Detailed formal protocol with illustrations and extensive bibliography.UT Southwestern--Internal Medicin

Chapman, Carleton B.

UT Southwestern Medical Center Institutional Repository (University of Texas)

~ . I DISSECTING ANEURYSM GRANO RouNos, JANlJARY 28i 1960 pRE L I M I NARY DISEASE PROCESSE S WHICH ARE SEEN FREQUENTLY BUT WHICH ARE ETIQLOGICALLY ~~D PATHOGENETICALLY OB SCURE SEEM TO BE FAVORITE TOPICS FOR REV IEW ARTICLES. DISSECT ING ANEURYSM IS A CASE IN POINT. IN THE LAST CENTURY THERE HAVE BEEN NuMEROUS REVIEWS OF THE SUB ~ECT ~ BUT SIGN IFI CA NT ADVANCE IN BA S IC KNOWLEDGE coNCERNING ITS ETIOLOGY IS CONSPICUOUSLY LA CK ING. MACALLUM 1S COMPLAINT (-ITH REGARD TO ARTERIOSCLEROSIS) THAT CURRENT LITERAT URE (AS OF 20 YEARS ~GO) CONSISTS LARGELY OF REVIEWS OF REVIEWS SEEMS APT. THE REV IEW TO END ALL ~~VIEWS ON DISSECTING ANEURYSM IS THAT BY HIRST, JOHNS AND KIME, WHIGH RUNS TO 62 PAGES AND PROVIDES )h6 REFERENCES BEGINNING WITH GALEN AND ENDING WITH p~PERS PUBLISHED IN 1956. IN THE LAS T FEW YEARS, THE CONTENT OF ARTICLES ON yHE SUB ~E CT HAS BEGUN TO REFLECT RENEWED INT ERES Ti NOT BECAUSE OF BETTER BASIC uND ERSTAND ING , BUT BECA USE SUCCESSFUL SURGICAL TREATMENT HAS BEEN REPORTED. . THE QUESTION AS IT NOW STAND S DOES NOT INV OLVE A COMPAR ISON OF SURG ICAL TREAT-~~NT WITH MEDICAL MANAGEMENT. APART FROM REST IN BED, RELIEF OF PAIN, AND oXYGEN THERAPY THERE IS NO SPECIFI C MEDICAL MANAGEMENT. THE REAL QUESTION 1S: CAN THE SURGEON ~ WITH DARING BUT IMPERF ECT TECHNIQUES, DECREASE MOR-T~LITY IN A DISEASE WHICH IS USUALLYs BUT NOT ALWAYS, RAP ID LY FATAL? THE QUESTION PROBABLY IS AN SWE RABLE IN THE AFFIRMATIVE. HISTORICAL ASPECTS (WH ICH, IN THIS INSTANCE AS IN MOST OTHERS, MEANS EVERYTHING COMMUNICATED BEFORE 0SLER 1S TIME) ARE WEL L COVERED BY HIRST, ET AL. WE KNOW THAT VESALIUS OBSERVED A CASE 9 THAT GEORGE I I DIED IN 176o (WH ILE STRAINING AT STOOL) PROBABLY OF A DISSECTING ANEURYSM FOUND AT AUTOPSY, THAT MORGAGNI (1761) PROVIDED A GOOD GROSS DESCRIPTION OF THE PATHOLOGY OF THE DISEASE, AND THAT THE TERM WE NOW APPLY TO IT CAME FROM THE CELEBRATED LAENNEC. IN OUR OWN TIME , THE LATE DR~ J AME S PAULLIN OF AT~A NTA ACHIEVED THE IMPRESSIVE BUT UNENVIABLE DISTINCTION OF BE ING THE FIRST TO DIAGNOSE THE DISEASE IN HIM-SELF AND TO PREDICT ITS SITE OF INTRATHORACIC RUPTURE. THE NORMAL AORTIC WALL IS AN INTENSELY TOUGH AND DYNAMIC STRUCTURE, THE TENSILE STRENGTH OF WHICH IS ENORMOUS. THE I NTIMA~ IN THI S SENSE, IS WEAKj ITS PURPOSE IS TO PROVIDE A SMOOTH SORFACE ~ HIGHLY RESISTANT TO THROMBOTIC 1 P~OCESSES, FOR THE OUTWARD -TRANSMISSI ON OF BLOOD. THE STRENGTH AND MARVELOUS ELASTIC PROPERTIES OF THE STRUCT URE ARE -SUPP·ll ED MOSTLY BY" THE MEt> I A- --COMPOSED MOSTLY OF ELASTIC TISSUE AND SMOOTH MUSCLEe THE STRENGTH OF THE NORMAL WALL liS SUCH THAT RUPTURE OF FRESH POST-MORTEM SPEC IM ENS REQUIRES PRESSURES OF 0QQ MM. He. OR MORE. IT HAS ALSO BEEN SH OWN THAT NORMALLY , THE INT~MA IS NOT EASILY SEPARABLE FROM THE MED IA. J N A-p.l-Y EVENT~ NA--T I:IR-A-L-LY OCCUR-R-I-N-G -"orn I C PRESSURE~- N-E-VER REA-CH LEVE~S SUFF ICIENT TO ENBA-NGER THE- I N-1E6RI TY ·OF ~HE N9RMAL AORTIC WALL. iT FOLLOWS THAT DI SSECTION OF THE AORTIC WALL DOES ~OT OCCUR IN FULLY NORMAL SUBJECTS EXCEPT 9 PERHAP5 9 IN . ASS9CIATION WITH TRAUMA No EVEN THIS 15 DUS IOUSo S THE CLINICAL IMPORTANCE OF CORRECT DIAGNOSIS HAD~ UNTIL RECENTLY , TO DO ~ 0 lELy WITH DIFFERENTIAL DIAGNOSIS. DISSECT I NG ANEURYSM MAY MIMIC MANY OTHER ~CUTE , PAINFUL DISEASES OF THE THORAX AND ABDOMEN. IT ALSO MAY MASQUERADE AS ~~ERIAL EMBOLISM, NEUROLOGICAL DISEASE~ OR DI SE!I SE OF THE GU TRACTo 'MosT - 2 -· cQUENTLY » IT IS CONF USED WI TH ACUTE MY OCARD IAL INFARCTI ON& A CORRECT DIAG-rR51 5 IS IMP ERATI VE SINCE TREA TM ENT OF THE TWO DISEASES IS VER Y DIFFERENT. I T NOY ~ LS D COMPLI CATE PREGNANCY. CORRECT ANTE~MORTEM DIAGNOS IS » ALTHOUGH IN-~~E~SINGLY IMPO RTA NT 9 IS OF TEN DI FF ICULT OR IMPOSSIBLE. I N MOST PUBLI SHED C~RIE S» COR REC T DIA GNOSIS WAS MA DE IN LESS THAN 40 PER CENT OF CASES ( AS ~~~GNO! ED AT AUTOPS Y) ALTHOUGH ONE AUTHOR MADE IT CORRE CTLY IN !0 OF 12 CASES. BACKGROUND S PRED ISPOS I NG TO AORT IC DISSE CTION ARE NOT ENTIREL Y CLEAR. CERT~I NL Y » HYP ERT ENSI ON EI THER PREDISPOSES TO THE PROCESS OR TENDS TO CONVERT MINO R I N TI M~L OR MEDIAL DEFE CTS TO FA TA L DISEASE. EQUA LLY CE RTAIN IS THE F~CT TH~T DISSECT ION 15 2- J T IMES MORE FREQUENT IN MEN THAN IN WOMEN. RACE AND occUP~ TION CANNOT BE SHOWN TO PREDI SPOSE TO THE DI SORDER. CERTAIN TYPE S OF coNGE NITAL CARD IOVAS CU LA R DISEASE CLEARLY P EDI SPOSE TO AORT IC DISSEC TION. ~CHNODACTY LY ~ OFTEN IN ASSOC IATION WITH AORTIC VALVULAR DISEASE ( MARFAN 1S sYNDROME) IS NOW FIRMLY LINK ED WI TH AORT IC DISSECTION. WHEN THE DISORDER IS sEEN IN YO UNG PEOP LE» ~OME ASPE CT OF MA RFA NU S SYNDROME IS OFTEN PRE SENT ~ (PYGOT T » GOYETTE ET A L) o OTHER CONGEN I TA L ANOMA LIES HAVE BEEN AS SOC I ATED WITH ~ORTI C DI SSE CT I ON 8 NOTABLY COARCTAT I ON OF THE AOR TA » AORTIC HYPOPLASIA, AND BICUS PID AORT IC VALVES (GORE AND SEIWERT). II & PAT HOGENESIs THE REIGNING ARTI CLE IN TH I 5 AREA 15 CU RENTL Y THAT BY GORE AND SEIWERT . THE BA S IC LESI ON AND PR IMARY MORPHOLOGIC CHANGE IN AORT IC DISS ECTION OF THE USUAL TYPE IS SOME FORM OF MEDICAL DISEASE» A POl T ON WHIC H THERE SEEMS TO BE NO DI SAGREEMENT. THE POSSIB LE EXCEPT I ON IS THE LI MITED DISSEC TION 9 USUALLY IN THE ABDOMINAL AOR TA 9 THAT SOMETIMES ACCOMPAN IES SEVERE AORTI C ATHEROSCLEROSIS. BREAKS I N THE I NTIMA ARE OFTEN FOUND A OUND CALCIF IED PLAQU ES AND SOME DIS-SECT I ON -MAY OCCUR . IT MA Y ST ILL BE ARGIJED» HOWEVER» THA T MEDI CA L DISEASE MU!T OCC UR SI NCE DISSECTION DOES NOT ALWAYS FOLL OW I NTERRUPTI ON OF THE INTIMAL SURFACE. AGREEME NT ON THE NAT URE OF THE MEDIA L DI SEASE IS NOT UNIFORM. THAf ASSOCIATED WITH ERDHE IMU S NA ME (ORIGINALLY DE SCRIBED 9 LESS F UL LY ~ BY GSELL) WAs FORMER LY ACKNOWLEDGED AS 11 THE CAUSE n OF AORT IC DISSEC T I ON. GSELL DES- . · CRIBED FOCAL NE CR0$1S OF MED i AL MU5CLE 9 FOLLOW ED BY ELAS TI C TISSU E AND COLLAGEN DEGEN ERATION SO THAT CLEF TS 9 OFTEN CONTAINING MUCOI D MATER IA L9 RESULT. SCARR ING l SOMETIME S WITH I NGROW TH OF THIN-WALLE D ARTERIAL BRA NCH ES» THEN TAKES PLACE. ERDHEI M ELABORATE D ON THE THEME AND NOTE D THAT THE LESIONS ARE USUALLY FOUND ~N THE MI DD LE AND OUTE R THIRDS OF THE MED IA AND ARE L IMI TED TO TH E ASC ENDING M0RT ION AND TOP OF THE AORTIC ARCH . Go Efis CONTRIB UTI ON IS THAT MED IONECROSIS ~y BE OF TWO TYPE5: (J) DEFECT MA INLY IN ELA~TIC TISSUE AND OCCURR IN G IN YOUNGER PATI ENTS (2) DE FECT MA INLY I N SMOOTH MUSCLE AND OCCURRING IN OLDER AGE GROUPS - 3 -THE PATHOGE NES IS OF THE DISORDER IS ALSO DEBA TED. GRANTING THAT DI SEA SE THE MEDIA MUST BE PRESENT 9 TWO PATHOGENETIC POSSIBILITIES ARE TO BE CO N-of · sloERED~ (I) RU PTURE OF VASA VASORUM INTO AN AREA OF MED IONECROS IS, FOLL OWED BY RUPTURE OF THE INTIMA INTO THE AORTIC LUMENe (2) COLLAPSE OF MEDI A IN A NECROTIC AREA WITH BULGING AND RUPTURE OF OVERLYING INT IMA. I N EITHER EVENT, AN INTIMAL TEAR RESULTS AND IS USUALLY TRANSVERSE. I T MAY OCCUR JUST ABOVE THE AOR T IC VALVE, NEAR THE ORIGINS OF ~HE GREAT VESSELS, OR (MORE RA REL Y) IN THE DESCENDING ARCH OR THORACIC AORTA. DISSECTI ON USUALLY pROCEEDS PROX IMALLY AND DI STALLY BUT MORE THE LATTER THAN THE FORMER . REENTRY iNTO THE AORTIC LUMEN AT A POINT DISTAL TO THE INITIAL INTIMA L RUP TURE OFTEN ocCURS AND IS ASSOCIATED WITH IMPROVED PROGNOSI S . MOST OF THE PATIENTS WHO sU RVI VE MON THS OR YEARS~ HAVE DOUBLE-BARRELLE D LESIONS CREA TED BY REENTRY. THE OUTER CHANNELS COME TO BE L INED WI TH ENDOTHEL I UM IF THE PATIENT LIVES LONG ENOUGH. I N ANY CASE» REE NTRY SEEMS TO RE TARD FURTHER DISSECTION. l EXPER IMENTAL PROD UC TI ON OF TRUE DISSECTING ANEURYSM IS DIFFICULT. BLANTON AND CO-WORKERS PRODUCED IT IN DOGS BY INC ISING THE INTIMA OF THE AORT IC ARCH AND CREA TING MEDI AL LESIONS . DISSECTION OCCURRED IN 13 OF 26 DOGS WHEN BLOOD AT NORMAL AORTIC PRESS URE WAS ADMITTED INTO THE PRE PARED SEGMENT OF AGRTA. DIS~ECT ION - WAS NEVER PROXIMA L (UNLIKE THE DI SEASE AS SEEN IN HYMAN BEINGS) AND USUALLY EXTENDED AT LEAST TO THE DIAPHRAGM. THE DISSECTION PR OCESS WAS MORE VIOLENT AND EXTENSIVE IF THE ANIMAL WAS GIVEN VASOPRE SSOR DRUGS. AN EUR YSMAL SAC S ( DI SSEC T ING HEMATOMAS ) WERE LARGE ENOUGH AT TIMES TO BLOCK FLOW THROUGH THE AORT IC LUMEN ; WHEN REENTRY OCC UR RED THE SACS TENDED TO COLLA PSE » REOPEN ING THE 0RIGINAL LUME N. THE DYNAMIC S INVOLVED SEEM CLEAR: AORTIC PRESSURE WAVES, ENTE RING THE MEDIA THROUGH AN INTI MA L T EAR~ ENCOUNTER A RESISTANCE AND CAN TRAVEL NO FURJHER. THE BATTERING OF THE PRESS URE WAVES 9 AND THE IR IN ITIA L 1 REFLECTION BY THE MEDIA 9 GENERATES ENOUGH FORCE TO SPLI T THE LAYER. SPLITTING ~y CONTINUE INDEF INITELY UNT IL AND UNLESS REENTRY OCCURS . I F THIS HAPPENS » PRESSURE ·WAVES TRAVEL 0UT OF THE AOR T IC LUMEN AND RETURN TO IT WITHOUT BEING SiGMtFICA~TLY OPPOSED ; PRE SSU RE ON BOTH S ID ES OF THE ISOLATED INTI MAL TUBE I 8EC@ME S EQUAL AND THE TENDENCY FOR SPLI TTING TO CONTINUE BEYOND THE REENTRY 81TE IS LESSENED. M i T HAS ALT ERNATELY BEEN PROPOSED THAT RUPTURE OF VA SA VASORUM IN TO THE lEOtA NOT ONL Y INITIATES THE PROCESS BUT PROPAGATES IT 9 INTIMAL TEARS BEING PARGELY INC IDENTAL. THIS SE EMS ILLOGIGAL 1 ESPECIALLY WHEN IT IS REAL IZED THAT ARESS URE IN VESSELS AS SMA LL AS THE VASA VASORUM IS PROBABLY TOO SMALL TO 00 I INYTHING MO RE THAN TO RUPTURE A VERY THIN~ AND POSS IBLY DISEASED~ VASC ULAR WALLo I IS VER Y DO UBTFUL THAT SUCH A PROCESS COULD SPLI T THE MEDIA ITSE LFo - 4 -MO RTALITY SI NCE SURGI CAL INTERVENT I ON IN DISSECTING ANE URYSM 15 RELATI VELY NEW , · IT NOT YET HAD TIME TO INFLUENCE MORTAL I TY. THE FOLLOW I NG DA TA ( FROM HIRST, M~SAL ) ARE BA SED ON UNT REA TED CASES OR ON THOSE TREATED WITH MEDI CAL MEAS URES fo/iAT ES AND RE ST) . MORTALI TY IN 425 CASES T IME NUMBER DFA D PER CENT DEAD SUDDEN DEAT H ~3 § 6 HouRs 35 12 II 57 13 18" 73 17 24 tl 9! 2! 2 DAYS !57 EZ K tl . !89 II 208 49 5 II 228 53 b II 252 g~ 7 II 2iS6 2 WEEK S 3!8 74 K II 3E5 ~ II 3 3 2 MONTHS §~ 87 2 n 89 b " 390 91 I YEAR E99 93 2 YEARS 07 95 5 YEARS 422 99 9 YEARS ' 425 100 I MANY OT HE R ES T IMATES ARE AVAILABLE BUT NONE ARE BASED ON SUCH A LARGE GRoupo WHIL E IT IS POSSIBLE THAT THE MATERIAL IS WE IGHTE D IN SOME WAY» IT S AGE· AND SE X DI STRIBUTION SEEM REASONABLE . FOUR HUN DR ED AND ELE VEN (85 PER CENT) WERE AGED 40 OR MORE AND ABOUT 75 PER CENT WERE MALE o ~ T I 5 .PERHAP S HiGHL Y S I GN IF ICANT TO NO TE THAT 9 AT THE END OF 24 HOURS 9 79 PER GENT OF THE ~0TAL MATERIAL WERE ST I LL AL I VE AND AF TER 2 DAYSv 63 PER CE NT ST I LL SURVI VEDo VER ONE- HA LF THE GROUP DIED IN THE FIRST 5 DAYS AND AFT ER ONE MONTH ONLY ;o PE R CENT WERE ST I LL ALIVEo THE INDICAT ION IS THAT -THE DI SEASE MAY NOT BE S IMMEDIAT EL Y FATAL AS WA S ONCE SUPP OSED . A CAUS ES OF EXIT US VARYv DEPEND ING ON THE ACUTE NESS OF THE LESI ON. I N l CCUT E CAS ES (sURVIVI NG LESS THAN 2 WEEKS) 9 HE MORRHAGE EX TERNA L TO THE AORTA . HA US ED 89 PER CENT OF THE DEATHS o MOS T OF THE CASES SHOWED I NTRAPERICARD IAL EMORRHAG E (!66 OF 236 ACUTE CASES); 74 WERE INT O PLEURAL SPA CES~ 3 ~ INTO THE · - 5 -M~oiASTINUM AND THE REST BELOW THE DIAPHRAGM. IN CHRONIC CASES (SURVIVING MoRE THAN 6 WEEKS), EXTERNAL HEMORRHAGE OCCURRED IN 37 OF 66 CASES AND THE NeXT MOST COMMON CAUSE WAS CONGESTIVE HEART FAILURE (22 OF 66 CASES). IV. CLINICAL MANIFE STATIONS (HIRST , ET AL. ~ CASE REP. MGH, COPPING, ET AL). V. ROENTGENOLOGIC DIAGNOSI S (EASTCOTT AND SuTTON ; GoLDEN AND WEANs; KNuTssoN; SAVAGE). vI • TREATMENT MEDICAL MEASURES , APART FROM RELIEF OF PAIN ~ ABSOLUTE REST, AND OXYGEN (IF INDICATED) ARE CONTROVER SIAL AND PROBABLY INEFFECTIVE. IT SEEMS LOGICAL TO USE HYPOTENSIVE MEASURES IF HYPERTENSION IS PRE SE NT AFTER THE DISSECTION TAKES PLACE. THE MEASURE , HOWEVER , CANNOT BE SA~D TO HAVE LOWERED MORTALITY VERY MUCH. ANTICOAGULANTS ARE CONTRAINDICATED. THE RATIONALE FOR SURGICAL THERAPY RESTS SOLIDLY ON THE IMPROVEMENT IN MORTALITY ASSOCIATED WITH THE REENTRY PHENOMENON. THE METHODS PROPOSED BY DE 8AKEY AND COLLEAGUES INVOLVE CREATION OF A SITE OF REENTRY AT SOME DISTANCE FROM THE INTIMAL TEAR ALONG WITH OBLITERATION OF THE DISTAL DISSECTION AND, DEPENDING ON CIRCUMSTANCES , INSERTION OF A HOMOGRAFT. THE TECHNIQUES HAVE BEEN USED ON THORACIC AND ABDOMINAL LESIONS WITH SOME SUCCESS BY DE 8AKEY AND BY OTHER GROUPS (WARREN , ET AL). • THE MOST TRYING QUESTION WITH REGARD TO SURGERY IS SELECTION OF PATIENTS. THE SIMPLEST STANO FOR THE INTERNI ST, AND POSS IBLY THE BEST, IS TO HOLD THAT ONCE DIAGNOSIS IS ACCOMPLISHED TH E PROBLEM IS A SURGICAL ONE. THE PROBLEM, HOWEVER, IS COMPLICATED BY THE SHAPE OF THE MORTALITY CURVE ; IT RISES VERY STEEPLY DURING THE FIRST 48 HOURS, SLIGHTLY LESS STEEPLY FOR THE NEXT 5 OR 6 DAYS , THEN MORE SLOWLY BUT STEADILY FOR MONTHS AND YEARS. SOME DECISION OUGHT, THEeEFORE, TO BE REACHED IN THE FIRST 48 HOURS ANB PREFERABLY WITHIN AN HOUR DR TWQ OF ONSET. AND THERE IS NO RELIABLE WAY, IN A SEVERELY STRICKEN PATIENT, TO IDENTIFY HIM AS ONE WHO WILL CREATE HIS OWN REENTRY AND SURVIVE MONTHS OR YEARS. IN PATIENTS WHOSE SYMP TOMS SUBS IDE QUICKLY, WHO DO NOT BEVELOP SIGNIFICANT ~RTERIAL OCCLUSION (CAROTID 9 SUBCLAVIAN , CORONARY , OR RENAL) AND ~ : IN WHOM HYPER-TENSION IS NOT MARKED OR CAN BE BROUGHT UNDER CONTROL » CONSERVATIVE MEASURES ~RE PROBABLY INDICATED. IN PATIENTS WHO ARE , SE VERELY- ILL, IN WHOM PAIN IS I DtF~lCULT TO CONTROL , SIGNS OF ADVANCING DI SS ECTION ARE PRESENT, AND SHOCK ~EVELDPS, SURGERY OFF~RS A SMALL CHANCE OF SURVIVAL. THIS, HOWEVER, IS l PROBABLY MORE THAN CONSERVATIVE MEASURE S CAN OFFER EVEN THOUGH A FEW SUCH 1AliENTS DO SURVIVE FOR A TIME WITHOWT SURGERY. SINCE TIME IS OF THE ESSENCE, MHis TYPE OF PATIENT SHOULD BE REGARDEG AS A MAJOR SURGICAL EMERGENCY. IT 11GHT BE SENSIBLE TO CONSIDER THE US E OF SOME SORT OF MODIFIED HYPOTHERMIA IN Hi s GROUP , WITH SURGERY ADDED IF THE DISEASE CONTINUES TO PROGRESS. THIS FORM - 6 -THE DISEASE IS SOMEWHAT ANALOGOUS TO OTHER MAJOR VASCULAR CATASTROPHES SUCH of fEMORAL OR POPLITEAL EMBOLISMs IN WHICH IT IS SOMETIMES JUSTIFIABLE Te ~!sERVE THE EFFECTS OF SYMPATHET IC BLOCK PROVI DED SURGERY IS IMMEDIATELY AVA I L-AeLE If THE MORE CONSERVAT IVE MEASURE FAILSe IF PROGRESS IN THE THERAPY OF DI SSECTING ANEURYSM IS TO BE MADE~ SUCH I THERAPY WILL HAVE TO BE I NTRODUCED EARLY AND THI S , IN TURN, WILL REQU I RE A MEDICAL-SURGICAL ORGANIZATIONAL ARRANGEMENT THAT CAN BE SROUG~T INTO ACTION WiTH MINIMAL DELAY. REFERENCES BLANTON, F.S., MULLER, W ~ H., JR., AND WARREN, W.O. : I• PRODUCTiON OF DISSECTING ANEURYSMS OF THE AORTA . ( JAN • ). 1 1959 • CASE REcORDS OF THE MAssACHUSETTS GENERAL HosPITAL .. 2• 26o! 335-339 (FEBo 12), 1959 . EXPERIMIINTAL SURGERY &2: 81-90 NEW ENGLAND J.MED . ~. COPP ING, G. A., AND SZENAS, P.: DISSECTING AORTIC ANEURYSM. CANAD. M.A.J 1 80: 3)6-339 (MAR. 1), 1959. 4 DEBAKEY, M.E.: DISSECTING ANEURYSM OF THE AORTA. SuRa., GYN., Oss. 102: • 372-373 (MARCH), 1956. 5• DEBAKEY, M.E., CREEcH, o.~ JR., ANo MoRRis, G.c. , JR.: ANEuRYsM oF THORACOABDOMINAL AORTA INVOLVING THE CELIAC, SUPERIOR MESENTERIC, AND RENAL ARTERIES. REPORT OF FOUR CASES TREATED BY RESECTION AND HOMOGRAFT REPLACEMENT. ANN. SURG. ~: 549-573 (QcT . ), 1956. 6. EAsTeoTT, H.a.G., AND suTTON, D.: AORTA DIAGNOSED BY AORTOGRAPHY. CHRO~IC OISSECT ING ANEeRYSM OF THE LANCET 2: 73-75 (JULY 12), 1958. ERDHEIM, J.: MEDIONECROSIS AORTAE IDIOPATHICA CYSTICA. ·F. PATH. ANAT. 276: 187-229 (FEs.l7), .,1930. VIRCHOWS ARCH. 8. GOLDEN, A., AND WEENS, H.S.: THE DIAGNOSIS OF DISSECTING ANEURYSM OF THE AORTA BY ANGIOCARDIOGRAPHY. AM. HEART J. 31._: JJ4-J22 (JAN.), 1949. 9. GORE, J .: PATHOGENESIS OF DISSECTING ANEURYSM OF THE AORTA. A.M.A. ARCH. PATHOL. 5.2,: 142-153 (FEB.), 1952 • 10. GORE, J ., AND SEIWERT, V. J.: DISSECTING ANE~RYSM OF THE AORTA. PATHOLOGI ASPE'CTS. · AN ANALYSIS OF EIGHTY-FIVE FATAL CASES. A.M . A. (\'RCH. PATHOL. 5.2,: 121-141 (FEs.), 1952 . 11. GOYETTE, E.M., AND PALMER, P.W. : CARDIOVASCULAR LESIONS IN ARACHNODACTYLY. CIRCULATI6N 1: 373-379 (MARCH), 195, . 12 . GSELL, 0.: WANDNEKROSEN OER.AORTA ALS SELBSTANDIGE ERKRANKUNG UNO IHRE 8EZIEHUNG ZWR SPONTXNRUPTUR. VIRCHOWS ARCH. F.PATH. ANAT. 270: 1-,6 (Nov. 20), 1928. l3. HIRST, A.E., JR., JOHNS, V.J., JR., AND, KIME~ s.w., JR.: DISSECTING ANEURYSM OF THE AORTA: A REVIEW OF 505 CASES. MEDICINE 11: 217-279 (SEPT . ), 1958. l4. KNUTSSON, F.: DISSECTING ANEURYSM GF THE THORACIC AORTA. ACTA RAOIOL. 21: 273-277, (APRIL), 1959. . - 2 ~ pyGOTT » F~: ARA CHN ODACTY LY ( MARFAN 1S SYNDROME ) WITH A REPORT OF TWO CASES . BRI T. J. RADIO L 28; 26-29 (JAN oL 1955 . 6 SAVAGE » C.R.: RE TROGRADE AORTO GRAP HY IN ACUTE DISSE CTING ANE URYSM OF THE I • AORTA .. LANCET 1: 281-282 (FE B. 7)» 1959. 7 WARR EN, WQD., BE CKWIT H» J., AND MULLER, WeHo: PROBLE MS IN THE SURGICAL I . MA NAG EMENT OF ACU TE DISSECT ING ANEURYSM OF THE AORTA . ANN . SURG. ~: 530-548 (Oc r.)» 1956. 

Dissecting aneurysm

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Dissecting aneurysm

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