LETTERS TO THE E D I T O R S
Contouring o f long vascular fabric grafts To the Editors:
Crimped vascular grafts present an advance in vascular surgery. It is important that grafts be inserted under the proper amount of tension. They must never be too short, because the excessive tension may disrupt a suture line and lead to excessive hemorrhage early in the postoperative period, or to a false aneurysm later on. For these reasons there is a tendency to overcompensate when estimating the length of graft necessary to complete a vascular reconstruction. However, if they are placed too loosely, kinking and subsequent graft occlusion can occur. The optimal length is difficult to estimate because crimped grafts elongate when filled with blood at systemic arterial pressures, and a seemingly acceptable graft may be too long when vascular reconstruction is completed. We describe a technique to "take up" the excess in a redundant crimped vascular graft. When a graft bows up or to one side, as shown in Fig. 1, A , the redundant material must be taken up. A 3-0 polypropylene suture is brought through the pleated folds from point x to pointy (inset, Fig. 1), and additional sutures are then placed in similar fashion on either side (Fig. 1, B). Each suture is then tied to bring the folds together (Fig. 1, C), and the vascular reconstruction is again examined. I f any excess graft remains, the procedure can be repeated, with new x and y points. The advantage of a crimped graft is its relative resistance to kinking when placed in an only slightly redundant
Fig. 1. Technique for contouring vascular graft--side view. (inset: amount of graft to be taken in is from x tO y).
fashion. Closure of surrounding tissue will help a slightly redundant graft to assume a straight course. The technique reported here can prevent the need for reclamping vessels and removing or replacing graft segments when the redundancy of the inserted vascular graft is greater than is acceptable. Neal D. Kon, MD Sidney W. Lavender, A4A~Sc A. Robert Cordell, A4D
Department of Cardiothoracic Surgery Wake Forest University Medical Center 300 S. Hawthorne Rd. Winston-Salem, NC 27103
Traumatic subclavian-axiUary artery aneurysm To the Editors:
The formation and rupture of a thoracic aortic aneurysm after blunt trauma is well described and often leads to death. Traumatic subdavian-axillary artery aneurysms, on the other hand, are very rare? An extensive review of the literature failed to reveal a case of a subclavian-axillary artery aneurysm after deceleration injury. CASE REPORT A previously healthy 45-year-old railroad worker was involved in a train wreck as a passenger. The locomotive moving at 35 miles per hour struck another train, throwing him suddenly forward and then backward. At that time he had no discernible injury and was not evaluated by a physician. He resumed work, but 6 weeks later he came to the emergency room with right-sided chest pain and dyspnea. A large pulsatile mass was evident at the base of his neck and left supraclavicular area. Blood pressure and pulses were equal in both arms. Chest radiography and CT scanning revealed a large right pleura/effusion. Arteriography revealed a large left subclavian aneurysm extending 1 cm from its origin to the proximal axillary artery. This fusiform aneurysm could also be illustrated on a CT scan. The presenting symptoms of right-sided chest pain and dyspnea necessitated right thoracotomy and decortication. The surgical findings were consistent with an organized hemothorax. Allowing 4 weeks for satisfactory recovery, he underwent left thoracotomy and ligation of the origin of the left subclavian artery. Because of the large size and length of the aneurysm within the superior mediastinttm, an anatomic tunnel could not safely be made for placement of a bypass graft. Supraclavicular and infraclavicnlar incisions were made to expose the common carotid and axillary arteries, respectively. An extraanatomic carotid to axillary artery interposition polytetrafluoroethylene graft was then constructed. His postoperative course was complicated by