RESECTION OF AN ANEURYSM OF THE ABDOMINAL AORTA
`Reestablishment of the Continuity by a Preserved Human Arterial Graft, with Result After Five Months
`CHARLES DUBOST, M.D.
`MICHEL ALLARY, M.D.
`AND
`NICOLAS OECONOMOS, M.D.
`PARIS, FRANCE
`
`Mr. Le G., aged 50 years, had an aneurysm of
`the abdominal aorta revealed by gross
`disturbances of function, predominantly in the left leg. Abdominal examination showed a large
`tumor in the left paraumbilical region, pulsating and expansile. The right femoral pulse was
`diminished and the left absent; oscillations were diminished on the right and absent on the left.
`infarction. The blood Wassermann test was negative.
`One year before he had had a myocardial
`The aortograph (Fig. 1) shows that the beginning of the aneurysm is just below the kidneys
`and that
`it extends as far as the bifurcation of
`the aorta. The left common iliac artery is
`blocked in its first 5 or 6 cm. The right common iliac artery, although patent, has at its origin
`two small aneurysmal dilatations. The superior mesenteric and renal arteries, perfectly deline-
`ated by the opaque medium, are clearly above the aneurysm. The inferior mesenteric artery,
`however, is not injected. The left iliac artery seems to receive its blood by the spermatic artery
`or one of
`its branches.
`Operative Intervention (March 29, 1951, Dr. Dubost).—A left
`incision
`thoracoabdominal
`was made, an extraperitoneal approach being used, and resection of
`the 11th rib was carried
`out. Retraction of the peritoneal sac disclosed an enormous aneurysm extending from the origin
`of the renal arteries to the common iliac arteries. It was decided to attempt its complete removal
`and to use a graft to reestablish continuity of the arteries.
`The operation was carried out
`in the following stages : Control of
`the aneurysm was
`obtained by a clamp placed proximally to it,
`immediately below the renal arteries. Next,
`in
`isolation, and provisional hemostasis of both
`the iliac arteries, came exposure,
`the region of
`iliac and both internal
`iliac arteries. Section of both common iliac arteries was
`external
`performed and then dissection of the aneurysm from below upward. The stripping was trouble¬
`some near the common iliac veins and the inferior vena cava, which were adherent
`in places
`fragments of which had to be left
`in some places. The lumbar vessels,
`to the aneurysmal sac,
`thrombosed, were sectioned without
`ligature. The inferior mesenteric artery did not bleed
`from the proximal cut end but did spurt blood from the peripheral end. The aneurysm, entirely
`freed, was turned upward and sectioned 2 cm. from the clamp on the aorta.
`the aorta proximally and the cut end of
`the right common iliac artery
`The cut end of
`(15 cm.
`peripherally were trimmed in order to interpose the graft
`in length and taken from
`three weeks previously). The superior anastomosis
`the thoracic aorta of a 20-year-old girl
`of the aortic graft was carried out with 5/5 silk 0 (Bruneau).
`Since we did not have a Y-shaped graft, it was necessary to make an end-to-end anastomosis
`between the graft and the right common iliac artery (Fig. 2).
`The obstruction in the left common iliac artery was removed, and after section of
`the
`iliac artery, which was itself blocked,
`the graft
`it was anastomosed to the side of
`internal
`(Prof. F. d'Allaines), Paris.
`From the Department of Surgery, No. 1 Broussais Hospital
`This case was previously discussed in La Semaine des h\l=o^\pitauxde Paris, Sept. 18, 1951.
`Permission to report it here and to reproduce the illustrations has been obtained.
`
`TMT 2088
`Medtronic v. TMT
`IPR2021-01532
`
`

`

`Fig. 1.—Preoperative aortograph. The aneurysm begins 2 or 3 cm. below the renal arteries.
`Inferiorly, it involves the aortic bifurcation ;
`the right common iliac artery shows at its origin
`two aneurysmal dilatations, and the left common iliac is obstructed. The inferior mesenteric
`artery is not delineated.
`
`Fig. 2.—Diagram of operation. The 14-cm. graft was anastomosed end-to-end with the aorta
`above and the right common iliac below. After removal of its obstruction, the left common iliac
`artery was anastomosed by its end to the side of the graft.
`
`

`

`Fig. 3.—Postoperative aortograph. The graft has kept a normal caliber ;
`arteries are perfectly delineated.
`
`the two iliac
`
`Fig. 4.—Operative specimen. The specimen is cut
`to demonstrate the importance of
`the
`peripheral clot, which allows the persistence through its center of a canal which was shown on
`the aortograph.
`
`

`

`immediately above the other anastomosis. After removal of the clamps,
`the three anastomoses
`were widely patent, and the femoral pulses were felt to be equal on the two sides.
`A check aortograph was carried out two months later and showed perfect
`function of
`the
`graft, which was not at all dilated but was widely patent, as were also the iliac and femoral
`arteries (Fig. 3).
`Three months after the operation the patient was in perfect health. The femoral pulses
`were strong and equal and also the posterior tibial and dorsalis pedis arteries.
`The specimen, 15 cm.
`long, was made up of a large sac with a very thin wall which was
`calcified in many places and was completely filled by a large clot which had a canal
`through
`in diameter (Fig. 4).
`its center about 3 cm.
`Histological Examination.—The aortic wall, extremely altered, shows the following changes
`from the cavity of the aneurysm outward : There is a much thickened intima, transformed into
`taking up the stain, studded with fatty acid crystals, and showing
`an amorphous mass not
`Immediately under
`calcareous degeneration in the deepest part.
`the calcified areas is the
`beginning of
`recognizable in this region from several areas of elastic fibers
`the media, still
`which are fragmented. The outer four-fifths of the media are totally lacking in elastic tissue.
`In contrast,
`the muscle fibers are almost normal
`fibrous tissue is more
`in appearance but
`prominent. The main feature,
`together with the destruction of elastic tissue,
`is the presence
`lymphocytic cells accompanying the vasa
`throughout
`the outer half of the aorta of masses of
`these cells form concentric sheets but also are seen sometimes to follow the vessels
`vasorum ;
`at right angles to the layers of
`the wall. This periarteritis is accompanied in places with
`endoarteritis obliterans, several vasa vasorum being completely obstructed.
`The narrow adventitious layer contains the same perivascular lymphocytic infiltration, the
`same obliteration of a number of vasa vasorum, and, moreover, a definite lymphocytic hyper-
`plasia in lymph nodules.
`No inflammatory sclerosis was seen.
`In summary, the lesion is an aneurysm with marked changes in the walls and calcium depo¬
`the vasa vasorum would suggest an inflammatory
`sition. The endarteritis and periarteritis of
`process without any specific indication as to its nature.
`
`CONCLUSIONS
`A case of aneurysm of the abdominal aorta extending from the renal to the iliac
`arteries is reported. The method chosen for its excision was a combined abdomino-
`thoracic approach on the left ; this gave the necessary exposure of the aortic bifur¬
`cation and the origin of the renal arteries.
`The reestablishment of continuity of the aorta was assured by a graft of human
`aorta which had been preserved for three weeks. An aortograph carried out two
`months after the operation showed perfect permeability of the graft as well as of
`the iliac arteries, of which the left one had been obstructed. Five months after
`surgical
`intervention the pulse and oscillations in both legs were normal and equal.
`
`