurysm of the interna mammary artery is presented. 2. Although injury to the interna mammary I.
Mammary
4. 5.
BURBANK, C. B., FALOR, W. H. and JONES, H. W. Three hundred seventy-four acute war wounds of thorax. Surgery, 21: 730~738. 1947. BURKE, J. and JACOBS,T. T. Penetrating wounds of chest. Ann. Surg., I 23: 363-376, 1946. GLARDASCIONE,V. Post-traumatic aneurism of intercostat artery, rare case. Rossegna Previd. Sock& 27: 28-35. 1940. JOHNSON,J. Battle wounds of thoracic cavity. Ann. Surg., 123: 321-342, 1946. DAY, E. B. and MEADE, R. H., JR. War injuries of chest. Surg., Gynec. 0 Obst., 82: 13-24, 1946.
American
Journal
of Surgery
ANEURYSM OF THE INTERNAL ARTERY * EDWARD
MAMMARY
0. FINESTONE, M.D.
New York, New York
T
HE literature is repIete with reports of a11types of aneurysms incIuding puIsating hematoma, false aneurysm and arteriovenous f%tuIa. These invoIve the aorta and periphera1 vesseIs. In spite of the great number of war injuries reported, especiaIly those that concern the chest, there is no report of any aneurysms involving the internal mammary A careful search of the literature artery. for the past twenty years faiIs to disclose any case similar to the one described in this articIe. The nearest approach to it in similarity is the case of a traumatic spurious aneurysm invoIving the intercosta1 artery. This case was reported by Guardascione3 who described a severe contusion of the thorax in a man who was found to suffer fractures of the right second and third ribs near their costovertebral angles. He deveIoped traumatic pleurisy and subcutaneous emphysema for a short time folIowing his injury. He resumed work after six weeks and died suddenIy five months foIIowing his injury. At the time of death he had a profound hemoptysis. Autopsy revealed an aneurysma sac which had penetrated into the right Iung and had perforated into the bronchotracheal tree. The aneurysm was derived from the interCosta1 artery at the site of the healed fracture of the second rib. AIthough severa Iarge series of war injuries involving the chest have been reported,1,2f416 onIy casua1 mention is made of any involvement of the internal mammary artery. This structure has been the site of injury in 4 per cent of a11 penetrating chest wounds during the war.4 The foIlowing case report derives interest from the fact that the diagnosis of traumatic aneurysm was made preoperatively. It aIso shows the various types of treatment indicated in three phases of the case, nameIy, (I) immediate treatment at the time of injury, (2) definitive treatment for the aneurysm and (3) *
subsequent decortication and treatment of the empyema. The patient was a twenty-eight year oId colored male who entered the Sydenham Hospital on October I, 1948, in a state of shock with muItipIe Iacerations invoIving his face, arms, right kidney region and chest. AI1 the lacerations were superficial, with the exception of the Iast. This Iaceration measured I 35 inches in length and extended obIiqueIy over the interna end of the right fifth costal cartilage. There was not much bIeeding from the wound. There was no sucking or subcutaneous emphysema. Examination of the chest reveaIed considerable duIIness and flatness indicative of a hemothorax. This was confirmed by x-rays of the chest which revealed a hemopneumothorax occupying about haIf of the right chest cavity with a shift of the mediastinum to the Ieft. The patient was in obvious shock, with a systolic bIood pressure of 80. Diastolic pressure was not obtained. He presented minima1 After administration of respiratory distress. 500 cc. of plasma folIowed with 2,000 cc. of 3 per cent gIucose in saIine intravenousIy, his genera1 condition improved; his bIood pressure rose to 90/60. There was some sIight rigidity in the right upper quadrant of the abdomen. The impression was that the patient had suffered a penetrating stab wound of the right chest with hemopneumothorax incident to invoIvement of the intercosta1 vessels, the interna mammary vesseIs or the lung. The signs in the right upper quadrant of the abdomen were deemed to be due to minima1 trauma to the diaphragm or Iiver. The attending surgeon beIieved that conservative treatment was indicated since the respiratory and cardiovascular functions were not seriously disturbed and since the patient’s genera1 condition improved and became we11 stabilized folIowing supportive treatment on admission. Four days after admission check-up x-rays
From the Surgical Service of the Sydenham Hospital, New York, N. Y. 824
American
Journal
of Surgery
Finestone-Aneurysm
of Internal
reveaIed a disappearance of the pneumothorax, but the fluid &II occupied the lower half of the right chest. The Iung was clear. The patient was feeling well. He suffered no pain, respiratory distress or fever. During the course of the lirst week aspiration of the right chest yieIded only IOO cc. of blood, most of which had clotted. One week following admission the patient arose from bed without permission and went to the lavatory. While straining at stool he suddenly went into shock, with respiratory distress, rapid p&e and Iow bIood pressure. Examination of the chest now reveaIed an increase in the pleural effusion. This was confirmed by x-ray. There was a to and fro machinery murmur localized directly over the wound which had now healed. The patient was again given supportive therapy by means of intravenous tluids and a transfusion so that he recovered from shock after a period of a few hours. He now appeared pale with more rapid pulse and respiration, eIevated temperature and the signs of increased fluid in the right chest. The impression was that he had suffered a secondary hemorrhage from a ruptured aneurysm of the interna mammary vesseIs, with increased pIeural effusion. Because of this red signa it was deemed imperative to subject him to expIoration rather than to continue to support him with transfusions and perform repeated tappings of the pleural cavity. Accordingly, on October 8, 1948, an operation was performed for the ligation of an aneurysm of the right internal mammary artery. Since the genera1 condition of the patient was precarious and because further bleeding was anticipated, genera1 anesthesia was not used. Under local anesthesia a vertical incision was made over the right rectus in the paramedian Iine. The rectus muscle was retracted and the deep epigastric vesseIs ligated as high up as possibIe. The wound was then closed, except for the upper portion of the skin incision. Another incision was made vertically in the right parasterna1 line, beginning over the third costal cartilage, continuing it down almost to the wound. The third and fourth costal cartilages were removed and the interna mammary vessels ligated as Iow as possibIe. By this procedure (of Iigating the deep epigastric vesseIs in the abdomen and the internal mammary vessels above the Iaceration of the chest) the danger of hemorrhage from the aneurysm June,
1952
Mammary
Artery
825
an was recluced to a minimum. Thereupon, incision was made over the original laceration, connecting both upper and lower preliminary incisions. Here, a clot representing the spurious aneurysm was found. It was traced down to and underneath the right fifth Costa1 cartilage which was resected over a distance of about 3 inches. Up to this point the operation had been conducted under local anesthesia, without entering the right pleural cavity. Now because the clot was traced through the pleura the Iatter was entered and a huge gush of bIood was expehed. Between 1,300 and 2,000 cc. of old fluid bIood were removed. When the wound was entireIy dry, bleeding could now be seen coming from the internal mammary vessels beneath the margin of the sternum. The bleeding was not very active and this was ascribed to the preliminary ligations. The vessel above and below the bleeding site was secured by sutures taken through the intercostal structures above and beIow the fifth costal cartilage where it joined the sternum. The latter part of the operation was conducted under a small amount of genera1 anesthesia. There was no unusual respiratory distress, the mediastinum being stabilized by traction on the Iung. After compIete evacuation of bIood cIots from the chest the lung was sutured into the margins of the wound which was compIeteIy closed. A stab wound was made in the right axiIlary line at the IeveI of the eighth intercostal space and a Pezzer catheter introduced for underwater drainage. The patient made an uneventful recovery without respiratory distress. After daily instiIlation of penicillin through the Pezzer catheter, it was removed on the sixth postoperative day. X-rays made a week following the operation showed a smaII amount of fluid with the Iung clearing. The wound healed by primary intention and the sutures were removed one week postoperatively. At this time only 30 cc. of blood could be obtained by aspiration of the chest. In spite of antibiotics the fever persisted and after two weeks was septic in type. Three weeks postoperatively only 20 cc. of bIood could be obtained by aspiration and it was deemed advisable to explore the chest. This was not carried out because the surgeon could not find any localized accumulation in the operating room and he did not think it wise to perform thoracotomy without a thorough IocaIization of an accumulation of pus or blood.
826
Finestone-Aneurysm
of Internal
One month following operation the patient was still running a septic course. S-ra,vs sho~~al fIuid completely enveloping the right upper and lower fobes with a large loculated effusion cxtending from the fourth rib to the diaphragm posteriorIy. A week Iater a compIete decortication of the right Iung was performed followed with underwater drainage. CuItures had been uniformly sterile except for one msde at operation which showed StaphyIococcus aureus. The patient did we11 foIlowing the decortication but a small residual empyema cavity developed which was drained on December 3, 1948, eight weeks foIIowing the origina thoracotomy. FoIlowing this Iast operation the wound healed promptly and his respiratory function was completely restored. SUMMARY
AND
Arteq-
vessels follows in 4 per cent ol’ penetrating \vountls 01 the chest, no similar case has been rccoi-dcd. 3. The case reported herein is of interest because a diagnosis was made preoperativeIy at the time of the secondary hemorrhage from the aneurysm. 4. The various types of treatment indicated in the three phases of the case are described. REFERENCES I.
2. 3.
CONCLUSIONS
A case of traumatic aneurysm of the interna mammary artery is presented. 2. Although injury to the interna mammary I.
Mammary
4. 5.
BURBANK, C. B., FALOR, W. H. and JONES, H. W. Three hundred seventy-four acute war wounds of thorax. Surgery, 21: 730~738. 1947. BURKE, J. and JACOBS,T. T. Penetrating wounds of chest. Ann. Surg., I 23: 363-376, 1946. GLARDASCIONE,V. Post-traumatic aneurism of intercostat artery, rare case. Rossegna Previd. Sock& 27: 28-35. 1940. JOHNSON,J. Battle wounds of thoracic cavity. Ann. Surg., 123: 321-342, 1946. DAY, E. B. and MEADE, R. H., JR. War injuries of chest. Surg., Gynec. 0 Obst., 82: 13-24, 1946.
American
Journal
of Surgery