Chapter 48: Ascending and Arch Aortic Aneurysms

INTRODUCTION

The Greek physician Galen first described superficial false aneurysms arising from venesection in the antecubital fossa and in gladiators injured during battle in the second century A.D.¹ Antyllos, during the same time period, distinguished between true and false aneurysms and attempted surgical treatment with proximal and distal ligation, opening of the aneurysmal sac, and removal of its contents.²

The French physician Jean Francois Fernel, in 1542, described aneurysms, “in the chest, or about the spleen and mesentery where a violent throbbing is frequently observable.”³ In 1543, Andeas Versalius described a thoracic aortic aneurysm. In the late 1500s, Ambroise Paré described a death by a ruptured thoracic aortic aneurysm and either Fernel or Paré proposed that syphilis played a causative role in some aortic aneurysms.¹ In 1760, Morgagni reported the first cases of aortic dissection and in 1773, Alexander Monro described three coats of the arterial wall, and the destruction of the wall in the formation of true and false aneurysms.¹

Peripheral arterial ligation was developed in the 1800s by John Hunter, who demonstrated safe and reproducible means of ligating certain peripheral arteries.⁴ Innovative measures used to cause thrombosis of aneurysms included the insertion of long segments of wire⁵ with the application of an electric current,⁶ and wrapping of aneurysms with cellophane or other irritating materials.^7,8

In 1888, Rudolph Matas introduced obliterative endoaneurysmorraphy in which stitches placed from within the aneurysm sac obliterated the arterial openings.⁹ This allowed closure of large aneurysms that would have been difficult to ligate externally. Recognizing the importance of maintaining arterial continuity for certain aneurysms, he subsequently devised techniques of restorative or reconstructive endoaneurysmorraphy, in which diseased segments of the aneurysm wall were resected and the remaining vessel wall was reconstructed to reestablish flow.¹⁰ The number of aneurysms to which these techniques could be applied, however, was very limited. The broad application of surgical treatment for major arterial aneurysms would have to await the development of satisfactory conduits and the techniques to insert them.

The first report of a descending aortic repair was described by Cooley and DeBakey in 1952. The technique involved lateral resection and aortography performed on a saccular aneurysm without cardiopulmonary bypass (CPB).¹¹ In 1956, Cooley and DeBakey performed replacement of the ascending aorta with a segment of homograft with CPB.¹² Polyester cloth grafts were introduced by DeBakey, who discovered it in a Houston department store, and it soon became the artificial conduit of choice for aortic replacement.¹³ Technical improvements in graft replacements included the impregnation of polyester grafts with albumin, collagen, or gelatin, which has greatly reduced the blood loss through the grafts.¹⁴

Wheat et al in 1964, resected the ascending aorta and entire aortic root except for the aortic tissue surrounding the coronary arteries.¹⁵ They then performed a mechanical ...