1988-03When operating on a false aneurysm arising in the ascending aorta, protruding over the sternum, and eroding the sternum, the problems are how to approach the aneurysm and how to preserve the myocardium and the brain safely. In the present case, the operation was performed for the first time, to the best of our knowledge, safely by flipping up the eroded upper half of the sternum with separated clavicles and ribs, under a femoro-femoro (F-F) bypass and isolated brain perfusion.departmental bulletin pape

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ABE, TOSHIO

MURASE, MITSUYA

TAKEUCHI, EIJI

TANAKA, MINORU

USUI, AKIHIKO

WATANABE, TAKASHI

English

Nagoya Repository

Nagoya J. Med. Sci. 50. 27 - 34, 1988NEW APPROACH TO THE ANEURYSM ORIGINATINGIN THE ASCENDING AORTA, ERODINGTHE STERNUM AND EXTENDING TO THE CERVIXEur TAKEUCHI, M.D. MrrSUYA MURASE, M.D. MINORU TANAKA, M.D.TAKASHI WATANABE, M.D. AKIHIKO USUI, M.D. and TOSHIO ABE, M.D.Department of Thoracic Surgery, Nagoya University School ofMedicine,Nagoya 466, JapanABSTRACTWhen operating on a false aneurysm arising in the ascending aorta, protruding over the sternum,and eroding the sternum, the problems are how to approach the aneurysm and how to preserve themyocardium and the brain safely. In the present case, the operation was performed for the firsttime, to the best of our knowledge, safely by flipping up the eroded upper half of the sternum withseparated clavicles and ribs, under a femoro-femoro (F-F) bypass and isolated brain perfusion.Key Words: aneurysm eroding the sternum, approach to the thoracic aneurysm, false aneurysmTHE CASEA 54-year-old man was admitted to the Nagoya University Hospital complaining of a pulsatingtumor in the cervical region accompanied with dysphagia. In August 1985, an abnormal shadowwas detected in the upper mediastinum on a chest X-ray film. From June 1986, the patientdeveloped dysphagia and in September became aware of a pulsating tumor in the right cervicalregion. The pulsating tumor, protruding over the sternum, was 7x 4x 2 em on the day of admis-sion. Blood pressure was 140/70 mmHg, and the blood sedimentation rate per hour had a valueof 70 mm. The serological test for syphilis was negative. An aneurysm of the ascending aortawas diagnosed by a digital subtraction angiography (DSA) examination (Fig. 1) and by a nuclearmagnetic resonance (NMR) image (Fig. 2). In a computed tomography (eT) scan of the sternum,the aneurysm was observed to adhere to the posterior surface of the sternum, which had alreadybeen partially destroyed, especially at the level of the first rib (Fig. 3a). The greatest compres-sion was found on the trachea at the level of the sternoclavicular joint, where the sectional areawas as small as 6x 10 mm (Fig. 3b). The entrance to the aneurysm had a diameter of 3.5 em andwas situated within 1 em from the origin of the innominate artery. The size of the aneurysmprotruding into the cervical region continued to increase and the skin color turned purple (Fig. 4).A rupture was threatened and an operation was performed on November 25, 1986, described asfollows.After the blood pressure was lowered to 60 mmHg with trimetaphan camsilate to preventrupture, an endotracheal tube of 6 mm in diameter was inserted beyond the narrow segment ofthe trachea compressed by the aneurysm, under direct observation with a bronchial fiberscope.At first, the right femoral artery, femoral vein and bilateral common carotid arteries wereexposed for cannulation. A V-shaped skin incision was made, oblique incisions along thetr~*=, «.ft&, W~ ~,~m ~,_*••,~M~.Received for Publication January 29, 19882728EIJI TAKEUCHI et af.Fig. 1. DSA picture indicates the aneurysm which originated from the ascendingaorta.Fig. 2. The NMR image exhibits the aneurysm protruding over the sternum. Theascending aorta is dilated.ANEURYSM ERODING THE STERNUMFig. 3a A CT image of the sternum at the level of the first rib. The aneurysm adheresto the back of the sternum and is destroying it.Fig. 3b The trachea is compressed at the level of the clavicle. The sectional area isonly about 6 X 10 mm.2930EIJI TAKEUCHI et al.Fig. 4. Pulsating mass protruding over the sternum.ANEURYSM ERODING THE STERNUMxFig. 5. The schema exhibits the approach to the aneurysm.Left : A Y-shaped skin incision was made.Right: Both pectoralis majors were peeled as far as the third costal cartilageregion. The sternum was transversed and the vertical incision wasmade on the lower part. The clavicles, first and second ribs were cut.~~~ M. perctralis major~: Mn. intercostales externi31Ioxygenator~centrifugalpumpFig. 6. The schema represents the cardiopulmonary by-pass and isolated brain perfu-sion with centrifugal pump.R.cA: a. 'carotis communis dextraL.cA a. carotis communis sinistraFAa. femoralisFV v. femoralisRA right atrium32EIJI TAKEUCHI et ai.clavicles and a median incision on the anterior chest. Both pectoralis majors were peeled offfrom the bilateral clavicles and from the sternum as far as the third costal cartilage region. Theclavicles were peeled periosteally and the subclavius muscles were dissected. After dissecting thesecond intercostal muscles from the sternum, the sternum was transversed. Then a verticalincision was made to the sternum as far as the second rib from the lower part (Fig. 5). When anincision was made in the pericardium, the aorta was found to be enlarged to a diameter of about6 cm and its wall was thick and rigid. Clavicles and the second ribs on both sides were cut witha wire saw, while the first ribs were cut bit by bit with rongeurs. A 26 Fr. cannula was insertedinto the right atrium from the right femoral vein and a femoro-femoral bypass was started.Brain perfusion was performed by using a centrifugal pump to send blood to both carotid arteries.After a venting cannula was set in the main pulmonary artery, another cannula for blood removalfrom the right atrium was inserted, then deep hypothermia was induced (Fig. 6). When ven-Fig. 7. The schema of the approach to the aneurysm.The pericardium is opened by making prior median sternal splitting below theeroded region and separating the medial portion of the clavicles, and the firstand second costal cartilages on both sides of the sternum. The upper half ofthe destroyed sternum was dissected from the aneurysm under a F-F bypassand isolated brain perfusion, and with a venting cannula and cardioplegiccircuit in place.~: the most eroded portion of the sternum33ANEURYSM ERODING THE STERNUMtricular fibrillation began, the upper half of the sternum was raised upward, and dissectionbetween the sternum and the aneurysm was started. There was bleeding from the eroded sternalregion when it was flipped up (Fig. 7). After the aortic cross clamping, oxygenated glucose-insulin-potassium (GIK) solution was injected into the ascending aorta to obtain the cardioplegia.The entrance to the aneurysm was searched for and found, and a deposit of calcium was noticedby palpation along the margin of the aneurysmal neck. A 33 mm occlusion ballooon catheterwas then inserted into the descending aorta from the neck, and patch closure with prostheticgraft was performed safely. The nasopharyngeal temperature was as low as 21.6°C. Isolatedbrain perfusion time was 108 min; there was no neurologic deficit. The cardioplegic time was 51min, and the F-F by-pass time was 188 min. The postoperative course was good and uneventful.The pathological specimen showed a false aneurysm. Sixteen months after the operation, thepatient has no signs or symptoms of recurrence.COMMENTIt is well known that an aneurysm of the aorta of the thoracic region has a tendency todestroy the sternum or vertebra (l, 2). When an aneurysm adheres to or erodes the sternum, themost important problem is how to approach it. There are many reports of incisions into thecervical region continuing to a vertical splitting of the sternum and severing of the unilateralclavicle for the treatment of injuries of the aortic arch, or including the three branches of theaortic region, and for false aneurysm operations (3, 4, 5, 6, 7, 8). One study reports using thesterno-clavicular flap for trauma to the subclavian vessel (9). In our case, the destruction of thesternum was advanced and the neck of the aneurysm was large. Calcium deposits were foundaround the entrance by preoperative study and it was believed to be dangerous to clamp theaortic wall with a side clamp. We therefore used the occlusion balloon catheter for a bloodlessoperative field. Isolated brain perfusion was necessary to operate safely in the present case.In our hospital, the profond hypothermia as low as 20°C (10) are used in the cases of aneurysmof the aortic arch for protecting the brain and the myocardium routinely. We have encounteredno neurological problems. The major points in the present method, which we believe is superiorto those methods in which a vertical incision is made in the sternum after circulatory arrest isconducted under hypothermia, are summarized as follows:1) By performing extracorporeal circulation and brain perfusion beforehand, and by dissectingthe destroyed region of the sternum and the region of the tumor, it is possible to deal with thenext step safely even if serious bleeding occurs during dissection.2) An important problem in the past methods was the time required for setting of the my-ocardial protection measures, if needed. With our method, the base region of the aorta is ex-posed before dissecting the crucial point. Taping, insertion of a venting cannula and insertion ofan additional cannula in the right atrium are possible when blood flow is insufficient in the F-Fby-pass.We believe that this new approach is preferable to the severe erosion of the sternum by theaneurysm.REFERENCES1) Cowley, R.A., Sloan, H.S. and Sullenberger, N.H.: Successful repair of an aortic aneurysm with sternalperforation. J. Thorac. Cardiovasc. Surg. 21,159-163 (1951).34EIJI TAKEUCHI eta/.2) Murray, R.O. and Jacobson, H.G.: The radiology of skeletal disorders. pp.427-431 (Vol. 1), pp.l525-1530, pp.1747-1748 (Vol. 3) (1977), Churchill-Livingstone, New York.3) Mittal, A., May, LA. and Samson, P.C.: Traumatic aneurysm of the aortic arch. Ann. Thorac. Surg. 13,494-498 (1972).4) Tector, A.J., Worman, L.W., Romer, J.F. DeCock, D.G. and Leplay, D.: Unusual injury to the aorticarch. A case report. J. Thorac. Cardiovase. Surg. 67,547-552 (1975).5) Brawley, R.K., Murry, G.F., Crisler, C. and Cameron, J.L.: Management of wounds of the innominate,subclavian, and axillary blood vessels. Surg. Gynec. Obstet. 131,1130-1140 (1970).6) Castagna, J. and Nelson, R.I.: Blunt injuries to branches of the aortic arch. J. Thorac. Cardiovasc. Surg.69,521-532 (1975).7) Imamoglu, K., Read, R.C. and Huebl, H.C.: Cervicomediastinal vascular injury. Surgery 61, 274-279(1967).8) Amato, J.J., Vanecko, R.M., Yao, S.T. and Weinberg, Jr., M.: Emergency approach to the subclavian andinnominate vessels. Ann. Thorac. Surg. 8,537-541 (1969).9) Steenberg, R.O. and Ravitch, M.M.: Cervico-thoracic approach for subclavian vessel injury from com-pound fracture of the clavicle: Consideration of subclavian-axillary exposures. Ann. Surg. 157,839-846(1963).10) Kirklin J.W. and Barratt-Boyes, B.G.: Hypothermia, circulatory arrest, and cardiopulmonary bypass.In Cardiac Surgery, edited by Kirklin, J.W. and Barratt-Boyes, B.G., pp.29-82 (1986), A Wiley MedicalPublication, New York.

New Approach to the Aneurysm Originating in the Ascending Aorta, Eroding the Sternum and Extending to the Cervix

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New Approach to the Aneurysm Originating in the Ascending Aorta, Eroding the Sternum and Extending to the Cervix

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