Ann Thorac Surg 2008;85:641-643. doi:10.1016/j.athoracsur.2007.07.081
© 2008 The Society of Thoracic Surgeons
Case Reports
Aneurysm of a Right-Sided Descending Aorta With a Normal Left-Sided Aortic Arch
Masahiro Daimon, MD, PhDa,*,
Hideki Ozawa, MDa,
Kazuo Kurihara, MDb,
Takahiro Katsumata, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
b Department of Cardiovascular Surgery, Cardiovascular Center, Kyoto-Katsura Hospital, Nishikyo, Kyoto, Japan
Accepted for publication July 26, 2007.
* Address correspondence to Dr Daimon, Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka, 569-8686, Japan (Email: m-daimon{at}jg7.so-net.ne.jp).
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Abstract
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We encountered an extremely rare case of a saccular aneurysm of the descending aorta developing to the right of the spinal column with a normal left-sided aortic arch. An 80-year-old man was admitted to our hospital because of a saccular aneurysm of the right-sided descending aorta that had increased in diameter. Resection of the aneurysm and prosthetic graft replacement of the right-sided descending thoracic aorta were successfully performed under deep hypothermia through a right thoracotomy.
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Introduction
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Because aneurysms of the right-sided descending aorta with the left-sided aortic arch are quite uncommon, few opinions on surgical treatment exist. We report our surgical strategy for this unusual entity and present a review of the literature.
An 80-year-old man was admitted to our hospital because of a saccular aneurysm of the descending aorta, which was detected on computed tomography several years previously, but it had increased in size from a diameter of 50 mm to 70 mm within 1 year. Hypertension had been present for more than 18 years. However, no symptoms had been noted. A chest x-ray film showed the dilatation of the mediastinum toward the right hemithorax (Fig 1). A computed tomographic scan (Fig 2) and angiographic examinations (Fig 3) revealed that the tortuous descending aorta was on the spinal column at the sixth thoracic vertebra just behind the esophagus, which ran along the right side of the spinal column to the first lumbar vertebra, and then returned to the usual position. The dilatation of the aorta was seen from the seventh thoracic to the first lumbar vertebra. The patient had a past history of tuberculous pleuritis of the left hemithorax, partial gastrectomy for a gastric ulcer, and cholecystectomy for cholecystitis. Serological tests for syphilis were negative. No congenital anomalies were found on examination.
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Fig 1. Posteroanterior chest x-ray film on admission shows a large mass occupying the right lower-lung field with a left-sided aortic arch.
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Fig 2. A saccular aneurysm of the descending aorta passing through the right side of the spinal column.
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Fig 3. Anteroposterior aortogram shows a saccular aneurysm of the descending aorta, which ran along the right side of the spinal column.
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The right fifth intercostal space was opened, and a seventh intercostal pleurotomy was added to access the distal part of the descending aorta. Dense adhesions were seen in the pleural cavity. Cardiopulmonary bypass through ascending aortic perfusion and right atrial drainage was established, and perfusion cooling was initiated. A venting catheter was inserted into the left atrium through the right upper pulmonary vein. When the rectal temperature dropped below 18°C, the descending aorta just proximal to the diseased segment was clamped. Partial extracorporeal circulation was continued to maintain the cerebral and coronary circulation under ventricular fibrillation. The partial circulatory flow was 1,000 mL/min and the mean aortic pressure was maintained around 40 mm Hg. The proximal aorta was transected at the appropriate level. The aneurysm was then incised longitudinally just above the diaphragm. The aneurysm was extensively atherosclerotic with dense calcification, and all intercostal arteries were occluded. The anastomosis to the proximal aorta using a woven polyester, gelatin coated, 22 mm-prosthetic branched graft (Gelweave Ante-Flo; Sulzer Vascutek Ltd, Renfrewshire, Scotland) was completed using 3-0 polypropylene sutures, reinforced with polyester felt. Distal anastomosis was performed by an open aortic technique. Extracorporeal circulation lasted 160 minutes. The duration of the ventricular fibrillation was 106 minutes and the circulatory arrest of the lower body was 49 minutes. No neurocognitive dysfunction was found during the postoperative period. The postoperative chest computed tomographic scan showed no abnormal findings. Respirator management was required for 12 hours. However, he took time for rehabilitation for respiratory functional disorder. The patient was discharged on postoperative day 40.
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Comment
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Although there are some reports of right-sided descending aortas with a right-sided aortic arch [1, 2], atherosclerotic aneurysm of the descending aorta developing to the right of the spinal column with a normal left-sided aortic arch is extremely rare. Because Epstein and Friedman [3] reported the first case of the aneurysm of the descending aorta protruding to the right of the spine in 1949, several case reports have been subsequently made [4–6]. These reports usually focused on the difficulty of the diagnosis, because chest x-ray films were the major diagnostic method in those days.
The first successful surgical case was reported by Claxton and Dillon in 1969 [5]. The patient underwent closure of the neck of the saccular aneurysm and resection of the aneurysmal wall through a right thoracotomy. In 1970, Engelman and Clauss [6] reported another case of an aneurysm presenting in the right thorax. They performed resection of the aneurysm and an end-to-end anastomosis using an aorta-to-aorta shunt through a left thoracotomy [6]. In our case, a right thoracotomy was chosen because total resection of the aneurysm and distal anastomosis would be difficult through a left thoracotomy.
Deep hypothermic partial extracorporeal circulation was used for the protection of the spinal cord and abdominal organs. Deep hypothermia also enables open distal anastomosis. In the present case, complete resection of the aneurysmal wall was impossible if the clamp was on the distal aorta of the anastomosis.
In this case, distal anastomosis could fortunately be made inside the right pleural cavity. However, if an aortic aneurysm progresses behind the liver, surgical approach is a major concern. In such a case, the total resection of the aortic aneurysm is very difficult, but two palliative methods are possible. First, through a right thoracotomy, partial resection of an aneurysm is performed and distal anastomosis is accomplished in the pleural cavity using an aneurysmal wall. However, the dilated aorta remains behind the liver. Second, an anatomical bypass is accomplished with a vascular prosthesis from the distal aortic arch to the abdominal aorta, and a bilateral stump of the aortic aneurysm is closed through a left spiral incision. However, because a right-side aneurysm remains untouched, the residual aneurysm might be at risk of rupture because of the inflow of blood from the intercostal artery to the aneurysm. Partial resection of a residual aortic aneurysm through a right thoracotomy can be performed after the bypass surgery, but the operative invasion becomes serious.
Antegrade physiologic perfusion reduces the risk of embolism formation and maintains the cerebral and coronary circulation during descending aortic surgery. Thus, femoral artery perfusion was avoided. In addition, this method was easily applicable in this case, because it is easy to access an ascending aorta through a right thoracotomy.
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References
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- Tsukube T, Ataka K, Sakata M, Wakita N, Okita Y. Surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery Ann Thorac Surg 2001;71:1710-1711.[Abstract/Free Full Text]
- Yasuda T, Yamamoto S, Ishida Y. Double aneurysms of arch and descending aorta associated with right aortic arch Ann Thorac Surg 2000;70:1405-1407.[Abstract/Free Full Text]
- Epstein BS, Friedman RL. Arteriosclerotic aneurysm of the descending thoracic aorta presenting to the right of the spine Radiology 1949;53:93-96.[Medline]
- Malcolm JA, Lawrence LR, Principato DJ. Aortic aneurysms of right side New York State J Med 1967;67:1772-1779.
- Claxton CP, Dillon Jr ML. Saccular aneurysm of the descending thoracic aorta presenting as a right chest mass Ann Thorac Surg 1969;7:34-37.[Medline]
- Engelman RM, Clauss RH. Descending thoracic aortic aneurysm presenting in the right thorax; diagnosis and surgical management Chest 1970;57:277-279.[Medline]
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Abstract
Introduction
