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Ann Thorac Surg 1999;67:1959-1962
© 1999 The Society of Thoracic Surgeons
a Texas Heart Institute, Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA
Address reprint requests to Dr Cooley, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345
Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.
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Abstract |
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My experience began in 1950, when I excised a large aortic aneurysm in one of Dr Alfred Blalock’s patients. The patient survived and was cured. After that experience, I knew that aortic aneurysms could be treated successfully by aggressive surgical means. Treatment has changed, however, from the early emphasis on excising the lesion to the present practice of restoring circulatory continuity with a suitable graft, ie, endoaneurysmorrhaphy. The development of reliable synthetic grafts has been one of the most important advances in the treatment of aneurysms. The surgical technique used today depends on the anatomic location of the aneurysm, which can occur anywhere from the aortic annulus and aortic valve to the distal thoracic aorta and visceral vessels in the abdomen.
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Introduction |
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Two centuries passed before much more was written about treatment of aortic aneurysms. In 1728, Lancisi [3] published De Motu Cordis et Aneurysmatibus, in which he proposed a cause for abdominal aortic aneurysms. In the mid 1800s, surgeons began to think about methods for preventing aneurysms from rupturing. After John Hunter showed that peripheral arteries could be ligated safely, Astley Cooper, one of his pupils, ligated an aneurysm of the aorta [4]. These investigators believed that ligation would slow or arrest circulation within the aneurysmal sac, which would cause thrombosis and eventually obliteration. Surgeons applied the ligature to the artery on the proximal side, the distal side, or both the proximal and distal sides of the aneurysm. Neither proximal nor distal ligation alone proved effective, although proximal and distal ligation together were used with some success by a number of physicians. Ligating the aneurysm, however, rendered the extremities vulnerable to ischemic damage. Thus, treating aortic aneurysms continued to frustrate even the best physicians. In 1900, Sir William Osler summarized the prevailing belief, "There is no disease more conducive to clinical humility than aneurysms of the aorta" [5].
In addition to ligation, introduction of foreign materials was tried as a way to promote coagulation of the blood. Of these materials, wire of various types was most successful (Fig 1). In 1864, Moore [6] inserted and left lengths of silver wire in a thoracic aneurysm to induce clot formation, and in 1879, Corradi passed a galvanic current through the wire [7]. During the next 40 years, the combined Moore-Corradi electrolysis method was adapted by other investigators. One of the most successful adaptations was by Blakemore and King [8], who devised an accurate means of electrothermic coagulation of aneurysms. A deposit of protein coagulum formed on the wire, which stimulated clot production throughout the aneurysm.
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At the same time that investigators were working on indirect methods of treatment, two major breakthroughs occurred in direct repair. In 1888, Dr Rudolph Matas [11, 12] reported a method for internal repair of aneurysms in which continuity of blood flow was restored by a simple intravascular suture of the arterial openings in the aneurysmal sac. In his landmark paper, he described the success of obliterative endoaneurysmorrhaphy and the value of restoring the continuity of the vessel lumen. Although the technique of obliterative endoaneurysmorrhaphy offered advantages over the Hunterian ligature, the disadvantages were apparent. It could not be used satisfactorily if the artery to be sacrificed proved necessary to prevent ischemia or gangrene, and it could not be applied to the aorta or major arteries of the extremities without the possibility of serious complications. Matas [13] subsequently devised two additional endoaneurysmorrhaphy procedures. One he called the restorative, which he used for saccular aneurysms. In the other technique, the reconstructive, he excised the diseased portion of the lesion and created a tunnel through the remaining normal portion. For a half century, this procedure was used in repair of aortic aneurysms, although the technique was limited by the pathologic condition of the aneurysmal sac. Also around the turn of the century, Carrel and Guthrie [14, 15] began experimenting with different techniques for homograft aortic replacements and vascular anastomoses, which would ultimately lead to techniques for excision and graft replacement of the aorta.
Shortly after Matas’ report, Tuffier [16] made several unsuccessful attempts to preserve the continuity of the aorta after the repair by excising the aneurysm. In 1944, Alexander and Byron [17] first successfully excised an aneurysm of the descending aorta associated with coarctation, but they did not attempt to restore aortic continuity. In the same year, Ochsner [18] successfully excised a small saccular aneurysm of the descending aorta. The base of the aneurysm was clamped, the sac excised, and the aorta sutured. In Sweden, Crafoord and Nylin [19] successfully resected and performed end-to-end reanastomosis for coarctation of the thoracic aorta.
My experience with aortic aneurysms began during my residency at Johns Hopkins Hospital. A 32-year-old man had been admitted to the hospital with a large, painful aneurysm in his right upper mediastinal area. Because Dr Blalock was out of town, I was given permission to operate on the aneurysm, which was about to rupture. This operation, performed on April 28, 1950, was my first successful direct surgical attack on an aortic aneurysm.
Shortly after joining the surgical faculty at Baylor College of Medicine in Houston, I operated on a patient with a syphilitic aneurysm of the innominate artery. I reported that case and a few others at the 1951 meeting of the Southern Surgical Association in a paper entitled "Surgical Considerations of Intrathoracic Aneurysms of the Aorta and Great Vessels," with Dr Michael DeBakey [20]. In that paper, we recommended excision of the aneurysm and restoration of aortic continuity by lateral aortorrhaphy. Restoration of distal peripheral flow in patients with extensive sacciform and especially fusiform lesions involving most of the aortic wall, however, awaited the development of aortic substitutes.
The first aortic substitutes were fresh or preserved homografts, that limited the number of procedures that could be done. Gross and colleagues [21], who deserve credit for beginning the modern era of vascular grafting, used preserved homografts to treat aortic coarctation. In 1951, Dubost and colleagues [22] reported using a preserved homograft in the first successful repair of an abdominal aortic aneurysm. Three years later, we reported the first successful repair of a ruptured abdominal aortic aneurysm, again with a preserved homograft [23]. Before such treatment became routine, however, many notable figures had died of ruptured abdominal aneurysms, including Albert Einstein and Joseph Pulitzer.
Fabric grafts made of synthetic fibers were developed in the late 1950s and early 1960s [24–27], which made aneurysmectomy and graft replacement for all aortic aneurysms a standard procedure. Today, synthetic grafts are more effective than ever before. The newer grafts are made of woven or knitted Dacron polyester fibers impregnated with collagen, gelatin, or other substances. Their low porosity minimizes operative bleeding, promotes healing, and resists infection. Because these grafts are more durable, the incidence of pseudoaneurysm formation has also decreased.
During the past century, the treatment of aortic aneurysms has come full circle. In the early 1980s, I began thinking again about endoaneurysmorrhaphy, the technique originally proposed by Matas, which had been abandoned with the advent of fabric grafts. The principle was still valid: relining rather than excising the diseased portion of the aorta would be a more physiologic repair. By leaving the aneurysmal wall intact, anatomic structures such as the lung, phrenic and vagus nerves, duodenum, and left kidney are not disturbed, and the limited dissection reduces blood loss (Fig 2) [28]. I have been using this technique successfully now for 15 years.
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The most important challenge, however, remains for the future—to find a method to repair lesions in the descending aorta that will consistently protect the spinal cord from ischemic injury. Currently, many methods have been proposed, but no single method has given uniformly good results. We have successfully used a method of distal exsanguination, or open distal repair [29]. The combination of a short clamp time and possibly a reduced cerebrospinal fluid pressure most likely is responsible for our excellent results.
Better techniques might eventually prevent both spinal cord and cerebral ischemia. Until then, however, surgeons should continue to use techniques that have worked well in their practices. In my experience, ischemic complications can be best controlled by limiting the period of induced ischemia through a simple, expeditious surgical technique.
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This article has been cited by other articles:
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  D. R. Brinster, D. M. McKee, D. M. Olsen, S. S. Berman, and J. A. Rodriguez-Lopez Endovascular treatment of a thoracic aortic pseudoaneurysm after previous open repair. Ann. Thorac. Surg., July 1, 2006; 82(1): 308 - 310. [Abstract] [Full Text] [PDF]
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