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Traumatic Aneurysms of the Thoracic Aorta
Traumatic Aneurysms of the Thoracic Aorta Excision and Repair Without Graft
Arthur M. Kahn, M.D., William L. Joseph, M.D., and Richard K. Hughes, M.D."
D
uring the last few decades a rising number of injuries due to sudden deceleration in auto accidents has resulted in an increased number of traumatic aneurysms. Improved angiography and techniques of extracorporeal circulation have led to definitive diagnosis and relatively safe repair [3, 41. T h e epidemiology, pathogenesis, diagnosis, and various methods of surgical repair have previously been adequately described [6, 91. The concept of repair of traumatic thoracic aortic aneurysms without grafts was first proposed in 1961 by Alley [l]. Although this approach seems to be rational, feasible, and successful, it has received only sporadic application. Only 9 cases have been reported in which repair without graft has been performed [Z, 5, 7, 8, lo]. We have excised 5 chronic traumatic aortic aneurysms, and we have repaired the aorta in each instance without a graft. The purpose of this report is to reemphasize the pathological anatomy of these aneurysms as well as the rationale and feasibility of surgical excision followed by repair without the use of a vascular prosthesis. CASE
1
A 46-year-old man was admitted to the hospital for treatment of a cutaneous basal cell carcinoma. H e had fractured three ribs on his left side 12 years before in an auto accident. After recovering from these injuries he was asymptomatic. A routine chest x-ray showed a calcified mass which was inseparable from the aortic shadow and projected into the left hemithorax at the distal aortic arch (Fig. 1). A traumatic aneurysm was suspected and was confirmed by aortography (Fig. 2). At operation the aneurysm measured 4 X 2 x 3 cm.; it was in a n anterior medial position directly in approximation with the ligamentum arteriosum and approximately 2 cm. distal to the origin of the left subclavian artery. From the Division of Thoracic and Cardiovascular Surgery, Wadsworth Hospital, Veterans Administration Center, Los Angeles, and the Department of Surgery, UCLA School of Medicine, Los Angeles, Calif. Accepted for publication April 17, 1967. 'Present address: Department of Surgery, College of Medicine, University of Utah, Salt Lake City, Utah. Reprint requests to Wadsworth Hospital (Dr. Kahn).
VOL.
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NO. 2, AUG.,
1967
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FIG. 1. Case 1. X-ray shows a calcified mass e x t e n d i n g into t h e left h e m i t h o r a x from t h e distal aortic arch.
F I G . 2. Case 1. Aortogram shows t h e anezlyysrn just distal t o t h e origin of t h e left subclauian artery. T h e wall of the aneurysm was calcified throughout and had an egg-shell character. With left atrium-femoral artery bypass the aneurysm was incised, and an anterior medial transverse tear was found in the aortic wall. There was no clot within the aneurysm. T h e aneurysm was excised and the normal posterior aortic wall left intact. T h e anterior defect was easily approximated. T h e patient’s postoperative course was uneventful, and he has done well for 2 years. His chest x-rays are unremarkable. CASE
2
A 35-year-old man fractured his left clavicle and right forearm 10 years before in an auto accident. There was no apparent chest injury. Eight years later an esophagogram showed an aortic aneurysm which was confirmed by a thoracic
176
THE ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
FIG. 3 . Case 2. Aortogram shows the typical location and saccular nature of these aneurysms. aortogram (Fig. 3). A subsequent chest x-ray revealed enlargement of the aneurysm. At operation a 4 x 3 x 3 cm. thin-walled and calcified aneurysm was found 2 cm. below the ligamentum arteriosum on the posterior medial aspect of the descending thoracic aorta. After resection of the aneurysm with left heart bypass, it was possible to anastomose the margins of the aorta without the use of a prosthetic graft. His postoperative course was uncomplicated, and he has done well for 3% years postoperatively. Chest x-rays have been unremarkable. CASE
3
A 44-year-old man was in a head-on auto accident 19 years prior to his current hospitalization. He fractured his left leg, left shoulder, skull, facial bones, and ribs. Recovery was satisfactory and he remained in good health except for the occurrence of recent mild left anterior chest pain and mild dyspnea on exertion. A preemployment chest x-ray showed a probable thoracic aneurysm. At physical examination the left radial pulse was diminished. Aortography confirmed the presence of a thoracic aortic aneurysm just distal to the left subclavian artery (Fig. 4). During left heart bypass a large traumatic aneurysm was removed. T h e margins of the aneurysm were trimmed to where the aortic wall was full in thickness, and the posterior third of the normal aorta was left intact. The anterior aortic wall was reapproximated. After a temporary left recurrent nerve palsy resolved, his postoperative course was uncomplicated. He is well 1 year after operation. CASE
4
A 24-year-old man was injured in an auto accident. He sustained multiple facial fractures as well as a blunt injury to his chest from the steering wheel. His recovery was satisfactory, and he was asymptomatic. Two years later a routine chest x-ray showed a posterior mediastinal mass (Fig. 5). During an exploratory thoracotomy an aneurysm of the descending aorta was found. He was referred to the UCLA Medical Center, where a 10 x 5 x 5 cm. fibrous aneurysm was located immediately below the origin of the left subclavian artery. During left heart bypass the aneurysm was excised. It contained 250 cc. of clot. T h e ends of the aorta were approximated without a graft. The postoperative course was uncomplicated, and chest x-rays after 2% years are unremarkable. VOL.
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NO. 2, AUG.,
1967
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FIG. 4. Case ?. Aortogram shows this traumatic aneurysm partially obstructing the left subclavian artery.
F I G . 5. Case 4. X-ray shows a large left paramediastinal mass which was a 10 x 5 x 5 cm. traumatic aortic aneurysm. CASE
5
A 52-year-old man had fractured his skull and ribs of his left side 10 years
before in an auto accident. Following recovery he was asymptomatic until one month before admission, when he experienced progressively worsening hoarseness. Paralysis of the left vocal cord was seen, and chest x-ray showed a large posterior mediastinal mass. An aortogram showed an aneurysm arising from the aorta just distal to the takeoff of the left subclavian artery, which it displaced superiorly and medially (Fig. 6). At operation the aneurysm encroached on the left subclavian artery. During left heart bypass the aneurysm was opened longitudinally, exposing a large clot. After most of the aneurysm was excised it became apparent that the aorta had been transversely torn just distal to the ligamentum
178
T H E ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
Case 5 . Aortogram shows a large traumatic aneurysm which is partially filled with clot. I t displaced the left subclavian artery and caused a left recurrent laryngeal nerve paresis.
FIG. 6.
arteriosum. T h e fracture extended around approximately 50% of the aortic circumference. T h e aorta was approximated without a graft. T h e postoperative course was uncomplicated; six months later his voice was normal, and his vocal cords moved normally. A postoperative aortogram showed no abnormalities at the site of repair (Fig. 7). He is well 1 year after operation.
Case 5. T h i s postoperative aortogram shows a normal aortic lumen at the site of repair. F I G . 7.
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4,
NO. 2, AUG.,
1967
179
KAHN, JOSEPH, AND HUGHES COMMENT
T h e patients’ ages ranged from 24 to 52 years. Each had a prior history of a serious auto accident. In all but one case the diagnosis was suspected after a standard posterior-anterior chest x-ray was viewed. In one case the chest x-ray was unremarkable, but an esophagogram showed a mass compressing the esophagus. In 4 patients the diagnosis of chronic traumatic aneurysm of the thoracic aorta was confirmed by angiography. The interval between the initiating trauma and operation ranged from 2 to 19 years, with an average of 10.6 years. T h e aneurysm was corrected surgically in all cases under left atrium-femoral artery bypass. There were no significant operative or postoperative complications and no deaths. Follow-up has ranged from 1 to 3 s years, and no late complications have developed. DISCUSSION
The natural history of traumatic thoracic aortic aneurysms is not well known. We do know that they can remain stable for many years and then begin to enlarge or rupture. The wall of these aneurysms is thin, usually calcified, and often free of laminated blood clot. Because of the threat of rupture of acute or chronic false aneurysms, we believe they should be removed when diagnosed. There are several advantages to aortic repair without a graft for traumatic thoracic aneurysms. Less operating time is required, since there is only one suture line rather than the two required when a graft is employed. At the time of exploration a linear transverse tear is often present in an otherwise normal aorta. After the false sac is removed, the edges of the torn aortic wall may be found to be intact and satisfactory for a primary repair. The margins of the chronic aneurysms are tough and hold sutures well. There is a potential for greater blood loss through a prosthetic graft following administration of heparin. Excision and complete or partial end-to-end anastomosis eliminates the risk of subsequent infection in a vascular prosthesis. The use of vascular prosthetics is a relatively recent surgical development. They have been and are continuing to be improved upon but, nevertheless, the long-term results (greater than 20 years) are unknown. Repair without a graft eliminates this unknown. This may be an important factor in the treatment of the young patient. SUMMARY
The concept of repair of traumatic thoracic aortic aneurysms without a graft was first proposed in 1961. Although this approach seems to be rational, feasible, and successful, there have been only 9 cases of 180
T H E ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
repair without graft in the literature. We have presented 5 cases in which traumatic aneurysms of the thoracic aorta were removed and aortic continuity restored without a graft. T h e aneurysms were excised, and a complete or partial end-to-end anastomosis was successfully performed. Left atrium-femoral artery bypass was employed in each case. All patients had good results and have now been followed from 1 to 3% years. T h e advantages of aortic repair without graft are emphasized. REFERENCES 1. Alley, R. D. In Discussion of F. C. Spencer, P. F. Guerin, H. A. Blake, and H. T. Bahnson, A report of fifteen patients with traumatic rupture of the thoracic aorta. J. Thorac. Cardiov. Surg. 41:1, 1961. 2. Alley, R. D., Van Mierop, L. H. S., Yi, E. Y., Jagdish, K. R., Kausel, H. W., and Stranahan, A. Traumatic aortic aneurysm: Four cases of graftless excision and anastomosis. Ann. Thorac. Surg. 2:514, 1966. 3. Cooley, D. A., Belmonte, B. A., De Bakey, M. E., and Latson, J. R. Temporary extracorporeal circulation in the surgical treatment of cardiac and aortic disease. Ann. Surg. 145:898, 1957. 4. Cooley, D. A., De Bakey, M. E., and Morris, G. C., Jr. Controlled extracorporeal circulation in surgical treatment of aortic aneurysm. Ann. Surg. 146:473, 1957. 5. Groves, L. K. Experience with thirteen cases of resection of aneurysms of the descending thoracic aorta. Cleveland Clin. Quart. 28: 176, 1961. 6. Groves, L. K. Traumatic aneurysm of the thoracic aorta. New Eng. J. Med. 270:220, 1964. 7. McClenathan, E. J., and Brettschnieder, L. Traumatic thoracic aortic aneurysms. J. Thorac. Cardiov. Surg. 50:74, 1965. 8. Maamies, T., Kyllonin, K. E. J., and Virkkula, L. Clinical observations on the surgery of aortic aneurysms. Acta Chir. Scand. 128:641, 1964. 9. Parmley, L. F., Mattingly, T. W., Manion, W. C., and Jahnke, E. J., Jr. Nonpenetrating traumatic injury to the aorta. Circulation 17: 1086, 1958. 10. Schonholtz, G. J., and Jahnke, E. J. Occult injury of the thoracic aorta associated with orthopaedic trauma. J . Bone Joint Surg. 46A: 1421, 1964.
VOL.
4,
NO. 2, AUG.,
1967
181
Arthur M. Kahn, M.D., William L. Joseph, M.D., and Richard K. Hughes, M.D."
D
uring the last few decades a rising number of injuries due to sudden deceleration in auto accidents has resulted in an increased number of traumatic aneurysms. Improved angiography and techniques of extracorporeal circulation have led to definitive diagnosis and relatively safe repair [3, 41. T h e epidemiology, pathogenesis, diagnosis, and various methods of surgical repair have previously been adequately described [6, 91. The concept of repair of traumatic thoracic aortic aneurysms without grafts was first proposed in 1961 by Alley [l]. Although this approach seems to be rational, feasible, and successful, it has received only sporadic application. Only 9 cases have been reported in which repair without graft has been performed [Z, 5, 7, 8, lo]. We have excised 5 chronic traumatic aortic aneurysms, and we have repaired the aorta in each instance without a graft. The purpose of this report is to reemphasize the pathological anatomy of these aneurysms as well as the rationale and feasibility of surgical excision followed by repair without the use of a vascular prosthesis. CASE
1
A 46-year-old man was admitted to the hospital for treatment of a cutaneous basal cell carcinoma. H e had fractured three ribs on his left side 12 years before in an auto accident. After recovering from these injuries he was asymptomatic. A routine chest x-ray showed a calcified mass which was inseparable from the aortic shadow and projected into the left hemithorax at the distal aortic arch (Fig. 1). A traumatic aneurysm was suspected and was confirmed by aortography (Fig. 2). At operation the aneurysm measured 4 X 2 x 3 cm.; it was in a n anterior medial position directly in approximation with the ligamentum arteriosum and approximately 2 cm. distal to the origin of the left subclavian artery. From the Division of Thoracic and Cardiovascular Surgery, Wadsworth Hospital, Veterans Administration Center, Los Angeles, and the Department of Surgery, UCLA School of Medicine, Los Angeles, Calif. Accepted for publication April 17, 1967. 'Present address: Department of Surgery, College of Medicine, University of Utah, Salt Lake City, Utah. Reprint requests to Wadsworth Hospital (Dr. Kahn).
VOL.
4,
NO. 2, AUG.,
1967
175
KAHN, JOSEPH, AND HUGHES
FIG. 1. Case 1. X-ray shows a calcified mass e x t e n d i n g into t h e left h e m i t h o r a x from t h e distal aortic arch.
F I G . 2. Case 1. Aortogram shows t h e anezlyysrn just distal t o t h e origin of t h e left subclauian artery. T h e wall of the aneurysm was calcified throughout and had an egg-shell character. With left atrium-femoral artery bypass the aneurysm was incised, and an anterior medial transverse tear was found in the aortic wall. There was no clot within the aneurysm. T h e aneurysm was excised and the normal posterior aortic wall left intact. T h e anterior defect was easily approximated. T h e patient’s postoperative course was uneventful, and he has done well for 2 years. His chest x-rays are unremarkable. CASE
2
A 35-year-old man fractured his left clavicle and right forearm 10 years before in an auto accident. There was no apparent chest injury. Eight years later an esophagogram showed an aortic aneurysm which was confirmed by a thoracic
176
THE ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
FIG. 3 . Case 2. Aortogram shows the typical location and saccular nature of these aneurysms. aortogram (Fig. 3). A subsequent chest x-ray revealed enlargement of the aneurysm. At operation a 4 x 3 x 3 cm. thin-walled and calcified aneurysm was found 2 cm. below the ligamentum arteriosum on the posterior medial aspect of the descending thoracic aorta. After resection of the aneurysm with left heart bypass, it was possible to anastomose the margins of the aorta without the use of a prosthetic graft. His postoperative course was uncomplicated, and he has done well for 3% years postoperatively. Chest x-rays have been unremarkable. CASE
3
A 44-year-old man was in a head-on auto accident 19 years prior to his current hospitalization. He fractured his left leg, left shoulder, skull, facial bones, and ribs. Recovery was satisfactory and he remained in good health except for the occurrence of recent mild left anterior chest pain and mild dyspnea on exertion. A preemployment chest x-ray showed a probable thoracic aneurysm. At physical examination the left radial pulse was diminished. Aortography confirmed the presence of a thoracic aortic aneurysm just distal to the left subclavian artery (Fig. 4). During left heart bypass a large traumatic aneurysm was removed. T h e margins of the aneurysm were trimmed to where the aortic wall was full in thickness, and the posterior third of the normal aorta was left intact. The anterior aortic wall was reapproximated. After a temporary left recurrent nerve palsy resolved, his postoperative course was uncomplicated. He is well 1 year after operation. CASE
4
A 24-year-old man was injured in an auto accident. He sustained multiple facial fractures as well as a blunt injury to his chest from the steering wheel. His recovery was satisfactory, and he was asymptomatic. Two years later a routine chest x-ray showed a posterior mediastinal mass (Fig. 5). During an exploratory thoracotomy an aneurysm of the descending aorta was found. He was referred to the UCLA Medical Center, where a 10 x 5 x 5 cm. fibrous aneurysm was located immediately below the origin of the left subclavian artery. During left heart bypass the aneurysm was excised. It contained 250 cc. of clot. T h e ends of the aorta were approximated without a graft. The postoperative course was uncomplicated, and chest x-rays after 2% years are unremarkable. VOL.
4,
NO. 2, AUG.,
1967
177
KAHN, JOSEPH, AND HUGHES
FIG. 4. Case ?. Aortogram shows this traumatic aneurysm partially obstructing the left subclavian artery.
F I G . 5. Case 4. X-ray shows a large left paramediastinal mass which was a 10 x 5 x 5 cm. traumatic aortic aneurysm. CASE
5
A 52-year-old man had fractured his skull and ribs of his left side 10 years
before in an auto accident. Following recovery he was asymptomatic until one month before admission, when he experienced progressively worsening hoarseness. Paralysis of the left vocal cord was seen, and chest x-ray showed a large posterior mediastinal mass. An aortogram showed an aneurysm arising from the aorta just distal to the takeoff of the left subclavian artery, which it displaced superiorly and medially (Fig. 6). At operation the aneurysm encroached on the left subclavian artery. During left heart bypass the aneurysm was opened longitudinally, exposing a large clot. After most of the aneurysm was excised it became apparent that the aorta had been transversely torn just distal to the ligamentum
178
T H E ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
Case 5 . Aortogram shows a large traumatic aneurysm which is partially filled with clot. I t displaced the left subclavian artery and caused a left recurrent laryngeal nerve paresis.
FIG. 6.
arteriosum. T h e fracture extended around approximately 50% of the aortic circumference. T h e aorta was approximated without a graft. T h e postoperative course was uncomplicated; six months later his voice was normal, and his vocal cords moved normally. A postoperative aortogram showed no abnormalities at the site of repair (Fig. 7). He is well 1 year after operation.
Case 5. T h i s postoperative aortogram shows a normal aortic lumen at the site of repair. F I G . 7.
VOL.
4,
NO. 2, AUG.,
1967
179
KAHN, JOSEPH, AND HUGHES COMMENT
T h e patients’ ages ranged from 24 to 52 years. Each had a prior history of a serious auto accident. In all but one case the diagnosis was suspected after a standard posterior-anterior chest x-ray was viewed. In one case the chest x-ray was unremarkable, but an esophagogram showed a mass compressing the esophagus. In 4 patients the diagnosis of chronic traumatic aneurysm of the thoracic aorta was confirmed by angiography. The interval between the initiating trauma and operation ranged from 2 to 19 years, with an average of 10.6 years. T h e aneurysm was corrected surgically in all cases under left atrium-femoral artery bypass. There were no significant operative or postoperative complications and no deaths. Follow-up has ranged from 1 to 3 s years, and no late complications have developed. DISCUSSION
The natural history of traumatic thoracic aortic aneurysms is not well known. We do know that they can remain stable for many years and then begin to enlarge or rupture. The wall of these aneurysms is thin, usually calcified, and often free of laminated blood clot. Because of the threat of rupture of acute or chronic false aneurysms, we believe they should be removed when diagnosed. There are several advantages to aortic repair without a graft for traumatic thoracic aneurysms. Less operating time is required, since there is only one suture line rather than the two required when a graft is employed. At the time of exploration a linear transverse tear is often present in an otherwise normal aorta. After the false sac is removed, the edges of the torn aortic wall may be found to be intact and satisfactory for a primary repair. The margins of the chronic aneurysms are tough and hold sutures well. There is a potential for greater blood loss through a prosthetic graft following administration of heparin. Excision and complete or partial end-to-end anastomosis eliminates the risk of subsequent infection in a vascular prosthesis. The use of vascular prosthetics is a relatively recent surgical development. They have been and are continuing to be improved upon but, nevertheless, the long-term results (greater than 20 years) are unknown. Repair without a graft eliminates this unknown. This may be an important factor in the treatment of the young patient. SUMMARY
The concept of repair of traumatic thoracic aortic aneurysms without a graft was first proposed in 1961. Although this approach seems to be rational, feasible, and successful, there have been only 9 cases of 180
T H E ANNALS OF THORACIC SURGERY
CASE REPORTS:
Traumatic Aneurysms of Aorta
repair without graft in the literature. We have presented 5 cases in which traumatic aneurysms of the thoracic aorta were removed and aortic continuity restored without a graft. T h e aneurysms were excised, and a complete or partial end-to-end anastomosis was successfully performed. Left atrium-femoral artery bypass was employed in each case. All patients had good results and have now been followed from 1 to 3% years. T h e advantages of aortic repair without graft are emphasized. REFERENCES 1. Alley, R. D. In Discussion of F. C. Spencer, P. F. Guerin, H. A. Blake, and H. T. Bahnson, A report of fifteen patients with traumatic rupture of the thoracic aorta. J. Thorac. Cardiov. Surg. 41:1, 1961. 2. Alley, R. D., Van Mierop, L. H. S., Yi, E. Y., Jagdish, K. R., Kausel, H. W., and Stranahan, A. Traumatic aortic aneurysm: Four cases of graftless excision and anastomosis. Ann. Thorac. Surg. 2:514, 1966. 3. Cooley, D. A., Belmonte, B. A., De Bakey, M. E., and Latson, J. R. Temporary extracorporeal circulation in the surgical treatment of cardiac and aortic disease. Ann. Surg. 145:898, 1957. 4. Cooley, D. A., De Bakey, M. E., and Morris, G. C., Jr. Controlled extracorporeal circulation in surgical treatment of aortic aneurysm. Ann. Surg. 146:473, 1957. 5. Groves, L. K. Experience with thirteen cases of resection of aneurysms of the descending thoracic aorta. Cleveland Clin. Quart. 28: 176, 1961. 6. Groves, L. K. Traumatic aneurysm of the thoracic aorta. New Eng. J. Med. 270:220, 1964. 7. McClenathan, E. J., and Brettschnieder, L. Traumatic thoracic aortic aneurysms. J. Thorac. Cardiov. Surg. 50:74, 1965. 8. Maamies, T., Kyllonin, K. E. J., and Virkkula, L. Clinical observations on the surgery of aortic aneurysms. Acta Chir. Scand. 128:641, 1964. 9. Parmley, L. F., Mattingly, T. W., Manion, W. C., and Jahnke, E. J., Jr. Nonpenetrating traumatic injury to the aorta. Circulation 17: 1086, 1958. 10. Schonholtz, G. J., and Jahnke, E. J. Occult injury of the thoracic aorta associated with orthopaedic trauma. J . Bone Joint Surg. 46A: 1421, 1964.
VOL.
4,
NO. 2, AUG.,
1967
181