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TRAUMATIC ANEURYSM OF THE THORACIC AORTA SIMULATING COARCTATION
TRAUMATIC A N E U R Y S M OF THE THORACIC AORTA SIMULATING
COARCTATION
A Case Report James R. Malm, M.D., and Ralph A. Deterling, Jr.,
M.D.*
New York, N. Y.
T
thoracic aneurysms have been described as a pathologic entity for many years 1-4 but only occasionally present as a surgically correctable lesion. This lesion has been encountered only twice among 126 patients with thoracic aneurysm operated upon at Presbyterian Hospital. During recent years, excisional therapy has proved increasingly safe and effective, emphasizing the need for increasing our knowledge of the clinical course of this entity. The majority of patients receiving trauma sufficient to rupture the aorta die almost immediately. Attesting to this is the fact that the largest reported series of 72 traumatic aneurysms was among 7,000 consecutive autopies re ported from the Chief Medical Examiner's office of New York City.5 The fate of those patients who survive the initial aortic injury appears variable and for the most part unpredictable. Survival and the subsequent clinical course must depend upon the depth and size of the aortic tears and the ability of the residual media, adventitia, and adjacent structures to buttress the laceration and hematoma against constant aortic pressure. The development of a widened mediastinum and clouding of the aortic knob, following severe chest trauma, should strongly suggest that rupture of the aortic wall may have occurred. The subseqtient x-ray appearance of a bulging or double contour in the area of the aortic arch, during the first to fourth weeks following injury, is diagnostic of traumatic aneurysm, or, better termed, a false aneurysm. The subsequent course of these lesions has been difficult to evaluate but, based on a summary of available reports of patients surviving the first 10 hours after injury, approximately 40 per cent of these aneurysms rup ture within the first 60 days (Table I ) . Steinberg 18 has recently emphasized that a certain number of these lesions become chronic, stable, and ultimately show calcification by roentgencgram. Unfortunately there is no satisfactory way to anticipate which of the acute lesions will become chronic and stable from RAUMATIC
From the Department of Surgery. Columbia University, College of Physicians and Surgeons, and Surgical Service, Presbyterian Hospital, New York, N. Y. Presented before the Meeting of the New York Society for Thoracic Surgery, May 21, 1959. Received for publication Nov. 18, 1959. •Now at Tufts University School of Medicine, Boston, Mass.
271
272
MALM A N D DETEKLING
J. Thoracic and Cardiovas. Surg.
those that will rupture. I n the case to be presented, there developed a clinical picture associated with a traumatic aneurysm of the descending thoracic aorta that has not previously been described; an awareness of this sequence of events may aid in the diagnosis and mangement of future cases. TABLE I.
COURSE
OF P A T I E N T S
SURVIVING 10
NUMBER OF CASES CHRONIC
Bradford and Johnstons Bahnson 7 Corbitts Eiseman and Rainera Forbes«) Goyette et a l . « Hardin et a l . " Henning and A g m a r " Hollingsworth et al. 1 4 Kuhnis Bice and Wittstruekie Sarot and Lazzaienii' Steinbergis Storey et a l . « Stranahan et al. 2 0 Strassmans Ware et al. Wyman 2 2
21
Zehnder 2 3 Totals CASE
1 1 1 6 1 3 1 1 4 1 1 1 5 2 1 4
HOURS
SURGICAL PROGRESSIVE CURE
INJURY
DEATH AFTER SURGERY
2
1
1
2 2
1 1 1
1
1 1
4
6
48 hr.
1 12 da.
1
2
20 hr. 9 da. 30 hr.
10 da. 5 wk.
1 1
10
RUPTURE
5 wk.
1
1 3 1 39
AFTER
5
(4) 12 and 18 hr. (3) 11 hr.; 15 hr.; 8 da. 4 % da. 16
REPORT
W. R., a 48-year-old man, was struck by a truck on Feb. 28, 1958. On admission to the hospital he was in extreme respiratory distress. A roentgenogram of the chest confirmed the clinical impression of multiple r i b fractures and a bilateral hemothorax. Thoracentesis and supportive therapy relieved respiratory distress and blood pressure was maintained a t 150/80 mm. H g . Ten days following injury the patient developed an episode of severe right chest and substemal pain accompanied by dyspnea, hyperpnea, and sweating. A t this time the blood pressure was recorded as 220/100 mm. H g . The electrocardiogram remained essentially unchanged throughout this period. Episodic pain recurred almost daily and alternating auricular fibrillation and flutter with a 2 : 1 block developed on the twentieth hospital day. The patient was discharged on the thirty-first hospital day. Although digitalized he was readmitted 8 days later in acute left ventricular failure. The patient responded promptly to oxygen, diuretic drugs, and an increased dosage of digitalis. Arterial tension in both arms was recorded as 240/80 mm. H g . A chest roentgenogram made 41 days after the injury nowshowed a double contour enlargement in the region of the aortic arch which suggested aneurysmal formation ( F i g . 1 ) . Chest pain and cardiac failure recurred and the patient was transferred to Presbyterian Hospital on April 28, 1958. On admission the patient was dyspneic, orthopneie, and cyanotic, with a rapid irregular pulse. Arterial pressure in the right arm was 220/80, in the left arm 240/80 mm. Hg. Carotid pulses were equal to palpation. The blood pressure was recorded as 90/0 mm. Hg in both lower extremities and pulsations in the abdominal aorta could not be felt. The heart was enlarged to the anterior axillary line and a soft systolie murmur could be heard over
Vol. 40, No. 2 August, 1960
TRAUMATIC ANEUKYSM OF THOBACIO AORTA
273
A.
c.
Fig. 1.—A, Roentgenogram of the chest taken 2 weeks following injury shows evidence of multiple rib fractures and some widening of the mediastinum. B, Subsequent x-ray studies 2 months following injury clearly demonstrated the prom inent aorta arch with a double contour. C, The lateral view shows the aneurysm arising in the proximal descending aorta.
274
MALM AND D E T E R L I N G
J. Thoracic and Cardiovas. Surg.
the left chest anteriorly and posteriorly. The patient was placed on a strict cardiac regimen and signs and sj'mptoms of cardiac failure resolved within 48 hours after admission. On May 14, an angiocardiogram was performed in two projections which confirmed the con ventional roentgcnographic appearance of an aneurysmal dilatation of the aorta just beyond the origin of the left subclavian artery.
Fig. 2.—A, The specimen shows the hematoma sac as viewed from the proximal end of the aortic segment. B, An intact aortic wall is seen distally. Microscopically the hematoma separated the adventitia from the media with infarction noted in the outer two thirds of the media. On May 20, approximately 3 months following injury, exploratory left thoracotomy was performed. An aneurysmal dilatation of the thoracic aorta was noted just distal to the left subclavian artery, measuring approximately 6 by 8 by 8 cm. Excision of the aneurysm was possible during partial perfusion of the distal aorta by a left atrium to left femoral artery bypass with a Sigmamotor pump. 2 4 A perfusion rate of 2,200 c.c. per minute was required to control proximal aortic hypertension. A preclotted crimped Dacron prosthesis* was in serted. On the day following surgery, the p a t i e n t ' s blood pressure was 130/80 mm. H g in •Ethigraft available from Ethicon Inc., Somerville, N. J.
Vol. 40, No. 2 August, 1960
TRAUMATIC ANEUEYSM O F THORACIC AORTA
275
all extremities. The postoperative course was uneventful except for an episode of auricular fibrillation occurring on the second postoperative day which responded to increasing doses of digitalis. Since discharge the patient has remained normotensive and is well 1 year following surgery. The pathologic specimen (Fig. 2) showed the large hematoma space outside the aortic lumen. The hematoma presented outside the media of the aortic wall microscopically, which probably explains why the dissection did not progress along the aorta as occurred in the case reported by Rice 16 of a pregnant woman at term, following chest injury. The diagram in Fig. 3 shows the probable sequence of events following aortic tear with formation of the partially obstructing hematoma.
Fig. 3.—The schematic diagram illustrates the location and obstructing nature of the hematoma mass following the aortic wall dissection through the intimai tear. DISCUSSION
The recent publications of Steinberg 18 and others 9 have raised a question as to the advisability of operating on a patient simply because the roentgenographic diagnosis of post-traumatic aneurysm is made. If observation proves to be an accepted form of clinical management, then a recognition of changing hemodynamics in the peripheral vascular system may be significant evidence of active bleeding and impending disaster following chest injury, as is well recognized in dissecting aneurysms. It is quite possible that the sudden de velopment of hypertension proximal to an aortic hematoma may be a cause of sudden rupture late in the course of the aneurysm. Such a sequence of events is suggested in Case 3 reported by Eiseman, 9 although blood pressures were not reported. The patient developed a left hemothorax on the ninth post-injury day. Two hours following this he complained of numbness in his feet and femoral pulses disappeared. The patient suddenly then went into shock and subse quently died immediately after resection of a ruptured aneurysm of the thoracic aorta.
MALM A N D D E T E R L I N G
276
J. Thoracic and Cardiovas. Surg.
It is apparent that when rupture occurs, attempts at surgical correction have been associated with a high mortality. "With the present-day use of atrialfemoral bypass, resection of aneurysms of the descending aorta can be carried out with a mortality of approximately 19 per cent,25 as compared to 27 to 50 per cent using hypothermia or external shunts. There seems then little reason for delaying early surgical excision of an acute traumatic aneurysm or of a chronic symptomatic lesion, once the diagnosis has been established. Observation may be justified in the chronic, stable, calcified anetirysms if careful follow-up is available. Careful repeated records of peripheral pulses, particularly the femoral pulses, in patients following chest injury may give valuable information in the diagnosis and management of a traumatic aneurysm, and indeed may be an early sign heralding disaster. SUMMARY
1. A case of post-traumatic thoracic aortic aneurysm has been described which presented a hemodynamic picture simulating coarctation of the aorta. 2. A careful apprasial of peripheral pulses in patients following chest in jury may give valuable information in establishing a course of management. REFERENCES
1. Rindfleisch, E . : Zuv Entstehung und Heilung des Aneurysma dissecans aortae, Virehows Arch. f. path. Anat. 131: 374-378, 1893. 2. Kemp, P . E. : Traumatic Eupture of the Aorta, Lancet 1: 953, 1923. 3. Kleinsasser, L. G. : Traumatie Eupture of the Thoracic Aorta, Ann. Surg. 118: 1071, 1943. 4. J a y , J . B., and French, S. W., I l l : Traumatic Eupture of the Thoracic A o r t a : Review of Literature and Case Eeport, A. M. A. Arch. Surg. 68: 657-662, 1954. 5. Strassman, G. : Traumatic Eupture of Aorta, Am. Heart J . 3 3 : 508-515, 1947. 6. Bradford, B., J r . , and Johnston, F . L. : Traumatie Eupture of the Aorta, Surgery 28: 893, 1950. 7. Bahnson, H. T . : Definitive Treatment of Saccular Aneurysms of the Aorta With Excision of the Sac and Aortic Suture, Surg. Gynec. & Obst. 96: 383, 1953. 8. Corbitt, A. W., and Mathews, A. E. K . : Eupture of the Aorta; A Case Eeport With Discussion, West Virginia M. J . 3 3 : 372, 1937. 9. Eiseman B., and Eainer, W. G. : Clinical Management of Posttraumatie Eupture of the Thoracic Aorta, J . THORACIC SURG. 35: 347-358, 1958.
10. Forbes, G.: Traumatic Eupture of the Aorta, Brit. M. J . 2 : 400, 1944. 11. Goyette, E . M., Blake, H . A., Forsee, J . H., and Swan, H. : Traumatic Aortic Aneurysm, Circulation 10: 824-828, 1954. 12. Hardin, C. A., Reisman, K. E., and Dimond, E . G. : The Use of Hypothermia in the Eesection and Homologous Eeplaeement of the Thoracic Aorta, Ann. Surg. 140: 720, 1954. 13. Henning, B . H., and Agmar, A. E. : Traumatie Eupture of the Thoracic Aorta; Eeport of a Case, Mil. Surgeon 103: 260, 1948. 14. Hollingsworth, R. K., Johnston, W . W., and McCooey, J . F . : Traumatie Saccular Aneurysm of the Thoracic Aorta, J . THORACIC SURG. 24: 325, 1952.
15. Kuhn, L. P . : Traumatie Rupture of the Thoracic Aorta With Review of 55 Abdominal Injuries, Illinois M. J . 47: 420, 1925. 16. Rice, W. G., and Wittstruck, K. P . : Acute Hypertension and Delayed Traumatic Rupture of the Aorta, J . A. M. A. 147: 915, 1951. 17. Sarot, I . A., and Lazzarini, A. A . : Resection of Aneurysms of the Aortic Arch and Descending A o r t a : Permanent " B y - P a s s " Homograft, Tr. Am. Coll. Cardiol. 5: 175A, 1955. 18. Steinberg, I . : Chronic Traumatic Aneurysm of the Thoracic Aorta, New England J . Med. 257: 913-918, 1957.
Vol. 40, No. 2 Au just 1960
TRAUMATIC ANEURYSM OF THORACIC AORTA
277
19. Storey, C. P., Nardi, G. L., and Sewell, W. H.: Traumatic Aneurysm of Thoracic Aorta: Report of Two Cases, One Successfully Treated by Resection and Graft-Replacement With Aid of Shunt, Ann. Surg. 144: 69-78, 1956. 20. Stranahan, A., Alley, R. D., Sewell, W. H., and Kausel, H. W. : Aortic Arch Resection and Grafting for Aneurysm Employing an External Shunt, J. THORACIC SURG. 29: 54, 1955. 21. Ware, P. F., Adler, R. H., and Hyter, C. S. : Traumatic Aneurysm of the Thoracic Aorta, U. S. Armed Forces M. J. 6: 1674-1690, 1955. 22. Wyman, A. C. : Roentgenologic Diagnosis of Traumatic Rupture of Thoracic Aorta, A. M. A. Arch. Surg. 66: 656-663, 1953. 23. Zehnder, M. A.: Delayed Posttraumatie Rupture of the Aorta in a Young Healthy Individual After Closed Injury, Angiology 7: 252, 1956. 24. Cooley, D. A., De Bakey, M. E., and Morris, G. C. : Controlled Extracorporeal Circulation in Surgieal Treatment of Aortic Aneurysm, Ann. Surg. 146: 473-485, 1957. 25. De Bakey, M. E., Cooley, D. A., Crawford, F., and Morris, G. C. : Aneurysms of the Thoracic Aorta, J. THORACIC SURG. 36: 393-420, 1958.
COARCTATION
A Case Report James R. Malm, M.D., and Ralph A. Deterling, Jr.,
M.D.*
New York, N. Y.
T
thoracic aneurysms have been described as a pathologic entity for many years 1-4 but only occasionally present as a surgically correctable lesion. This lesion has been encountered only twice among 126 patients with thoracic aneurysm operated upon at Presbyterian Hospital. During recent years, excisional therapy has proved increasingly safe and effective, emphasizing the need for increasing our knowledge of the clinical course of this entity. The majority of patients receiving trauma sufficient to rupture the aorta die almost immediately. Attesting to this is the fact that the largest reported series of 72 traumatic aneurysms was among 7,000 consecutive autopies re ported from the Chief Medical Examiner's office of New York City.5 The fate of those patients who survive the initial aortic injury appears variable and for the most part unpredictable. Survival and the subsequent clinical course must depend upon the depth and size of the aortic tears and the ability of the residual media, adventitia, and adjacent structures to buttress the laceration and hematoma against constant aortic pressure. The development of a widened mediastinum and clouding of the aortic knob, following severe chest trauma, should strongly suggest that rupture of the aortic wall may have occurred. The subseqtient x-ray appearance of a bulging or double contour in the area of the aortic arch, during the first to fourth weeks following injury, is diagnostic of traumatic aneurysm, or, better termed, a false aneurysm. The subsequent course of these lesions has been difficult to evaluate but, based on a summary of available reports of patients surviving the first 10 hours after injury, approximately 40 per cent of these aneurysms rup ture within the first 60 days (Table I ) . Steinberg 18 has recently emphasized that a certain number of these lesions become chronic, stable, and ultimately show calcification by roentgencgram. Unfortunately there is no satisfactory way to anticipate which of the acute lesions will become chronic and stable from RAUMATIC
From the Department of Surgery. Columbia University, College of Physicians and Surgeons, and Surgical Service, Presbyterian Hospital, New York, N. Y. Presented before the Meeting of the New York Society for Thoracic Surgery, May 21, 1959. Received for publication Nov. 18, 1959. •Now at Tufts University School of Medicine, Boston, Mass.
271
272
MALM A N D DETEKLING
J. Thoracic and Cardiovas. Surg.
those that will rupture. I n the case to be presented, there developed a clinical picture associated with a traumatic aneurysm of the descending thoracic aorta that has not previously been described; an awareness of this sequence of events may aid in the diagnosis and mangement of future cases. TABLE I.
COURSE
OF P A T I E N T S
SURVIVING 10
NUMBER OF CASES CHRONIC
Bradford and Johnstons Bahnson 7 Corbitts Eiseman and Rainera Forbes«) Goyette et a l . « Hardin et a l . " Henning and A g m a r " Hollingsworth et al. 1 4 Kuhnis Bice and Wittstruekie Sarot and Lazzaienii' Steinbergis Storey et a l . « Stranahan et al. 2 0 Strassmans Ware et al. Wyman 2 2
21
Zehnder 2 3 Totals CASE
1 1 1 6 1 3 1 1 4 1 1 1 5 2 1 4
HOURS
SURGICAL PROGRESSIVE CURE
INJURY
DEATH AFTER SURGERY
2
1
1
2 2
1 1 1
1
1 1
4
6
48 hr.
1 12 da.
1
2
20 hr. 9 da. 30 hr.
10 da. 5 wk.
1 1
10
RUPTURE
5 wk.
1
1 3 1 39
AFTER
5
(4) 12 and 18 hr. (3) 11 hr.; 15 hr.; 8 da. 4 % da. 16
REPORT
W. R., a 48-year-old man, was struck by a truck on Feb. 28, 1958. On admission to the hospital he was in extreme respiratory distress. A roentgenogram of the chest confirmed the clinical impression of multiple r i b fractures and a bilateral hemothorax. Thoracentesis and supportive therapy relieved respiratory distress and blood pressure was maintained a t 150/80 mm. H g . Ten days following injury the patient developed an episode of severe right chest and substemal pain accompanied by dyspnea, hyperpnea, and sweating. A t this time the blood pressure was recorded as 220/100 mm. H g . The electrocardiogram remained essentially unchanged throughout this period. Episodic pain recurred almost daily and alternating auricular fibrillation and flutter with a 2 : 1 block developed on the twentieth hospital day. The patient was discharged on the thirty-first hospital day. Although digitalized he was readmitted 8 days later in acute left ventricular failure. The patient responded promptly to oxygen, diuretic drugs, and an increased dosage of digitalis. Arterial tension in both arms was recorded as 240/80 mm. H g . A chest roentgenogram made 41 days after the injury nowshowed a double contour enlargement in the region of the aortic arch which suggested aneurysmal formation ( F i g . 1 ) . Chest pain and cardiac failure recurred and the patient was transferred to Presbyterian Hospital on April 28, 1958. On admission the patient was dyspneic, orthopneie, and cyanotic, with a rapid irregular pulse. Arterial pressure in the right arm was 220/80, in the left arm 240/80 mm. Hg. Carotid pulses were equal to palpation. The blood pressure was recorded as 90/0 mm. Hg in both lower extremities and pulsations in the abdominal aorta could not be felt. The heart was enlarged to the anterior axillary line and a soft systolie murmur could be heard over
Vol. 40, No. 2 August, 1960
TRAUMATIC ANEUKYSM OF THOBACIO AORTA
273
A.
c.
Fig. 1.—A, Roentgenogram of the chest taken 2 weeks following injury shows evidence of multiple rib fractures and some widening of the mediastinum. B, Subsequent x-ray studies 2 months following injury clearly demonstrated the prom inent aorta arch with a double contour. C, The lateral view shows the aneurysm arising in the proximal descending aorta.
274
MALM AND D E T E R L I N G
J. Thoracic and Cardiovas. Surg.
the left chest anteriorly and posteriorly. The patient was placed on a strict cardiac regimen and signs and sj'mptoms of cardiac failure resolved within 48 hours after admission. On May 14, an angiocardiogram was performed in two projections which confirmed the con ventional roentgcnographic appearance of an aneurysmal dilatation of the aorta just beyond the origin of the left subclavian artery.
Fig. 2.—A, The specimen shows the hematoma sac as viewed from the proximal end of the aortic segment. B, An intact aortic wall is seen distally. Microscopically the hematoma separated the adventitia from the media with infarction noted in the outer two thirds of the media. On May 20, approximately 3 months following injury, exploratory left thoracotomy was performed. An aneurysmal dilatation of the thoracic aorta was noted just distal to the left subclavian artery, measuring approximately 6 by 8 by 8 cm. Excision of the aneurysm was possible during partial perfusion of the distal aorta by a left atrium to left femoral artery bypass with a Sigmamotor pump. 2 4 A perfusion rate of 2,200 c.c. per minute was required to control proximal aortic hypertension. A preclotted crimped Dacron prosthesis* was in serted. On the day following surgery, the p a t i e n t ' s blood pressure was 130/80 mm. H g in •Ethigraft available from Ethicon Inc., Somerville, N. J.
Vol. 40, No. 2 August, 1960
TRAUMATIC ANEUEYSM O F THORACIC AORTA
275
all extremities. The postoperative course was uneventful except for an episode of auricular fibrillation occurring on the second postoperative day which responded to increasing doses of digitalis. Since discharge the patient has remained normotensive and is well 1 year following surgery. The pathologic specimen (Fig. 2) showed the large hematoma space outside the aortic lumen. The hematoma presented outside the media of the aortic wall microscopically, which probably explains why the dissection did not progress along the aorta as occurred in the case reported by Rice 16 of a pregnant woman at term, following chest injury. The diagram in Fig. 3 shows the probable sequence of events following aortic tear with formation of the partially obstructing hematoma.
Fig. 3.—The schematic diagram illustrates the location and obstructing nature of the hematoma mass following the aortic wall dissection through the intimai tear. DISCUSSION
The recent publications of Steinberg 18 and others 9 have raised a question as to the advisability of operating on a patient simply because the roentgenographic diagnosis of post-traumatic aneurysm is made. If observation proves to be an accepted form of clinical management, then a recognition of changing hemodynamics in the peripheral vascular system may be significant evidence of active bleeding and impending disaster following chest injury, as is well recognized in dissecting aneurysms. It is quite possible that the sudden de velopment of hypertension proximal to an aortic hematoma may be a cause of sudden rupture late in the course of the aneurysm. Such a sequence of events is suggested in Case 3 reported by Eiseman, 9 although blood pressures were not reported. The patient developed a left hemothorax on the ninth post-injury day. Two hours following this he complained of numbness in his feet and femoral pulses disappeared. The patient suddenly then went into shock and subse quently died immediately after resection of a ruptured aneurysm of the thoracic aorta.
MALM A N D D E T E R L I N G
276
J. Thoracic and Cardiovas. Surg.
It is apparent that when rupture occurs, attempts at surgical correction have been associated with a high mortality. "With the present-day use of atrialfemoral bypass, resection of aneurysms of the descending aorta can be carried out with a mortality of approximately 19 per cent,25 as compared to 27 to 50 per cent using hypothermia or external shunts. There seems then little reason for delaying early surgical excision of an acute traumatic aneurysm or of a chronic symptomatic lesion, once the diagnosis has been established. Observation may be justified in the chronic, stable, calcified anetirysms if careful follow-up is available. Careful repeated records of peripheral pulses, particularly the femoral pulses, in patients following chest injury may give valuable information in the diagnosis and management of a traumatic aneurysm, and indeed may be an early sign heralding disaster. SUMMARY
1. A case of post-traumatic thoracic aortic aneurysm has been described which presented a hemodynamic picture simulating coarctation of the aorta. 2. A careful apprasial of peripheral pulses in patients following chest in jury may give valuable information in establishing a course of management. REFERENCES
1. Rindfleisch, E . : Zuv Entstehung und Heilung des Aneurysma dissecans aortae, Virehows Arch. f. path. Anat. 131: 374-378, 1893. 2. Kemp, P . E. : Traumatic Eupture of the Aorta, Lancet 1: 953, 1923. 3. Kleinsasser, L. G. : Traumatie Eupture of the Thoracic Aorta, Ann. Surg. 118: 1071, 1943. 4. J a y , J . B., and French, S. W., I l l : Traumatic Eupture of the Thoracic A o r t a : Review of Literature and Case Eeport, A. M. A. Arch. Surg. 68: 657-662, 1954. 5. Strassman, G. : Traumatic Eupture of Aorta, Am. Heart J . 3 3 : 508-515, 1947. 6. Bradford, B., J r . , and Johnston, F . L. : Traumatie Eupture of the Aorta, Surgery 28: 893, 1950. 7. Bahnson, H. T . : Definitive Treatment of Saccular Aneurysms of the Aorta With Excision of the Sac and Aortic Suture, Surg. Gynec. & Obst. 96: 383, 1953. 8. Corbitt, A. W., and Mathews, A. E. K . : Eupture of the Aorta; A Case Eeport With Discussion, West Virginia M. J . 3 3 : 372, 1937. 9. Eiseman B., and Eainer, W. G. : Clinical Management of Posttraumatie Eupture of the Thoracic Aorta, J . THORACIC SURG. 35: 347-358, 1958.
10. Forbes, G.: Traumatic Eupture of the Aorta, Brit. M. J . 2 : 400, 1944. 11. Goyette, E . M., Blake, H . A., Forsee, J . H., and Swan, H. : Traumatic Aortic Aneurysm, Circulation 10: 824-828, 1954. 12. Hardin, C. A., Reisman, K. E., and Dimond, E . G. : The Use of Hypothermia in the Eesection and Homologous Eeplaeement of the Thoracic Aorta, Ann. Surg. 140: 720, 1954. 13. Henning, B . H., and Agmar, A. E. : Traumatie Eupture of the Thoracic Aorta; Eeport of a Case, Mil. Surgeon 103: 260, 1948. 14. Hollingsworth, R. K., Johnston, W . W., and McCooey, J . F . : Traumatie Saccular Aneurysm of the Thoracic Aorta, J . THORACIC SURG. 24: 325, 1952.
15. Kuhn, L. P . : Traumatie Rupture of the Thoracic Aorta With Review of 55 Abdominal Injuries, Illinois M. J . 47: 420, 1925. 16. Rice, W. G., and Wittstruck, K. P . : Acute Hypertension and Delayed Traumatic Rupture of the Aorta, J . A. M. A. 147: 915, 1951. 17. Sarot, I . A., and Lazzarini, A. A . : Resection of Aneurysms of the Aortic Arch and Descending A o r t a : Permanent " B y - P a s s " Homograft, Tr. Am. Coll. Cardiol. 5: 175A, 1955. 18. Steinberg, I . : Chronic Traumatic Aneurysm of the Thoracic Aorta, New England J . Med. 257: 913-918, 1957.
Vol. 40, No. 2 Au just 1960
TRAUMATIC ANEURYSM OF THORACIC AORTA
277
19. Storey, C. P., Nardi, G. L., and Sewell, W. H.: Traumatic Aneurysm of Thoracic Aorta: Report of Two Cases, One Successfully Treated by Resection and Graft-Replacement With Aid of Shunt, Ann. Surg. 144: 69-78, 1956. 20. Stranahan, A., Alley, R. D., Sewell, W. H., and Kausel, H. W. : Aortic Arch Resection and Grafting for Aneurysm Employing an External Shunt, J. THORACIC SURG. 29: 54, 1955. 21. Ware, P. F., Adler, R. H., and Hyter, C. S. : Traumatic Aneurysm of the Thoracic Aorta, U. S. Armed Forces M. J. 6: 1674-1690, 1955. 22. Wyman, A. C. : Roentgenologic Diagnosis of Traumatic Rupture of Thoracic Aorta, A. M. A. Arch. Surg. 66: 656-663, 1953. 23. Zehnder, M. A.: Delayed Posttraumatie Rupture of the Aorta in a Young Healthy Individual After Closed Injury, Angiology 7: 252, 1956. 24. Cooley, D. A., De Bakey, M. E., and Morris, G. C. : Controlled Extracorporeal Circulation in Surgieal Treatment of Aortic Aneurysm, Ann. Surg. 146: 473-485, 1957. 25. De Bakey, M. E., Cooley, D. A., Crawford, F., and Morris, G. C. : Aneurysms of the Thoracic Aorta, J. THORACIC SURG. 36: 393-420, 1958.