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
l C
Fig. 1. Technique for contouring vascular graft--side view. (inset: amount of graft to be taken in is from x tO y).
848
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
Volume 11 Number 6 June 1990
a transient left vocal cord paralysis that resolved. Blood pressure in the left arm was normal after operation.
DISCUSSION The subclavian and axillary arteries comprise less than 1% of all reported peripheral artery aneurysms. The most common causes are either severe crushing chest trauma or extrinsic compression by the confines of the thoracic outlet? Blunt shoulder girdle injuries and anterior dislocations can also result in major upper extremity arterial damage. ~ Another unusual cause is extrinsic trauma caused by chronic crutch usage as reported by Abbott and Darling. 4 The development of an isolated subclavian artery aneurysm after deceleration injury is a rare event. The subdavian arteries appear to have been spared the risk of aneurysmal complications as a manifestation of generalized atherosclerosis. The most common presentations of subclavian artery aneurysms, especially those caused by thoracic outlet syndrome, are peripheral embolization and brachial nerve compression? Repeated emboli from subclavian artery ane,,~'~sm may result in tissue loss and gangrene. Rupture and thrombosis of subclavian artery aneursyms has been reported but is rare. In the case reported here, the cause of the sudden tight hemothorax was not found. A possible source of the bleeding was an unsuspected injured intercostal artery, although there were no discemible rib fracnares. His left subclavian artery aneurysm was essentially asymptomatic. Surgical treatment of these aneurysms is recommended in all patients in good health because of the significant risk to life and extremity from rupture, thrombosis, and peripheral embolization. ~ The primary goal in the therapy of subclavian artery aneurysms is to exclude or resect the aneurysm. All aneurysms should be resected and replaced with an interposition graft. Ligation without arterial reconstruction should not be performed because claudication occurred after operation in 25% of patients reported by "~firolero et al.6 The complex anatomic relationship of the subclavian artery can make exposure and vascular control difficult. The surgical approach to intrathoracic subclavian artery aneurysms depends primarily on the side of the aneurysm. Median sternotomy is preferred for the treatment of rightsided aneurysms, permitting proximal and distal control with access to the innominate artery and ascending aorta. Left subclavian artery aneurysms are best approached through a left lateral thoracotomy for proximal control. A supraclavicular incision is-used for distal subclavian artery control, and an infraclavicular incision is used if it extends to the axillary artery. Anatomic reconstruction is performed if possible, although alternative extraanatomic procedures are necessary when the configuration of the aneurysm or general medical condition of a patient imposes limitations. A carotid to axillary artery bypass was placed in our patient because of the large width and length of the aneurysm that prevented placement of a graft in the normal anatomic location.
Letters to the Editors
849
In summary, subclavian artery aneurysms are a rare result of traumatic deceleration injuries. Prompt diagnosis by angiography and repair are indicated because of its disabling complications of thromboembolism and brachial plexus compression. Exclusion and reestablishment of flow is the procedure of choice when the aneurysm size and location precludes its anatomic reconstruction. Andrew J. Olinde, MI)
Department of Surgery Ochsner Clinic of Baton Rouge 16777 Medical Center Dr. Baton Rouge, LA 70816 REFERENCES
1. Rich NM, Hobson RW, Jarstfer BS, Geer TM. Subclavian artery trauma. J Trauma 1973;13:485-96. 2. Hobson TW, Israel MR, Lynch TG. Axillosubclavian arterial aneurysms. New York: Grtme& Stratton, 1982. 3. Zelenock GB, Kazmas A, Graham LM, et al. Nonpenetrating subdavian artery injuries. Arch Surg 1985;120:685-92. 4. Abbott WM, Darling RC. Axillary artery aneurysms secondary to crutch trauma. Am J Surg 1973;125:515-20. 5. Cosell IS, Crawford ES. Surgical treatment of aneurysms of the intrathoracic segment of the subclavian artery. Chest 1987;91:704-8. 6. Pairolero PC, Walls JT, Payne WJ, Hollier LH, Fairbairn JF. Subclavian-axillary artery aneurysms. Surgery 1981;90:75763. Resection o f abdominal aortic aneurysm in patients with l o w ejection fractions
To the Editors:
I read with interest an article entitled, "Resection of abdominal aortic aneurysm in patients with low ejection fractions" by McCann and Wolfe (J VASC SUltG 1989; 10:240-4). I was very surprised to find that I was quoted as having suggested that patients with ejection fraction (EF)~
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
l C
Fig. 1. Technique for contouring vascular graft--side view. (inset: amount of graft to be taken in is from x tO y).
848
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
Volume 11 Number 6 June 1990
a transient left vocal cord paralysis that resolved. Blood pressure in the left arm was normal after operation.
DISCUSSION The subclavian and axillary arteries comprise less than 1% of all reported peripheral artery aneurysms. The most common causes are either severe crushing chest trauma or extrinsic compression by the confines of the thoracic outlet? Blunt shoulder girdle injuries and anterior dislocations can also result in major upper extremity arterial damage. ~ Another unusual cause is extrinsic trauma caused by chronic crutch usage as reported by Abbott and Darling. 4 The development of an isolated subclavian artery aneurysm after deceleration injury is a rare event. The subdavian arteries appear to have been spared the risk of aneurysmal complications as a manifestation of generalized atherosclerosis. The most common presentations of subclavian artery aneurysms, especially those caused by thoracic outlet syndrome, are peripheral embolization and brachial nerve compression? Repeated emboli from subclavian artery ane,,~'~sm may result in tissue loss and gangrene. Rupture and thrombosis of subclavian artery aneursyms has been reported but is rare. In the case reported here, the cause of the sudden tight hemothorax was not found. A possible source of the bleeding was an unsuspected injured intercostal artery, although there were no discemible rib fracnares. His left subclavian artery aneurysm was essentially asymptomatic. Surgical treatment of these aneurysms is recommended in all patients in good health because of the significant risk to life and extremity from rupture, thrombosis, and peripheral embolization. ~ The primary goal in the therapy of subclavian artery aneurysms is to exclude or resect the aneurysm. All aneurysms should be resected and replaced with an interposition graft. Ligation without arterial reconstruction should not be performed because claudication occurred after operation in 25% of patients reported by "~firolero et al.6 The complex anatomic relationship of the subclavian artery can make exposure and vascular control difficult. The surgical approach to intrathoracic subclavian artery aneurysms depends primarily on the side of the aneurysm. Median sternotomy is preferred for the treatment of rightsided aneurysms, permitting proximal and distal control with access to the innominate artery and ascending aorta. Left subclavian artery aneurysms are best approached through a left lateral thoracotomy for proximal control. A supraclavicular incision is-used for distal subclavian artery control, and an infraclavicular incision is used if it extends to the axillary artery. Anatomic reconstruction is performed if possible, although alternative extraanatomic procedures are necessary when the configuration of the aneurysm or general medical condition of a patient imposes limitations. A carotid to axillary artery bypass was placed in our patient because of the large width and length of the aneurysm that prevented placement of a graft in the normal anatomic location.
Letters to the Editors
849
In summary, subclavian artery aneurysms are a rare result of traumatic deceleration injuries. Prompt diagnosis by angiography and repair are indicated because of its disabling complications of thromboembolism and brachial plexus compression. Exclusion and reestablishment of flow is the procedure of choice when the aneurysm size and location precludes its anatomic reconstruction. Andrew J. Olinde, MI)
Department of Surgery Ochsner Clinic of Baton Rouge 16777 Medical Center Dr. Baton Rouge, LA 70816 REFERENCES
1. Rich NM, Hobson RW, Jarstfer BS, Geer TM. Subclavian artery trauma. J Trauma 1973;13:485-96. 2. Hobson TW, Israel MR, Lynch TG. Axillosubclavian arterial aneurysms. New York: Grtme& Stratton, 1982. 3. Zelenock GB, Kazmas A, Graham LM, et al. Nonpenetrating subdavian artery injuries. Arch Surg 1985;120:685-92. 4. Abbott WM, Darling RC. Axillary artery aneurysms secondary to crutch trauma. Am J Surg 1973;125:515-20. 5. Cosell IS, Crawford ES. Surgical treatment of aneurysms of the intrathoracic segment of the subclavian artery. Chest 1987;91:704-8. 6. Pairolero PC, Walls JT, Payne WJ, Hollier LH, Fairbairn JF. Subclavian-axillary artery aneurysms. Surgery 1981;90:75763. Resection o f abdominal aortic aneurysm in patients with l o w ejection fractions
To the Editors:
I read with interest an article entitled, "Resection of abdominal aortic aneurysm in patients with low ejection fractions" by McCann and Wolfe (J VASC SUltG 1989; 10:240-4). I was very surprised to find that I was quoted as having suggested that patients with ejection fraction (EF)~
