CHAPTER VIII
Arterial Aneurysms and Arteriovenous Fistulas
Maintenance of Arterial Continuity
Norman E. Freeman, M. D.* and Harris B. Shumacker, Jr., M. D.
Though the principles which underlie vascular repair, the precautions which must be observed, the hazards entailed, and the methods applicable, have since been established by experimental investigations upon laboratory animals, actually the-first closure of an arterial defect was carried out upon man.1 Indeed this lateral closure was performed some 125 years before another successful instance of arterial repair in man or experimental animal was accomplished. Dozens of workers contributed to the evolution of the reparative techniques now employed, but Carrel's beautifully planned and executed experiments 2 perhaps served more than any other investigation to revive and maintain interest in the use of these measures in the management of both arterial aneurysms and arteriovenous fistulas.
The first clinical application of the principles of arterial repair seems to have been made in 1759 when Hallowell, acting on Lambert's suggestion,3 closed a small wound of the brachial artery by placing a pin through the margins, elevating the lacerated area, and twisting a thread about the pin. The next reported successful arterial repair in man was performed in 1886 by Postempski,4 who, by lateral arteriorrhaphy, repaired a rent in the femoral artery which he had made accidentally while draining an abscess. By 1903 Hopfner 5 was able to collect from the literature reports of 30 successful operations in which reparative techniques had been used.
In 1888 Matas 6 introduced endoaneurysmorrhaphy, a method of intrasaccular suture. This technique was first applied "while operating upon a traumatic brachial aneurysm which had resisted proximal and distal ligature." It was subsequently systematized as a method and carried out also in other
* Associate Clinical Professor of Surgery, University of California School of Medicine. Formerly Lt. Colonel, MC, AUS.
1 Lambert, R.: Wound of artery treated by pin suture. Med. Obs. Soc. Phys., London, 1762, vol 2, p. 360-364.
2 Carrel, A.: Surgery of-blood vessels. Bull. Johns Hopkins Hosp. 18: 18-28, Jan 1907.
3 See footnote 1, above.
4 Postempski, P.: La sutura dei vasi sanguigni. Arch. Soc. Ital. char. Roma 3: 391-395, Apr 1886.
5 H?pfner, E.: Uber Gef?ssnaht, Gef?sstransplantationen and Replantation von amputirten Extremit?ten. Arch. f. klin. Chir. 70: 417-471, 1903.
6 Matas, R.: Traumatic aneurysm of the left brachial artery; . . . incision and partial excision of sac; recovery. Phila. Med. News 53: 462-466, Oct 1888.
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cases of popliteal and femoral aneurysms. In 1903 Matas 7 recommended restoration of the circulation through the damaged artery as the ideal treatment for arterial aneurysms. In the following year Bickham 8 suggested that the Matas endoaneurysmorrhaphy be employed for the intravascular repair of arteriovenous fistulas and recommended transvenous closure of the defects in the vascular walls as a practical method of preserving the continuity of both artery and vein.?
The first end-to-end arterial suture in man was reported by Murphy 9 in 1897. The lesion was a traumatic arteriovenous fistula. He closed the wound of the vein, resected the damaged portion of the artery, and accomplished a successful end-to-end anastomosis by invaginating the proximal into the distal segment. In the same year Djemil-Pascha 10 also reported two successful cases in which this technique was used. Although the first end-to-end arterial sutures in man were performed by the invagination method devised by Murphy, it subsequently became apparent that direct approximation of the divided ends of the artery was a superior method.
In 1906, shortly after Carrel 11 and his associates had demonstrated the possibility of arterial repair by transplantation of a vein, Goyanes 12 treated a syphilitic popliteal aneurysm by proximal and distal ligation and then re-established the blood flow by anastomosing the femoral artery to the distal end of the divided femoral vein and the proximal end of the divided popliteal vein to the distal segment of the popliteal artery. Good circulation was maintained through the venous segment and into the popliteal artery, and feeble dorsalis pedis and posterior tibial pulses were palpable during the brief (6-day) postoperative period of observation. In 1907 Lexer 13 reported a case in which he repaired a traumatic axillary aneurysm by excising it and then suturing a segment of the saphenous vein into the arterial defect. The patient died of an unrelated cause (delirium tremens) on the fifth postoperative day, but necropsy revealed that the vein graft was intact and the brachial artery patent. Lexer subsequently employed the same technique in several other cases. The first successful vein graft to be recorded in the American literature was performed by Bernheim 14 in 1916. He used such a graft to bridge a defect in the popliteal artery following excision of a syphilitic aneurysm.
7 Matas, R.: Operation for the radical cure of aneurysm based upon arteriorrhaphy. Ann. Surg. 37: 161-196, Feb 1903.
8 Bickham, W. S.: Arteriovenous aneurisms. Ann. Surg. 39: 767-775, May 1904.
9 Murphy, J. B.: Resection of arteries and veins injured in continuity; end-to-end suture; experimental and clinical research. Med. Record N. Y. 51: 73-88, Jan 1897.
10 Djemil-Pascha: Uber die Arteriennaht. Kongress Moskow. Centralblatt f. chir. 24: 1048, Aug 1897, No. 39.
11 Carrel, A., and Guthrie, C. C.: Uniterminal and biterminal venous transplantations. Surg., Gynec. & Obst. 2: 266-286, Mar 1906.
12 Goyanes, J.: Nuevos trabojas de cirugia vascular; sustituci?n pl?stica de las arteries por las venas, ? arterio-plstia venosa, aplicada, como nuevo m?todo, al tratamiento de los aneurismas. Siglo m?d. 53: 561-564, Sep 1906.
13 Lexer, E.: Die ideale Operation des arteriellen and des arteriell-ven?sen Aneurysma. Arch. f. klin. Chir. 83: 459-477, 1907.
14 Bernheim, B. M.: Ideal operation for aneurisms of the extremity; report of a case. Bull. Johns Hopkins Hosp. 27: 93-95, Apr 1916.
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Between World Wars I and II increased knowledge regarding the peripheral circulation radically altered the surgical approach to arterial lesions. The surgeon of the Second World War was far better equipped to handle casualties with vascular injuries than was the surgeon of the First World War. It is true that results achieved in the treatment of acute arterial injuries were little, if any, better in World War II than in the earlier war. On the other hand, the record of the vascular centers established in the Zone of Interior in the Second World War for the definitive treatment of arterial injuries was extremely impressive. This record can be attributed in part to a better understanding of fundamental physiologic mechanisms and to developments in the basic medical sciences. In addition, advances in anesthesiology, chemotherapy, and adjuvant supportive measures, particularly the use of whole blood transfusions, played an important role. From the standpoint of technique, of course, the good results obtained could be attributed to the careful and general application of Halsted's principles concerning the handling of tissues and to the surgical teachings of Matas, particularly to his emphasis on the importance of the preservation of all collateral vessels.???
In general the surgical methods for the management of arterial aneurysms which were being employed at the outbreak of World War II were:
1. the endoaneurysmorrhaphy devised by Matas;
2. measures designed to produce a clot in the aneurysmal sac or to induce the formation of fibrous tissue about it and thus prevent further expansion and possible rupture;
3. obliteration of the sac by closure of the offending vessel;
4. extirpation of the aneurysm-bearing portion of the artery; and
5. extirpation of the lesion combined with some procedure which permitted maintenance or reestablishment of the continuity of the affected artery.
Surgical methods for the management of arteriovenous fistulas were in general:
1. mass ligation of the fistula;
2. quadruple ligation and division of the main vessels with excision of the fistula;
3. transvenous closure of the arterial opening; and
4. repair of the opening in both artery and vein.
While it had long been recognized that the ideal method of management of arterial aneurysms and arteriovenous fistulas involving important arteries was some procedure which would permit the maintenance or restoration of the continuity of the affected artery, the general feeling was that operations of this kind were fraught with too much risk to justify their extensive clinical use. However, technical improvements in vascular surgery and the development of the means of combating postoperative thrombosis had begun to alter this situation, and by the time World War II commenced the total number of clinical cases in which some type of reparative surgery was being performed was on the increase.
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In World War II the large numbers of patients with arterial lesions and their concentration in the three vascular centers in the Zone of Interior where they were cared for by experienced vascular surgeons, permitted the selection of numerous cases for reparative surgery. This chapter is concerned with a report of that experience at the vascular centers of DeWitt General Hospital and Mayo General Hospital.
CRITERIA FORSELECTION OF CASES
The attitude of the surgeon, perhaps more than any other single consideration, determines whether or not reparative procedures shall be applied in the management of arterial aneurysms and arteriovenous fistulas. At the vascular center of Mayo General Hospital it was originally the practice to use this method of treatment only in those cases in which it was reasonably certain that normal arterial structure could be utilized and in which the operation could be performed without undue difficulty. An examination of those cases in which the lesion involved the arteries upon which the main blood supply to a part is dependent and in which repair is most desirable-innominate, common carotid and extracranial portion of the internal carotid; the subclavian, axillary, brachial, iliac, common femoral, and popliteal arteries-revealed that only 4 reparative procedures had been carried out in the first 138 cases handled at this center. This amounted to 2.9 percent. After this assessment of the situation it was decided that repair would be carried out in every instance in which it could possibly be performed without sacrificing collateral arteries and without leaving in situ obviously badly damaged portions of arteries. This altered approach resulted in the use of reparative procedures in 30 of the last 57 cases handled in this vascular center (52.6 percent). At DeWitt General Hospital this altered approach resulted in the use of reparative procedures in 23 of 67 patients operated upon for arterial lesions between June and November of 1945 (34.3 percent).
In a few cases reparative surgery was undertaken when the outcome was questionable because of the degree of local damage and the presence of infection, but this was done in the hope that success would follow and the indications for reparative methods would be, thereby, extended. While it is true that almost all of the failures occurred in this group, it is also true that results in many of the questionable cases were successful.
Problems of Arterial Repair
Although the attitude of the surgeon is of paramount importance in the application of reparative procedures to the surgery of aneurysms and fistulas, the anatomic situation revealed at operation often precludes reparative surgery. In the first place there may be thrombosis of the distal artery. In a number of cases this has made impossible any arterial repair. According to Bigger, 15
15 Bigger, I. A.: Treatment of traumatic aneurysms and arteriovenous fistulas. Arch. Surg. 49: 174-179, Sep 1944.
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calcification of the wall of the artery inthe area to be sutured represents the most importantcontraindication to repair. Extensive arterial obliterative disease hasalso often made arterialrepair impossible, though this factor was not of importance in theaneurysms and arteriovenousfistulas observed during World War II because most of them were oftraumatic origin. However,repair under unfavorable circumstances was sometimes attended withsuccess. In one casetreated at a vascular center in the Zone of Interior, vein graft wassuccessful in spite of extensivemedionecrosis of the popliteal artery (Table 32, Case 32).
In traumatic lesions, extensive damage to the artery is often a determining factor in preventing restoration of continuity, at least by the simpler means such as lateral arteriorrhaphy or end-to-end anastomosis. In contrast to the limited injury to the artery which is the rule when aneurysms or fistulas have resulted from stab wounds, for example, there is generally extensive injury when these lesions have resulted from shell fragments, land mines, or bullets, as was the case in almost all of the patients observed at the vascular centers. There is frequently gross and much more often microscopic injury to the artery, not only in the immediate neighborhood of the aneurysm or fistula, but some distance from it. Whether the damage which is evident only on microscopic examination is a real threat to successful arterial repair is still an unsettled question. The military experience of World War II did not solve this problem.
A fairly common contraindication to end-to-end suture or vein graft is the presence of an important collateral vessel so near the end of the undamaged portion of the artery that to utilize these methods of repair would mean to sacrifice the collateral vessel. Except in the occasional case in which circumstances are such that continuity of the artery can safely be maintained by some simpler procedure such as ligation and transfixion of a fistula, definitive surgery should not be undertaken without good evidence that the collateral circulation is entirely satisfactory. It is almost never the part of wisdom to sacrifice a sizeable collateral vessel in order to achieve preservation of the artery. This principle was never violated in the cases observed in the vascular centers in the Zone of Interior during World War II.
Arteriovenous communications are frequently not simple fistulas but are associated with one or several saccular aneurysms as well. Sometimes these aneurysms arise from the veins or from the fistula itself, but often they originate in the artery and can be corrected only by excision of the involved segment. When this is necessary, unless the ends of the vessel can be mobilized sufficiently to permit approximation, a vein transplant is the only means of restoring an arterial vessel. Such a transplant is an ingenious means of bridging an arterial defect, but the threat of thrombosis is probably greater when this technique is employed than when end-to-end suture or lateral arteriorrhaphy is employed.
It should be noted that associated nerve lesions requiring suture were not considered a contraindication to arterial repair. Nerve lesions were present
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in a number of the combat-incurred vascularlesions discussed in this chapter but they presentedfew difficulties of management. The usual procedure was (1) to dissectfree the involved nerveor nerves, (2) to excise the aneurysm or fistula totally or subtotally,(3) to accomplish arterialrepair, and (4) to perform the necessary nerve surgery.
The chief local factors which endanger the success-of the repair appear to be damage to the wall of the artery (a determining factor in repair in many of these lesions which were of traumatic origin), infection, and a lumen of such small diameter as to make difficult accurate approximation of the parts.
TECHNICAL CONSIDERATIONS IN VASCULAR REPAIR
The general principles of vascular surgery were carefully observed in all reparative operations. Asepsis was strictly maintained. All the vessels were handled gently to avoid local injury, and the intima was always kept moist with physiologic salt solution or mineral oil. Nontraumatizing methods were employed to occlude the blood supply--rubber-shod serrefine artery clamps were used at Mayo, rubber tubing clamped close to the vessel wall by means of fine curved hemostats at DeWitt. The edges of the vessels were carefully brought together with fine suture material in such a way as to approximate intima-to-intima. Care was always taken not to allow the adventitia to fall within the suture line.
Complete control of the arterial supply to an arteriovenous fistula is essential for repair. Occlusion of the principal afferent and efferent arteries often does not suffice. At the vascular centers the use of a sterile stethescope at the time of operation was found to be invaluable in confirming the completeness of the control of the arterial components. Persistence of a bruit signified that some additional arterial supply was present.
Complete control of the venous component facilitates the repair, but such control may require prolonged and tedious dissection and may result in destruction of collateral vessels. In 7 patients at the vascular center of DeWitt General Hospital, control of the arteries alone was achieved. At the moment of severing the connection between the artery and the vein or the aneurysmal sac, digital pressure was used to control the venous bleeding. Suture of the open vein was then readily accomplished. In 5 patients at this center, after the afferent and efferent arteries had been isolated, a pneumatic tourniquet, which had previously been placed about the extremity at a higher level, was inflated. This procedure was not especially useful since the venous system in the presence of an arteriovenous fistula is capacious and therefore already full of blood. In all of these cases retrograde bleeding necessitated digital pressure in addition to the use of the tourniquet. In several instances the venous pressure appeared to be even higher when the tourniquet was used than when it was not.
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Careful inspection of the wall of the damaged portion of the artery was another important phase of the reparative procedure. The incidence of additional points of damage of the arterial wall in the presence of arteriovenous fistulas is high. After irrigation of the lumen of the artery, the entire wall was carefully inspected both from within and from without. Two defects each, for instance, were present in arteries of 6 of the patients in the DeWitt General Hospital series, the first communicating with the main vein and the second with an aneurysmal cavity or another vein. In a seventh patient three venous communications were present. One objection to the transvenous method of closure is that additional defects or weak points in the arterial wall may be overlooked.
At the vascular center of DeWitt General Hospital excision of the damaged arterial wall was the preferred method. After excision of part of the arterial wall the resultant defect was closed by approximation of its edges. Usually, in the presence of an arteriovenous fistula, the artery, especially the proximal portion, has become so dilated that sufficient length is readily available. The preference at this installation was to use any sound portion of the arterial wall, even to one-sixth of the circumference (Case 13) rather than to perform a complete transection of the vessel with end-to-end anastomosis. In 11 patients at this center a portion of the arterial wall was excised. The use of the wall of the sac, or of a segment of vein, to reconstruct the arterial wall was not practiced on the ground that this tissue, which is largely fibrous, cannot withstand the increased pressure to which it is subjected in its new location. The recurrence of the arterial aneurysm in a patient at the DeWitt General Hospital (Case 11) was thought to be an illustration of the futility of using anything but normal arterial wall in the repair.
Transverse closure of the defect in the arterial wall sometimes produces distortion of the wall and turbulence of the blood stream. Auscultation over the vessel at the suture line occasionally reveals a loud, sharp, systolic murmur which may be audible through the skin and soft tissues even after healing has taken places. It was the experience at DeWitt General Hospital where 16 patients were treated by this method of repair, that in the absence of a diastolic component the murmur is without significance. The distortion of the vessel which may be produced by the transverse closure is, in fact, likely to be advantageous: The greater diameter at the point of closure may serve to prevent thrombosis and thus may increase the likelihood of a successful repair.
At DeWitt General Hospital approximation of the edges of the incised vessels was facilitated by manipulating the rubber tubing and clamps which had been placed above and below the fistula to occlude the artery. If this maneuver did not work, additional relaxation was obtained by dissecting the artery up to the point of origin of the nearest branch. However, no important collateral vessel was sacrificed.
At the vascular center of Mayo General Hospital in instances of arteriovenous fistula in which the fistula was not closed by ligation and transfixion or
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by lateral arteriorrhaphy, the affectedsegment of both artery and vein, together with the fistula,was excised. Repair was then accomplished by end-to-end suture or byvein transplantation. Thesame procedures were employed in a number of instances followingexcision of aneurysms.
At this center when end-to-end suture or interpolation of a vein graft was carried out, the procedure was facilitated by first placing 4 interrupted mattress sutures according to the suggestion of Frouin.16 It was felt that 4 sutures could be spaced more accurately at equidistant points than could 3 traction sutures according to the method of Carrel.17 It was not felt necessary to utilize an instrument for holding the sutures such as that devised by Horsley.18 At DeWitt the practice was to suture the opening into the vein after severing the connection between the artery and the vein or aneurysmal sac. When the artery had been disconnected the opening into the vein was closed longitudinally with a running stitch. This procedure was employed mainly for the purpose of simplicity in dealing with the venous component of the fistula since it is rarely necessary to repair the vein. In one patient (Table 29, Case 4) the continuity of the left innominate vein was deliberately preserved since the thoracic duct empties into it. No instance of thrombophlebitis or pulmonary embolism was encountered at this center although thrombosis occurred in a few cases. These complications therefore seem to be no more of a hazard after suture of the vein than after its ligation.
In contrast to the practice of suturing the opening into the vein as practiced at DeWitt, it was the policy at the vascular center of Mayo General Hospital to divide and ligate the vein rather than repair it.
Although differences of opinion concerning the best suture material for vascular surgery still exist, it has long been established that only the finest nonabsorbable sutures should be used. Silk, which is generally preferred, was used in all instances at DeWitt General Hospital. Silk suture material was not available at Mayo General and No. 120 cotton suture material was substituted. That this material is satisfactory is shown by the many successful cases in the Mayo series.
Practically every type of suture has been recommended for vascular surgery including continuous sutures, interrupted sutures, continuous mattress sutures, interrupted everting mattress sutures, and continuous cobbler's sutures. At Mayo interrupted everting mattress sutures were used for all reparative operations because they gave satisfactory assurance of accurate, intimal approximation without interposition of adventitia and because such anastomoses could be accomplished without noticeable constriction. Fine straight or curved artery needles were used.
16 Frouin, A.: Sur la suture des vaisseaux. Presse m?d. 16: 233-236, 1908.
17 Carrel, A.: La technique op?rtoire des anatomoses vasculaires et la transplantation des visceres. Lyon m?d. 98: 859-864, 1902.
18 Horsley, J. Shelton: Surgery of the Blood Vessels. St. Louis, C. V. Mosby Co., 1915.
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TABLE 29. LIGATION AND TRANSFIXION OF FISTULA - DATA ON 13 PATIENTS WITH ARTERIOVENOUS FISTULAS
At DeWitt General Hospital a running stitch was used which passed through all layers. The suture material was usually doubled back on itself and tied at the point of origin.No. 0000 silk, passed through sterile mineral oil, was used on an atraumatic needle. Bleeding from the suture line was seldom of any consequence and usually stopped spontaneously. When it did not, an additional stitch of No. 00000 silk was added.
Mechanical aids were not used in the reparative operations in any case in these two series. Permanent nonabsorbable intraluminal prosthesis are doomed to failure because of thrombosis, and no need was felt for the employment of removable glass splints or soluble rods in these cases. For various reasons the vitallium tubes introduced by Blakemore, Lord, and Stefko 19 were not used The sutured vessel has no permanent, rigid, nonabsorbable, partially constricting ring about it, as does a vessel repaired by the vitallium tube method, and in the hands of those experienced in vascular surgery the suture method carries less risk of subsequent hemorrhage and the occurrence of thrombosis is not significantly increased. Moreover, the nonsuture method is attended with certain difficulties. In several cases at the Mayo General Hospital in which its use was contemplated, a vein of suitable size could not be found. In one or two other cases the tubes could not be used because their length would have necessitated occlusion of a collateral vessel which lay near the damaged portion of the artery. In one case in which a vein graft had been completed by the
19 Blakemore, A. H.; Lord, J. W., and Stefko, P.: Severed primary artery in war wounded; nonsuture method of bridging arterial defects. Surgery 12: 488-508, Sep 1942.
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nonsuture method, a brisk hemorrhage occurredas the wound was being closed because the tubeslipped out of the proximal artery even though it had been tightlyanchored in place with severalsilk ligatures.
Even when arterial repair had been planned and was thought to be practical, the endeavor was made, in every case in these two series, to make certain that collateral circulation was adequate. Furthermore, as much care was used at operation to preserve all collateral vessels as if ligation of the affected artery were to be carried out. In retrospect it would seem to be wise to reexamine the collateral circulation at the time of operation during temporary occlusion of collateral arteries in cases in which by sacrificing one or more of them the repair of the main artery might be accomplished. Reparative procedures might have been undertaken in a number of other cases if this special technique had been used routinely and the efficacy of the collateral circulation established at the time of operation.
VASCULAR REPAIR AT DEWITT GENERAL HOSPITAL
Analysis ofData
Between June and November 1945 restoration of the continuity of the artery was attempted in 23 patients with aneurysms and arteriovenous fistulas at the vascular center of DeWitt General Hospital. (During this period 67 patients with arterial injuries were treated by surgical intervention.) This number (23) includes a patient with arteriovenous fistula of the abdominal aorta which, because of its rarity, is described in detail later in the volume. (See Chapter IX.)
Successful results were achieved in 18 of the 23 cases, including, in addition to the fistula involving the abdominal aorta, 3 lesions of the common carotid artery, 7 of the popliteal artery, 4 of the superficial femoral artery, and 1 each of the subclavian, brachial, and posterior tibial arteries. Longitudinal suture was employed in 2 instances, end-to-end anastomosis in 1, and transverse suture in 15.
Failure occurred in 5 of the 23 cases. In 1 patient treated by transvenous suture, initial success was followed by recurrence of the lesion. In another patient, this one treated by transverse suture, initial success was also followed by recurrence which necessitated subsequent excision of the fistula. The 3 remaining patients, in all of whom the operation failed, were treated by transverse suture, transvenous suture, and end-to-end anastomosis, respectively.
For two reasons anticoagulant therapy was not used in any of the patients operated on at DeWitt General Hospital: It was believed that (1) the reestablishment of an adequate lumen was sufficient to prevent thrombosis, and (2) complications which could conceivably arise from the use of these agents contraindicated their employment.
In all of the cases classified as successful, continuity of the artery was demonstrated either by the presence of normal arterial pulsations distal to
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the site of repair or by arteriogram. Patencyof the vein was demonstrated by phlebogram in 6patients in whom the venous wall was repaired by longitudinal suture,and venous obstructionwas demonstrated by the same method in 6 other patients. The status ofthe vein in the remainingpatients is not known.
Methods of Repair
Four techniques of repair were used at this center: (1) longitudinal suture, (2) transvenous suture, (3) end-to-end anastomosis, and (4) transverse suture. In view of the limited number of successful cases of arterial repair on record in the literature, case histories of certain patients treated by this method at the vascular center of DeWitt General Hospital are presented herewith. These are representative of the various types of reparative procedures employed at this center.
LongitudinalSuture
Case 1. A 23-year-old infantry sergeant was wounded by shell fragments 21 November 1944. Approximately 2 weeks later a pulsating mass was discovered on the anterior aspect of the right thigh. This increased in size for a period and then remained stationary.
The patient was transferred to the vascular center of DeWitt General Hospital. At the time of admittance physical examination disclosed the presence of a large tumor on the anteromedial aspect of the right thigh. Over it a loud, continuous bruit could be heard. An arteriogram taken 9 February 1945, showed a large arteriovenous aneurysm involving the superficial femoral artery and vein. This aneurysm measured 13 by 8.5 cm. in diameter. A phlebogram taken 2 March 1945, demonstrated displacement of the saphenous vein to the medial side of the thigh.
After sufficient time had been allowed for the development of a collateral circulation, an operation was performed 28 June 1945. Continuous spinal anesthesia was used. An incision was made over Hunter's canal above the aneurysm. After the dilated superficial femoral artery had been encircled with rubber tubing, the incision was carried down the thigh over the aneurysmal sac, and the sartorius muscle reflected medially to expose the superficial femoral artery and vein below the sac. The artery at this level was also encircled by rubber tubing. No attempt was made to control the blood flow through the femoral vein.
The artery was dissected free from the aneurysmal sac and venous bleeding from the opening into the sac controlled by digital pressure. The defect in the arterial wall measured approximately 1.5 cm. in length. It was closed with a continuous stitch of No. 0000 silk on an atraumatic needle. During this phase of the procedure the lumen of the vessel was irrigated with physiologic salt solution. After completion of the suture, the lower and then the upper rubber tubes were released. Good expansile pulsation across the suture line was observed.
The sac was then opened widely and bleeding from the two orifices of the femoral vein controlled by digital pressure until the ends could be dissected free from the sac and ligated individually. No effort was made to excise the sac. A rubber tissue drain was brought out from the lower end of the wound, and the wound was then closed in layers.
The circulation to the foot and leg appeared to be excellent after operation. An arteriogram taken 27 July 1945 demonstrated the patency of the superficial femoral artery although the lumen was considerably diminished at the point at which the defect had been repaired.
Although pulsations of the peripheral arteries were normal, oscillometric readings 4 months after operation showed that there was still some impairment of circulation. Seven months after operation the patient still complained of aching in the leg after walking six blocks.
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Case 2. A 23-year-old infantryman was wounded in the right side of the neck 13 February 1945 by a shell fragment. Immediately after injury he noted hoarseness. Debridement was performed, followed by secondary closure of the wound. A few hours later he noted a thrill in the region of the wound. A slight ptosis of the right eyelid was also observed. All symptoms and signs persisted up to the time he was admitted to DeWitt General Hospital.
Physical examination at that time revealed the classical signs of an arteriovenous fistula involving the right side of the neck just above the clavicle. Laryngoscopic examination showed, in addition, paralysis of the right vocal cord. Pressure upon the fistula caused a paroxysm of coughing. The bruit could be made to disappear by applying pressure over the common carotid artery behind the clavicle. This procedure did not produce any symptoms of cerebral ischemia.
An operation was performed 2 August 1945, with the patient under intratracheal nitrous oxide-ether-oxygen anesthesia. A transverse incision was made above the right clavicle. The muscles were divided close to their insertion and the greatly dilated internal jugular vein exposed. The inferior thyroid vein was divided and the common carotid artery, which appeared about normal in size, dissected free. Compression with a piece of rubber tubing did not entirely obliterate the bruit heard over the fistula. Dissection was therefore carried above the fistula, and the common carotid artery isolated and surrounded by a second piece of rubber tubing. Compression of the artery both above and below the fistula reduced the bruit, but did not completely abolish it. Digital palpation revealed the presence of another large artery lying beneath the fascia lateral to the jugular vein. This artery, which proved to be the inferior thyroid, was divided above and below the fistula. Following this procedure no bruit was audible when the contributory vessels were compressed. Accordingly, the jugular vein was ligated above and below the fistula and the carotid artery dissected away from the aneurysm. The defect in the wall of the carotid was closed with a longitudinal running stitch and the segments of the jugular vein, with the aneurysm which lay posterior to it, excised.
The wound was closed in layers without drainage. Good pulsation was present in the distal part of the carotid artery 1 hour after suture. Convalescence was uneventful. When the patient was discharged 4 weeks after operation pulsation of the right temporal artery was normal. This pulsation was not affected by compression of the left carotid artery though it was obliterated when compression was made on the right side of the neck. Six months later the patient reported that his only residual symptoms were hoarseness and some drooping of the right eyelid. There was no evidence of recurrence of the aneurysm and he was able to exercise as much as he desired.
Comment. Longitudinal closure of the defect in the arterial wall was successfully accomplished in these 2 patients. When the opening is small, distortion of the arterial wall by suture is not great. In larger defects, how ever, distortion of the normal contour resulting from suture may curtail the volume of blood flowing through the restored artery. Reinforcement of the suture line by the use of a part of the sac wall may still further reduce the caliber of the vessel. Waugh 20 reported a case in which the diameter of the vessel was reduced one-half by this procedure. The maintenance of a full volume flow of blood past the suture line seems to be of importance in preventing subsequent thrombosis at this site.
20 Waugh, W. G.: Arteriovenous aneurysm of the popliteal vessels; arteriorrhaphy under heparin. Brit. J. Surg. 31: 192-193, Oct 1943.
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Transvenous Suture
Case 3. A 28-year-old infantry private was wounded in left knee by a rifle bullet 13 March 1945. There was considerable hemorrhage initially and bleeding recurred on several occasions. He was admitted to the vascular center of DeWitt General Hospital 6 April 1945. At this time there was considerable swelling of the left calf and ankle. A pulsating mass was present in the popliteal space over which was observed the characteristic thrill and bruit of an arteriove-nous fistula. Pulsations about the left ankle were absent and oscillometric readings showed a marked decrease in the circulation. An arteriogram 12 April revealed an arterfovenous fistula at the level of the head of the fibula. Dye was present in the veins on both sides of the artery, but the significance of this observation was not realized until later. Lumbar sympathectomy performed 13 August was followed by improvement in the collateral time and in the circulation to the left foot.
The vascular operation was performed 13 September 1945. Continuous spinal anesthesia was used. The involved vessels were exposed between the heads of the gastrocnemius muscle in the lower portion of the popliteal space where the popliteal artery lay between the two veins. Without separation of the veins from the artery the entire vascular bundle was encircled by rubber tubing both above and below the fistula. Each vein was opened in turn and its communication with the artery visualized. The opening on each side was approximately 7 mm. long. Each was closed longitudinally, according to the Matas-Bickham technique, 21 using a running stitch of No. 0000 silk on an atraumatic needle. The sutures were tied outside of the vein. When the upper tube was released a small amount of bleeding from the artery into one of the veins was observed and two additional stitches were taken in the suture line within this vein. At the conclusion of this procedure there was no further bleeding.
The incision on the posterior surface of the vein was closed with a running longitudinal stitch, after which all of the blood vessels were released. Auscultation revealed a very faint continuous bruit in the region of the fistula. Further dissection failed to disclose its source and it was assumed that it, resulted from the turbulence of the blood stream as it passed over the suture lines. The wound was closed without drainage.
Following the operation the posterior tibial pulse was excellent and oscillometric readings showed a considerable improvement in the circulation to the left leg and foot. Auscultation, however, revealed the same faint continuous bruit with systolic accentuation heard during the operative procedure.
The patient was then sent on a convalescent furlough. Upon his return he stated that while walking one day he had suddenly felt something snap and upon palpation had noticed a recurrence of the thrill. When he was reexamined a loud continuous bruit was audible.
The second vascular operation was performed 17 November 1945. A longitudinal incision was made posterior to the head of the fibula and was extended upward medially to the biceps tendon. The peroneal nerve was exposed and retracted laterally and the lateral head of the gastrocnemius muscle retracted posteriorly to expose the popliteal vessels as they passed through the ring of the soleus muscle. An aneurysm measuring 2 cm. in diameter was found at this point. The artery above the aneurysm was freed and encircled by a piece of rubber tubing, compression of the artery by this tubing obliterated the bruit.
The head of the soleus muscle was then divided close to its attachment to the head of the fibula and retracted posteriorly together with its nerve and blood supply. The popliteal artery was thus exposed below the aneurysm. At this point there was a moderately dilated vein lying over the artery. It was possible to observe the turbulent flow of mixed arterial and venous blood in it. This vein was divided and ligated in order to expose the popliteal artery below the fistula. The artery was again encircled by a piece of rubber
21 See footnotes 6, p. 264, 7, and 8, p. 265.
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tubing. The proximal and distal arteries were divided and ligated; thecomponent veins were treated similarly andthe aneurysm excised. Examination of the specimen revealed two openingsfrom the artery, a small one,communicating with a small vein, which had apparently been overlookedat the original operation, and a larger onewhich was the result of a rupture of the artery into the vein at thepoint where it had been sutured at the originaloperation.
Recovery from the second operation was without complications, but thereafter the circulation to the left foot was definitely decreased. Oscillations at the ankle were less than one-fourth of those on the normal side.In spite of this fact, the circulation was fairly well maintained and the patient was able to walk as many as three blocks before signs of intermittent claudication developed.
Case 4. A 24-year-old sergeant was struck by a shell fragment just above the left clavicle 29 July 1944. It was noted after the initial debridement that the left radial pulse was absent although it subsequently returned. The patient stated that from the time of the injury he believed the temperature of the left upper extremity was lower than that of the right upper extremity. Except for difficulty in articulation for the first few days after injury, he had no complaints. However, a loud continuous bruit was audible over the left sternoclavicular joint.
When he was admitted to the vascular center at DeWitt General Hospital in October 1944, his venous pressure was 16.4 cm. of water on the left side and 13.4 cm. on the right in the antecubital vein. The circulation time was 20 seconds on the left and 9 on the right. At examination, attempts to compress the aneurysm by pressure in the supraclavicular region were unsuccessful. In spite of the fact that the aneurysm was close to the heart, no evidence of cardiac enlargement was noted during a long period of observation.
An operation was performed 10 September 1945 with the patient under endotracheal nitrous oxide-ether-oxygen anesthesia. A transverse supraclavicular incision was made on the left side and extended down over the manubrium to the second rib, thence laterally to the costochondral junction (Fig. 36). The muscles attached to the clavicle and the sternum were divided close to their insertions. The internal jugular vein was thus exposed and the turbulent mixing of arterial and venous blood characteristic of arteriovenous fistula could be observed. Pressure on the junction of the internal jugular and subclavian veins stopped the bruit in the fistula.
The common carotid artery on the left side was then exposed; its pulsation was found to be feeble and its wall thick. Occlusion of this artery, however, did not eliminate the thrill in the aneurysm. Further dissection revealed a greatly dilated innominate vein which it was impossible to expose adequately without opening the thorax. Accordingly, the medial 2.5 inches of the left clavicle were resected subperiostially, and the sternoclavicular articulation left intact. The tissues were then freed beneath the sternum in the midline and the manubrium split to the upper border of the second rib and then cut transversely at this level. The left half of the manubrium was now readily retracted laterally to expose the thymus lying on the large dilated innominate vein. Some branches of this vein were ligated and divided. The innominate vein and left carotid artery were retracted medially to expose the left subclavian artery as it arose from the arch of the aorta. The subclavian artery was considerably larger than the carotid, its walls were thin and the pressure within it seemed to be low. It was encircled by a fine catheter fitted to a Bethune tourniquet. Compression of the subclavian artery at the arch of the aorta obliterated the thrill in the aneurysm. The bruit also ceased abruptly as soon as the subclavian artery was compressed but after a short interval it was again faintly audible. The recurrence of the bruit was thought to be indicative of collateral circulation.
The internal jugular vein was then divided above its junction with the subclavian. Dissection on the medial side of this vein revealed a large lymphatic duct which entered the jugular vein at its junction with the subclavian. The phrenic nerve was retracted
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medially and the scalenus anticus muscledivided in order to expose the second portion of the subclavian artery.Theinternal mammary artery was carefully preserved, but the costocervicaland the thyrocervical trunks were ligated.The subclavian artery distal to the fistula was greatly reduced incaliber; it was encircled in this location by a pieceof rubber tubing. The first portion of the subclavian artery justproximal to the origin of the vertebral artery was thenexposed and encircled by a second piece of rubber tubing. When thesubclavian artery had been compressed justproximal to the vertebral artery and distal to the fistula, and thevertebral artery had also been compressed, the bruitwas abolished and the innominate vein no longer filled with arterialblood.
The subclavian and innominate veins were then occluded by additional pieces of rubber tubing after which the innominate vein was opened on its anterior aspect close to the junction of the jugular with the subclavian vein and flushed out with physiologic saline solution. It was now possible to see an aperture which measured approximately 1 cm. in length lying over the subclavian artery (Fig. 36). The opening from the artery into the vein was sutured from within the vein by the Matas-Bickham technique, using No. 0000 silk. The suture was started from outside the vessel and was passed into the lumen; then, after the opening had been closed with a running stitch, it was doubled back on itself and its ends brought outside of the vein to be tied at the starting point. After this suture had been completed, the distal artery, the vertebral artery, and the proximal artery were released in that order. Some slight bleeding into the vein was controlled by an additional stitch. The incision on the anteromedial surface of the innominate vein was closed with a running longitudinal stitch. The divided halves of the manubrium were approximated with two steel wire sutures and the muscles and superficial tissues closed in layers.
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A wound infection necessitated incision and drainage 2 weeks after the original operation, but recovery thereafter was satisfactory. Although there were no signs of circulatory insufficiency of the left upper extremity, the radial pulse continued to be markedly diminished and oscillometric readings showed reduced circulation on this side. Six weeks after operation a phlebogram demonstrated the patency of the left innominate vein. Five months after operation the patient reported that he had noticed no recurrence of the fistula. He stated, however, that he was short of breath and that he experienced precordial pain on exercise. Since there was no cardiac enlargement even before operation it seemed unlikely that the fistula could have caused serious cardiac disturbance.
Comment. Transvenous suture, although it has been considered a logical procedure, has two decided drawbacks: (1) Since the artery need not be fully mobilized, a second, or even a third, communication may be overlooked. This complication, which has been reported by Reid and McGuire, 22 accounted for the persistence of the arteriovenous fistula in Case 3 of this series.(2) The arterial wall may be weakened or defective either close to the fistula or at some other point. Without careful scrutiny, both from within and from without, this damaged area may be overlooked. Subsequent rupture with the formation of an aneurysm may result.
End-to-End Anastomosis
Case 5. A 25-year-old infantryman, shortly after being wounded in the left thigh 15 January 1945, showed signs of an arteriovenous fistula. When admitted to the vascular center at DeWitt General Hospital 15 July 1945, examination revealed the characteristic signs of an arteriovenous fistula. An arteriogram taken on 20 July showed an aneurysmal sac lying to the medial side of the femoral artery with a communication into the lower femoral and popliteal veins. Sympathectomy was performed 30 July. After this operation, the collateral circulation improved and appeared to be adequate.
The vascular operation was performed 23 August 1945. A longitudinal incision was made over the lower part of the adductor canal and the femoral artery exposed above and below the fistula. The aneurysm was found on the lateral side of the artery. After digital compression of the veins the artery was dissected free from the aneurysm and from the veins. The opening into the vein was closed with a longitudinal running stitch. Two large defects were present in the arterial wall. Because so little sound arterial wall remained the damaged portion was excised and an end-to-end anastomosis performed. After release of the rubber tubing expansile pulsation was transmitted across the suture line. The wound was closed without drainage.
The peripheral pulses were good after operation and at the left ankle an oscillometric reading of 3 units was noted in comparison to a reading of 5 units on the uninjured side. The excellent peripheral pulses and the practically normal circulation encouraged the belief that a successful repair had been accomplished, but an arteriogram taken 6 weeks after operation showed that the segment had been completely obliterated and that the circulation was being carried on entirely by means of collateral vessels.
Case 6. A 28-year-old infantryman was wounded in the left thigh by a rifle bullet 28 February 1945. The wound of entrance was 2 inches below Poupart's ligament. Debridement was carried out while the patient was in the forward area. Later an arteriovenous fistula was discovered in the traumatized area of the thigh. The patient was admitted to the vascular center of DeWitt General Hospital 1 July 1945. An arteriogram taken
22 Reid, M. R., and McGuire, J.: Arteriovenous aneurysms. Ann. Surg. 108: 643-693, Oct 1938.
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7 September 1945 showed a communicationbetween the femoral vessels just distal to the profunda.
An operation was performed 1 October 1945. A semilunar incision, with its center at the wound of entrance, was made over the upper portion of the thigh. The common femoral artery was exposed below Poupart's ligament. It was greatly dilated and its walls were thin. The artery was encircled by a piece of rubber tubing, compression of which obliterated the thrill in the arteriovenous fistula although a slight bruit remained audible. The artery was also exposed below the profunda femoris and a temporary ligature placed about it, but further auscultation revealed that the aneurysm involved the superficial femoral artery below this second temporary ligature. Dissection was accordingly carried farther down the thigh by retracting the sartorius muscle medially and exposing the femoral artery in Hunter's canal. When the artery was occluded both proximally and distally the bruit was completely abolished. The artery was separated from the vein by sharp dissection. Rather brisk venous bleeding was controlled by digital pressure until the femoral vein could be sutured.
Examination now showed that the wall of the femoral artery had been destroyed over a very wide range and that it showed perforations, one on the lateral and one on the medial side. The artery was therefore divided and the damaged portion excised. In order to obtain sufficient relaxation to permit suture, the artery had to be dissected free below for a distance of 2 inches and upward to the point at which the profunda femoris left it. An end-to-end anastomosis was then performed; a continuous running stitch of No. 0000 silk was used. After release of the rubber tubing there was some bleeding which was controlled with additional stitches. At the conclusion of the operation good pulsation was transmitted across the suture line. The wound was closed without drainage.
The peripheral pulses remained excellent and convalescence was uneventful. Oscillo metric readings showed no diminution of the circulation on the injured side. An arteriogram and a phlebogram taken 2 months after operation demonstrated patency of the vessels. The patient reported 5 months after operation that he had been working steadily, but that he had pain in the lower part of the leg when standing for a long time or when walking for some distance. There was no swelling in the limb and the circulation was good.
Comment. End-to-end anastomosis was successful in the second of these 2 cases. Obliteration occurred in the first case. The patient recovered, however, since the collateral circulation was abundant and little vascular insufficiency resulted.
TransverseSuture
Case 7. A 24-year-old infantryman was wounded in the neck, arms, and legs by multiple mortar fragments 1 April 1945. Subcutaneous emphysema of the neck developed, but subsided spontaneously. Subsequently characteristic signs of arteriovenous fistula were observed on the left side of the neck at the level of the thyroid cartilage. These signs persisted up to the time he was admitted to the vascular center at DeWitt General Hospital 27 May 1945. Laryngoscopic examination showed, in addition, paralysis of the left vocal cord. Three months after the injury compression of the common carotid artery below the fistula produced no evidence of cerebral ischemia.
An operation (Fig. 37) was performed 23 July 1945. Local anesthesia was used. An oblique incision (Fig. 37A) was made parallel to the skin creases at the level of the thyroid cartilage. Dissection was carried down medially to the sternomastoid muscle, and the common carotid artery was isolated below the fistula. A rubber tube was placed about the artery at this point. The common carotid artery was again isolated and similarly treated above the fistula. The jugular vein was greatly dilated. It was dissected free and a heavy black silk thread placed about it both above and below the fistula. The vagus nerve was then freed to the point at which it was incorporated in the scar between the carotid artery
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and the jugular vein. Procaine hydrochloride (1 percent) was injected into the vagus nerve above the line of scar tissue. With the common carotid artery compressed both above and below the fistula, the vagus nerve was dissected free and the communication between the artery and vein opened. The communication measured 1 cm. in diameter.
On inspection of the defect in the arterial wall, which was on the posterolateral side, it was noted that the media was defective in the region of the aperture. The defective portion of the wall was excised. After relaxation of tension had been accomplished, the defect in the arterial wall was closed in a transverse direction (Fig. 37E) by a running stitch doubled back on itself. When the rubber tubing was released, pulsation took place across the suture line. There was no evidence of narrowing of the vessel. The jugular vein was divided between ligatures. The two ends of the vagus nerve were united after excision of the damaged segment. When, at the conclusion of the operation the carotid artery was again examined, good pulsatile flow could be demonstrated above the suture line. The wound was closed in layers without drainage.
Recovery occurred without complications and the patient was discharged from the hospital a month after operation. It was possible, in the postoperative period, to demonstrate the patency of the left common carotid artery by noting that the temporal pulse on the left side was unaffected by compression of the right common carotid artery but could be obliterated by compression ofthe artery on the left side. Six months after operation no swelling hadrecurred in the neck, butnormal voice had not yet returned. The patient reported he was stillunable to work and that hecould not exercise as much as he would like because he was"short-winded."
Case 8. A 21-year-old infantryman sustained many wounds of the chest, abdomen, and right leg from mortar shell fragments 21 December 1944. During his hospitalization it was discovered that he had an arteriovenous fistula in the right popliteal space. On his admission to DeWitt General Hospital 28 March 1945, the diagnosis was confirmed. A preoperative arteriogram 22 May showed considerable reflux of dye into the dilated popliteal vein. The communication between the artery and the vein seemed to be at the superior level of the patella.Lumbar sympathectomy was performed 9 July 1945. After this operation the collateral circulation appeared excellent.
The vascular operation was performed 9 August 1945.Continuous caudal anesthesia was used. A Z-shaped incision was made with the transverse bar across the popliteal crease. The incision was deepened along the tendon of the semimembranous muscle. Many small veins were encountered which entered the greatly dilated popliteal vein. Rubber tubing was placed about the entire vascular bundle including both the artery and the vein. Dissection was then carried out below the fistula and the popliteal artery isolated and encircled by a section of rubber tubing. The popliteal vein was surrounded by heavy silk cord. Further dissection above the aneurysm resulted in separation of the artery from the vein so that each could be controlled independently. When the component vessels had been occluded the artery was dissected from the vein and the communication severed. The defect measured 1 cm. in length. The opening in the wall of the vein was closed with a longitudinal running stitch. Since the arterial wall was found to have been damaged for about one-half its circumference, a wedge-shaped portion of the lateral wall was excised and the defect closed in a transverse direction with a continuous suture of No. 0000 silk placed through all coats of the vessel. Some bleeding followed release of the occlusive rubber tubing, but was controlled with a suture. There was only slight reduction in the diameter of the artery at the point of suture and vigorous pulsation was noted below the suture line after release of the rubber tubes. At the conclusion of the operation the posterior tibial pulse was full and bounding. The wound was closed without drainage.
Normal pulses were present during the postoperative period at the right ankle and oscillometric readings showed that the circulation on the right side was almost equal to that of the left. An arteriogram 24 August showed practically no distortion at the suture line.
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Reexamination 4 months after operation disclosed a normal peripheral circulation and 6 months after operation the patient reported that he was able to walk several miles without difficulty.
Case 9. A 22-year-old corporal was struck by a shell fragment 18 July 1944 just above the right calvicle. In addition, he sustained severe wounds of both legs and the left forearm. Amputation of the left forearm was necessary. He was admitted to DeWitt General Hospital 5 March 1945 with classical signs of an arteriovenous fistula at the base of the neck on the right side. It was difficult to obliterate the bruit by pressure above the clavicle. In spite of the length of time between injury and operation there were no signs of cardiac damage.
An operation was performed 20 August 1945 with the patient under endotracheal nitrous oxide-ether-oxygen anesthesia. A supraclavicular incision was made. The muscles attached to the sternum and clavicle were divided at their insertion in order to expose the internal jugular vein. Both the right and left inferior thyroid veins were divided and ligated, and the deep cervical fascia incised. The internal jugular vein was retracted laterally and dissection carried down behind the clavicle to expose the innominate artery. This artery was encircled by a piece of rubber tubing fitted to a Bethune tourniquet. Occlusion of the artery caused marked decrease in the bruit over the fistula. Compression of the common carotid artery did not affect the bruit. The rubber tubing was then transferred to the subclavian artery just proximal to the origin of the vertebral artery. The scalenus anticus muscle was divided, after retraction of the phrenic nerve medially, to expose the second portion of the subclavian artery. The communication appeared to involve the internal jugular vein and the subclavian artery just proximal to the origin of the thyroid axis. The jugular vein was divided and its upper portion ligated. After compression of the subclavian artery proximal and distal to the fistula the vein was dissected free from the artery to expose a small opening approximately 0.5 cm. in diameter. This opening was closed transversely with interrupted stitches of No. 0000 silk. Good pulsation was present in the artery distal to the suture line after release of the occluding rubber tubing. The jugular vein was ligated close to its junction with the right subclavian, and the wound was closed in layers without drainage.
Convalescence was uneventful and at the time of the patient's discharge from the hospital the right radial pulse was normal.
Case 10. A 27-year-old soldier was wounded by shell fragments in the right thigh, trunk, and face 20 January 1945. During his convalescence from these wounds an arteriovenous fistula of the right femoral vessels was noted. He was admitted to the vascular center at DeWitt General Hospital 18 May 1945. An arteriogram (Fig. 38A) taken 20 May 1945 revealed an arteriovenous fistula in the upper portion of the superficial femoral vessels on the right side and, in addition, a small aneurysm on the lateral aspect of the artery. A lumbar sympathectomy was performed 8 August because of impaired circulation. Following this operation there was considerable improvement in the collateral circulation.
The vascular operation was performed 13 September 1945. The superficial femoral artery was exposed in the upper third of the thigh. Rubber tubes were placed about the artery both above and below the fistula. A pneumatic tourniquet was then inflated and the artery dissected away from the vein and from the aneurysm. The aneurysm was found on the posterolateral side of the artery while the opening between the artery and the vein was on the posteromedial side. The opening into the vein was closed with a longitudinal running stitch. The pneumatic tourniquet was then deflated.
The defect in the arterial wall was approximately 1.5 cm. long. The damaged portion of the wall, including the segment between the openings into the vein and the aneurysm, was excised. Approximately three-fourths of the circumference was lacking and in order to approximate the two ends it was necessary to free the artery both above and below the fistula for approximately 1.5 inches. No large branches were found. Because of the location of the arterial defect, the suture line was oblique rather than transverse or longitudinal.
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There was a small amount of bleeding from the suture line after release of the rubber tubing, and an additional stitch was added. Slight distortion of the arterial wall on the side opposite the repair was noted. No attempt was made to remove the aneurysm. The wound was closed without drainage.
Convalescence was uneventful. Oscillometric readings before operation had shown a maximum of 2 units on the right side and 7 on the left, but after repair of the femoral artery the readings were 3 units on the right side and 3.5 on the left. An arteriogram taken 3 months after repair showed normal continuity of the superficial femoral artery (Fig. 38B). A phlebogram demonstrated patency of the femoral vein. Four months after operation, however, the patient reported that he was not able to exercise as much as he desired because his leg became swollen below the knee if he walked too much. There was no recurrence of the arteriovenous fistula nor was there any evidence of swelling in the region of the aneurysm.
Case 11. A 26-year-old infantryman was wounded in the left thigh by shell fragments 30 March 1945. He complained of numbness and tingling in his left foot. A pulsating mass appeared 8 cm. below the inguinal ligament, directly beneath the scar of the wound. He was evacuated to the Zone of Interior and admitted to the. vascular center of DeWitt General Hospital. Examination at this center revealed a systolic thrill and a high-pitched bruit, but there was no diastolic component to the murmur. An arteriogram 10 August revealed an aneurysm about 4 cm. in diameter arising from the upper portion of the superficial femoral artery. Lumber sympathectomy was performed 4 October 1945.
The vascular operation was performed 18 October 1945. The superficial femoral artery was exposed above the aneurysm medial to the sartorius muscle. The artery was encircled by rubber tubing. Compression on this tubing caused the aneurysmal sac to collapse. The artery below the aneurysm was then exposed and a tube placed about it to control the retrograde circulation. With both the proximal and distal arteries occluded, the sac was exposed and incised. After removal of the clots and fresh blood the opening of the afferent and efferent portions of the artery were observed to be approximately 1 cm. apart.
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The artery was freed from the sac by sharp dissection. There was considerable scar tissue present, as well as some edema. With the aid of traction applied by means of the rubber tubes, the orifices of the artery could be approximated. After cutting away excess portions of the sac, the opening was closed in a transverse fashion with a continuous running stitch. In addition numerous interrupted stitches of silk were used to approximate the scar tissue in the wall of the sac so as to take tension from the suture line. Upon release of the constricting tubing, pulsatile blood flow took place across the suture line. The artery in this location appeared to be quite small and contracted and there was considerable distortion of the superficial femoral artery at the site of suture. The wound was closed without drainage.
The postoperative course was uneventful. Readings taken by oscillometer showed the circulation at the left ankle to be about two-thirds of that of the normal contralateral ankle. An arteriogram 6 weeks after operation revealed considerable distorion of the femoral artery. Three months after operation the patient reported recurrence of the bruit. It was assumed, in view of the considerable degeneration and fibrosis of the arterial wall in the region of the aneurysm, that the scar tissue had given way and that the vascular lesion had recurred. Further treatment was believed to be contraindicated owing to the degeneration of the arterial wall.
Case 12. A 29-year-old officer was wounded in the left thigh by mortar fragments 11 November 1944. He sustained a compound fracture of the left femur. Six weeks later an arteriovenous fistula was discovered close to the site of the fracture. He was admitted to the vascular center at DeWitt General Hospital 8 May 1945. An arteriogram taken 25 May disclosed a simple arteriovenous fistula just below the fracture line. It also revealed considerable distortion of the superficial femoral vein. This was attributed to scar tissue about the fracture. Lumbar sympathectomy performed 13 September was followed by satisfactory improvement in the collateral circulation.
The vascular operation was performed 18 October 1945. Continuous spinal was the anesthetic of choice. An incision was made over the femoral vessel and the sartorius muscle was retracted medially. The superficial femoral artery was exposed above the fistula and rubber tubing was placed about it. Compression of the artery at this point obliterated the bruit of the fistula. The artery was exposed below the fistula and controlled by rubber tubing in this location also. All the small branches of the artery were carefully preserved. The vessels at the site of the fistula were bound down in scar tissue. The communication was exposed by sharp dissection and the artery cut away from the vein during digital compression of the superficial femoral vein above and below the fistula.
The vein was irrigated with physiologic salt solution and closed longitudinally. The defect in the artery measured 1 cm. in length. Its edges were composed of dense scar tissue. The damaged portion of the artery was excised in an elliptical fashion and the opening closed in a transverse direction with a continuous running stitch. There was no bleeding from the suture line after release of the rubber tubing. The suture line occupied approximately three-fourths of the circumference of the vessel and caused considerable distortion. However, good expansile pulsation was transmitted across the suture line. The wound was closed without drainage.
After healing had taken place oscillometfic readings showed that there was greater pulsation on the affected side than on the normal side. An arteriogram made after recovery showed some distortion of the superficial femoral artery, but also showed that the lumen had been preserved. Three months after operation the patient reported that there had been no recurrence. His activities were still limited because of the stiffness of his knee resulting from the prolonged period of traction, and he stated that the leg tired more readily than normally.
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Case 13. A 23-year-old soldier was struck by fragments from a defective mortar shell 24 September 1945 and incurred multiple wounds of the neck, left shoulder, and arm. One fragment penetrated the left arm just above the elbow and lodged beneath the skin on the medial side. Immediately after injury a wrist drop and some weakness of the left hand developed. He was transferred to a regional hospital after debridement of the wounds. At this installation a pulsatile swelling was noted in the region of the brachial artery above the elbow. As this mass increased in size, progressive paralysis of the median nerve developed. The patient was evacuated to the Zone of Interior and admitted to the vascular center at DeWitt General Hospital 17 October 1945. At that time, pulsations in the vessels at the left wrist could not be detected by means of an oscillometer. Because of the increasing size of the pulsating hematoma and the resulting compression of the median nerve, operation was performed 3 days later.
A longitudinal incision was made on the medial aspect of the arm above the elbow and was curved slightly outward at the lower angle of the wound. When the deep fascia was opened some discoloration of the fat was noted. A pneumatic tourniquet previously applied about the arm was inflated and the hematoma incised. It contained some fresh blood and old clots. The median nerve was exposed and dissected free from the aneurysm. It was found to have become stretched and flattened out as it passed over this tumor. Rubber tubes were passed about the brachial artery above and below the laceration in the wall and the artery separated from the aneurysm. The tourniquet was then released and no further bleeding occurred. The damaged portion of the arterial wall was then excised leaving not more than one-sixth of the circumference intact. The two sections of the artery were approximated and the defect in the wall closed in a transverse direction; a continuous stitch of No. 000000 silk was used. All layers of the arterial wall were included. Though there seemed to be considerable spasm of the proximal portion of the artery, at the conclusion of the operation a good pulsatile flow could be demonstrated distal to the suture line. The cavity of the aneurysm was drained through the wound of entrance on the lateral side of the arm and the incision closed.
Immediately after operation the color of the hand was good and a faint radial pulse was palpable. By the next day the radial pulse had returned to its full volume, and oscillometric readings 2 weeks after operation showed that the pulsations at the wrist were greater on the affected side than on the normal side. An attempt to make an arteriogram was not successful, but since it was possible to obliterate the left radial pulse by pressure applied to the brachial artery just above the elbow, it was concluded that the arterial repair had probably been successful.
Comment. Transverse repair of the artery was successful in 15 of the 17 cases in which it was attempted. Restoration of the continuity of the vessel was demonstrable by arteriogram in 10 of these cases and in the other 5 by the persistence of normal pulses distal to the site of repair. Of the 2 unsuccessful attempts, thrombosis occurred at the suture line in 1 patient, but this was due in part to faulty technique, i. e., failure to obtain adequate control of the artery above the fistula. In the second patient (Case 11) scar tissue of the aneurysmal wall was used to reinforce the suture line. This patient reported the recurrence of the aneurysm and it may be that the scar tissue gave way, permitting a new aneurysm to form.
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SUMMARY
The value of arterial repair in the treatment of aneurysms and arteriovenous fistulas has been questioned since the incidence of gangrene after ligation of major arteries of the extremities is negligible. While it is true that gangrene is rare after ligation, the end results are often not favorable. Remarkably little consideration has been given to the results of permanent reduction of the blood supply to the tissues, especially the muscles, distal to the lesion. After ligation the development of collateral circulation will usually suffice to care for the metabolic requirements of the tissues at rest, but it is only rarely that symptoms of impaired circulation are not noted.
In this connection certain studies made at the vascular center of DeWitt General Hospital are of interest. A questionnaire was sent to former patients in whom the popliteal or the femoral artery had been ligated as treatment for arteriovenous fistula. Nine of the 12 individuals who replied complained of restriction in their activities. A similar questionnaire was sent to those in whom the popliteal or the femoral artery had been repaired. Nine of the 11 who replied had no complaints, and the 2 patients with complaints both stated they could walk from 6 to 8 blocks before any symptoms appeared.
The oscillometer provided another means of assessing results of operative procedures. At DeWitt General Hospital a comparison of the oscillometric readings was made between those patients with arteriovenous fistulas treated by ligation and those treated by arterial repair. In 10 patients treated by ligation the average oscillometric readings were:
Before operation:
Affected side...............2.72
Normal side ............... 5.0
After operation:
Affected side.................0.75
Normal side...................4.0
In the 12 patients treated by reparative procedures the average oscillometric values were:
Before operation:
Affected side...................2.77
Normal side....................4.44
After operation:
Affected side..................3.85
Normal side....................3.79
On the basis of this evaluation, all the advantages seem to lie with repair instead of ligation of the affected artery.
Even conceding that preservation of the continuity of the artery is to be preferred, the question may still be posed as to the possible risk to the patient.
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In the past it has been held that this technique was contraindicated because even though the arterial repair was successful, there remained the possibility of recurrence of the fistula or the development of a false aneurysm close to the site of repair. In only 2 patients in this series did the fistula recur. One followed transvenous suture of the popliteal artery and the other recurrence of an arterial aneurysm was reported subsequently by the patient.
The dangers of hemorrhage or infection do not appear to be increased by arterial repair. In only one patient was serious infection encountered. Thrombosis at the suture line occurred in 3 patients, but the collateral circulation proved sufficient to prevent gangrene. There was nothing to suggest propagation of the thrombus in these patients.
The defect in the wall of the vein was sutured in 18 patients. Phlebograms taken of 12 patients after they had recovered demonstrated the patency of the vein in 6 patients, but in 6 others it was occluded. Neither thrombophlebitis nor pulmonary embolism was encountered in any instance.
It was the opinion at this center that transverse suture of the defect in the arterial wall after excision of the damaged portion was the most satisfactory method of arterial repair.
VASCULARREPAIR AT MAYO GENERAL HOSPITAL
Analysis ofData
In the course of World War II more than 300 aneurysms and arteriovenous fistulas were observed at the vascular center of Mayo General Hospital. The majority of patients with these lesions were treated by various surgical pro cedures involving extirpation of the lesion. In 34 patients, including 21 with arteriovenous fistulas and 13 with arterial aneurysms, some type of reparative surgery was employed.
Four techniques of repair were used: (1) ligation or transfixion of the fistula, (2) lateral arteriorrhaphy, (3) end-to-end suture, and (4) vein transplantation. Anticoagulants were usually employed when lateral suture, end-to-end anasto mosis, or vein graft were carried out. Except in those instances in which an adequate prothrombin level had been obtained before operation by the administration of dicumarol, it was the policy to give 50 mg. of heparin intravenously as soon as the decision to attempt arterial repair was reached. Heparin was continued at 4-hour intervals until a suitable response had been obtained from dicumarol, administration of which had been started as soon after operation as the prothrombin level could be determined. In most patients dicumarol was continued for 21 days. A small amount of fibrin foam was often placed in the wound. This seemed to give some protection against bleeding from the operative site without adding any risk of intravascular clotting.
Methods ofRepair
Ligation andTransfixion of Fistula
Thirteen patients with arteriovenous fistulas (Table 29) were treated by ligation and transfixion. The age range in this group was from 19 to 45 years, 11 of the 13 patients were under 36 years of age. The duration of the lesion at the time operation was performed ranged from 4 to 11 months and was 6 months or more in 10 patients. The fistula involved the carotid artery and the jugular vein in 3 instances, the popliteal in 4, the femoral in 5, and the axillary in 1. The saccular aneurysms present in 6 patients arose from the vein in 3 instances, from the fistula in 2, and from the artery in 1. In the last mentioned patient the aneurysmal sac had a small neck which could be ligated and transfixed. Associated injuries included a fracture of the femur in 1 instance (Case 10) and peripheral nerve injuries in 2 instances (Cases 4 and 6). Neurorrhaphy was performed at the same time as the vascular operation in 1 of these patients and at a later date in the other.
Eight patients were treated by sympathectomy before operation to improve unsatisfactory collateral circulation, and 4 received anticoagulants. In 1 patient (Case 6) heparin was given at the time of operation and continued until a satisfactory prothrombin level had been obtained from dicumarol. In 2 patients (Cases 8 and 10) dicumarol was given preoperatively for several days. In all 3 patients dicumarol was continued for from 2 to 3 weeks. In the fourth patient (Case 13) a single 50-mg. dose of heparin was given at the time of operation.
In 12 of the 13 patients in this group the fistula was ligated and transfixed at the point of its emergence from the artery, then was buttressed by a segment of the divided vein (Fig. 39). In the remaining patient (Case 13) the fistula was simply ligated in continuity without disturbing the artery or vein. Case 13 represents the only failure by the ligation and transfixion technique. Recurrence of the bruit and thrill was observed within 48 hours of operation and a second operation (excision of the fistula and quadruple ligation of the vessels) had to be performed 2 weeks later. The second operation was successful.
Results were good in the other 12 patients. No thrill or bruit could be demonstrated over periods of observation ranging from 1 to 4 months. The affected artery was not demonstrably narrowed or distorted in any instance, nor was it dilated. The two limbs were of equal warmth and color except in those patients upon whom sympathectomy had been performed; in those the affected foot was warmer than the normal foot. All the pulses distal to the site of anastomosis were full and were considered by a number of observers to be about equal to those in the contralateral extremity. In the patients upon whom sympathectomy was not performed oscillometric readings were approximately the same on both sides. In the patients upon whom sympathectomy was performed they were slightly higher on the affected side. The only abnormal physical findings after operation were limited to edema which was present in 2 patients; in both it was slight and became progressively less as time passed.
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LateralArteriorrhaphy
There were 5 patients in which the arterial defect was repaired by lateral suture; of these, 2 exhibited aneurysms and 3, arteriovenous fistulas.(Table 30.) The age range in this group was from 20 to 29 years.Duration of the lesion at the time of operation ranged from 2.5 to 6.5 months. The brachial artery was affected in 1 patient, and the subclavian and the femoral artery in 2 patients each. There were no associated injuries.
Heparin was given in 3 patients, in 1 (Case 14) for 48 hours and in the others (Cases 15 and 17) until dicumarol had become effective. In the latter, dicumarol was continued for 11 days. Sympathectomy was not regarded as necessary in any patient in this group.
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TABLE 30. LATERAL ARTERIORRHAPHY-DATA ON 5 PATIENTS WITH ANEURYSMS AND ARTERIOVENOUS FISTULAS
The same basic technique was used on all patients (Fig. 40). The edges of the rent, after being freshened, were stripped of adventitia and approximated with interrupted mattress sutures. In the 3 arteriovenous fistulas the cuff of vein which remained was used to reinforce the closure.
Results in 3 patients were excellent. At the conclusion of the operation the diameter of the artery, which was in good condition in 2 patients and in fair condition in 1, was but slightly reduced. The color and warmth of the affected and nonaffected limbs were the same, as were the pulses. In the 2 patients in which oscillometric studies were made, the oscillations were bilaterally equal in 1; in the other, moderately reduced on the affected side.
In 2 patients the operation was a failure. In the first patient (Case 14), although the artery appeared in good condition, gross infection was present at operation. The arterial diameter was reduced only slightly at the conclusion of the procedure and continuity of blood flow was maintained, but on the 13th day after operation serious hemorrhage occurred through the sutured defect. Exploration showed no evidence of healing at the line of suture. The affected segment was therefore excised and the artery ligated. Results of this procedure were good. In the second patient (Case 18), the artery was in poor condition at operation and its diameter was reduced more than 50 percent by the surgical procedure. At this time the question arose whether immediate excision of the damaged segment might not be the wiser course. No pulse could be felt distally after operation and within 3 hours it was evident that thrombosis had occurred. The wound was reopened and the diagnosis verified, though neither central nor
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peripheral propagation of the thrombus hadoccurred. The thrombosed segment was excised andrecovery was thereafter uneventful.
End-to-End Suture
There were 10 patients in whom the artery was repaired by end-to-end suture; 8 were instances of aneurysm and 2 of arteriovenous fistula.(Table 31.) In 1 of the fistulas a saccular aneurysm was also present. The age range in this group was from 19 to 35 years and the duration of the lesion at the time of operation, from 3 to 8.5 months. The brachial artery was involved in 7 patients and the axillary artery in 2. In the remaining patient a double fistula was present between the femoral vein and the femoral and profunda femoris arteries. Five patients had injuries of the peripheral nerves; these injuries required neurolysis in all and neurorrhaphy in 2.
In 1 patient sympathectomy was performed before operation, and in all anticoagulant therapy was administered. In 1 patient receiving anti-
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TABLE 31. END-TO-END SUTURE DATA ON 10 PATIENTS WITH ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS
coagulant therapy (Case 25) heparin was givenat operation and also, by mistake, 1,500 mg. ofdicumarol and 250 mg. of heparin during the course of the following 20hours.When the errorwas discovered, anticoagulant therapy was discontinued and syntheticvitamin K was given atonce. No hemorrhagic difficulties ensued.
Damage to the involved arteries required the excision of segments ranging from 1.5 to 3.0 cm. in length. End-to-end suture was accomplished by first placing four evenly spaced mattress sutures which were used as traction sutures. This technique facilitated the insertion of the everting mattress sutures which completed the anastomosis (Fig. 41). In lesions of the axillary and brachial vessels, the length of the available artery was increased by adducting the arm against the body and flexing the forearm upon the arm. This position was maintained after operation by the use of elastic bandages or plaster splints. In the patient in whom the femoral artery and the profunda were involved (Case 28), he divided ends of the femoral artery could not be approximated, but it was possible, without tension, to approximate the proximal end of the profunda to the distal stump of the femoral artery (Fig. 42).
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Good results were obtained in 8 of the 10 patients managed by end-to-end suture, but operation was unsuccessful in the other 2 patients. In 1 patient (Case 25), although good circulation was maintained in the hand, thrombosis of the sutured segment soon became evident. In this patient the aneurysm was near the distal end of the brachial artery, the sac lying partly in the belly and tendon of the biceps muscle. The divided ends of the artery could be sutured after the sac had been excised, but the diameter of the vessel was small and the distal segment was somewhat scarred as the result of the original trauma. Additional resection at this end to make more normal tissue available for suture would have been desirable, but this was impractical because of the proximity of the bifurcation of the vessel. In the other failure (Case 26) damage to the distal arterial segment was probably even more extensive than in the case just described. Though the patient continued to have a good radial pulse after operation, the ulnar pulsations were significantly reduced as were the oscillometric readings. The anastomosis may have remained patent, but it seemed more reasonable to assume that thrombosis had occurred and had perhaps been followed by recanalization.
Vein Transplant
There were 6 patients, 3 instances of aneurysm, 3 of arteriovenous fistula, in whom an arterial defect was repaired by vein transplantation. In 1 of the fistulas a saccular aneurysm was also present. In 5 of the patients the lesion
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was of traumatic origin, in the sixth patient(Case 32) a saccular popliteal aneurysm hadfollowed medionecrosis of the artery. The age range in this group wasfrom 19 to 36 years andthe duration of the lesion at the time of operation, in the 5 patientsin which this information wasavailable, ranged from 4 to 5.5 months in 4 patients. For the fifthpatient it was 6 years The
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TABLE 32. VEIN TRANSPLANT - DATA ON 6 PATIENTS WITH ARTERIAL ANEURYSMS AND ARTERIOVENOUS FISTULAS
femoral artery was involved in 4 patients andthe brachial and the popliteal artery in 1 patienteach. One patient had an associated fracture of the femur, and anothera nerve injury for whichneurolysis and neurorrhaphy were necessary.
All the patients in this group received anticoagulant therapy. In 2, sympathectomy was carried out.
The venous segment used for repair was excised from any accessible vein of suitable caliber. The main saphenous vein was used in 3 patients, and the femoral vein, a branch of the femoral vein, and the small saphenous vein in 1 patient each. The technique employed in end-to-end suture (that is, the use of mattress sutures as traction sutures before the other sutures are placed) was used in all 6 patients (Fig. 43). The segment of vein was so
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inserted that its proximal end was sutured tothe distal end of the artery and its distal end to theproximal end of the artery. This was done to inhibit the action of anyvalves which might bepresent in the transplanted segment.
Failure resulted in 1 patient (Case 34). Good circulation was maintained but thrombosis occurred. A possible explanation for this failure might be that the suture was technically imperfect because the brachial artery was unusually small. Excellent results were achieved in the other 5 patients. Arteriograms revealed patent vessels, and showed no postoperative dilatation of the venous insert. When the vessels were of approximately the same size, the relative diameters remained essentially unchanged. When the venous transplant had been larger than the artery at operation, it was found to have assumed much the same proportions as the artery.
Results
In general, the results of arterial repair were excellent. Twenty-eight reparative procedures out of a possible 34 were successful. Except for some edema in 2 of the patients listed in Table 29, a symptom which diminished progressively with the passage of time, the circulatory status appeared normal. None of the patients had sensitivity of the hand or foot to cold-a fairly common sequela in those in whom aneurysm or fistula was treated by a procedure involving ligation of the artery. Excluding a few patients in whom exercise tolerance could not be judged fairly because of motor paralysis or fracture, and a few who had fatigability of the extremity before operation at a time when blood flow through the affected artery was intact, none had any appreciable decrease in tolerance of exercise. This was in decided contrast to those in whom surgical treatment had necessitated ligation of a major artery. To illustrate, those with ligated popliteal or femoral arteries could walk only an average of about seven-tenths of a mile before onset of extreme fatigue or cramps in the calf. 23
In retrospect, of course, it becomes clear that certain of the failures might perhaps have been avoided if a different plan of treatment had been adopted, though in other instances no alternative method could conceivably have altered the outcome. In Case 13 (Table 29) the vein should have been divided and used to reinforce the transfixed fistula, the technique employed in the other 12 patients treated by this method. In Case 14 (Table 30) gross infection was present and it is not surprising that satisfactory healing did not occur. In Case 34 (Table 32) no technique other than vein transplantation could have been used for repair because of the length of the arterial segment which had to be excised. In this patient the vessel was unusually small and while it is possible that repair was not technically perfect, it appeared satisfactory at the time of operation and there was a free flow of blood through the venous insert when the incision was closed. In Cases 18 (Table 30), 25 and 26 (Table 31),
23 Shumacker, H. B., Jr.: Sympathectomy as an adjuvant in the surgery of aneurysm and arteriovenous fistulas. Surgery 22: 571-596, Oct. 1947.
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local damage to the artery was sufficient toaccount for the postoperative thrombosis. In Case 18lateral suture should probably not have been performed; it would havebeen better to excise thedamaged segment and to accomplish repair by end-to-end suture or veingraft. Anticoagulantsshould also have been used. In Cases 25 and 26 additional resection ofthe distal segment wasrecognized as desirable, but was not possible because of the closeproximity of the point ofbifurcation of the vessel to the severed distal end. In Case 26 therewas a difference of opinionabout the end results. The operating surgeon believed that thrombosisand subsequentrecanalization had occurred, but several other surgeons who examinedthe patient differed withhim and regarded the operation as successful.
In addition to the complications just discussed there were a few others. One patient had a postoperative hematoma which required exploration of the wound 2 hours after the original operation (Case 30, Table 32). The vein graft was found to be functioning well and the bleeding to be coming from a small branch to a muscle. This was clamped and ligated. Three other patients had hematomas develop in the wound.(Case 15, Table 30, and Cases 32 and 33, Table 32.) In 1 instance the hematoma was evacuated by aspiration. In the other 2 instances exploration of the wound revealed diffuse capillary bleeding. All of these patients were receiving anticoagulant therapy and in each patient the therapy was stopped and no further difficulty encountered. In 2 patients (Cases 32 and 33, Table 32) mild wound infections developed, but did not interfere with the success of the vascular repair.
Methods of Evaluating Results
Various examinations were used to evaluate the success of the reparative operation in terms of patency of the repaired artery. That the foot was warm and of a healthy color was not considered sufficient evidence, nor was the presence of pulsations distal to the repair. The presence of a palpable radial pulse after brachial or axillary repair or of a dorsalis pedis pulse after femoral or popliteal repair was also not sufficient evidence since such pulses may be present after ligation of main arteries proximally if the collateral circulation is adequate. The presence of call pulses distal to the site of repair, if they were equal in volume to the pulses in the contralateral limb, was felt to provide adequate evidence of successful maintenance of continuity of the artery. When, for instance, full popliteal, posterior tibial, and dorsalis pedis pulses were present after repair of the femoral artery, the patency of the latter vessel could be assumed. Arteriograms were of great value after operation to determine the patency of the repaired artery and to furnish evidence of dilatation or other changes which might result from arterial repair. In addition, criteria of success included oscillometric results comparable to those in patients in which the patency of the artery was established by arteriographic examination and in excess of those observed in proved instances of arterial ligation.
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Data concerning oscillometric studies are available in 28 of the 34 patients in whom reparative surgery was carried out at Mayo General Hospital (Table 33). In 23 of these patients the operation was successful, in the other 5 patients either thrombosis occurred or ligation had to be done secondarily because of hemorrhage or recurrence of the fistula. In general, oscillometric readings were high in those patients in whom the continuity of blood flow through the repaired artery was maintained and low in those in whom the segment was occluded by thrombosis or the artery was ligated.
Of considerable interest was the observation that oscillations were, in general, about equal on both sides when the fistula was simply ligated and transfixed, were only slightly reduced on the affected side when lateral arteri-
TABLE 33. OSCILLOMETRIC STUDIES FOLLOWING ARTERIAL REPAIR IN 28 PATIENTS
orrhaphy was performed, but were reduced to asomewhat greater degree in those patients inwhom end-to-end suture or vein graft was done. This observation came asa surprise since in allof these patients comparison of the color, warmth, and pulsations inthe normal and in theaffected limb were substantially the same after reparative surgery. Thereduction in oscillationsdid not seem explicable on a basis of local or generalvasoconstriction, since the limbs showedno evidence of vasospasm. Moreover, in some patients in whomsympathectomy had beenperformed a similar reduction in oscillations was noted. Arteriogramsshowed no evidence ofconstriction at the site of repair. Since there was little or noevidence of any functionalcirculatory impairment, the diminished oscillations were considered oflittle practical concern.
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SUMMARY
The ideal method for the surgical treatment of aneurysms and arteriovenous fistulas is extirpation of the lesion and maintenance or restoration of the continuity of the artery. Though local anatomic factors sometimes preclude the use of reparative methods, the attitude of the surgeon determines, perhaps more than anything else, the frequency with which these procedures are applied. A high degree of success can be expected; nevertheless, one cannot assume that the results of arterial repair will be uniformly successful. Since this is the case, it is advisable to do everything possible to make certain that the collateral circulation is adequate before definitive surgery is attempted.
The chief hazards of surgical repair of arteries are hemorrhage, thrombosis, and subsequent development of aneurysmal dilatation at the site of repair. The chief local factors which endanger the success of the repair appear to be damage to the wall of the artery, infection, or a lumen of such small caliber as to make accurate approximation difficult.
In the present series postoperative hemorrhage occurred only once; the sutured artery lay in a pool of pus and healing did not take place. Thrombosis occurred 4 times; 3 times following lateral arteriorrhaphy or end-to-end suture in which local arterial damage was sufficiently extensive to raise doubts in the mind of the surgeon at the time of the operation that the artery would remain patent. In the other instance an exceedingly small brachial artery was repaired with a vein transplant.
Extension of a thrombus so as to compromise important collateral arteries has been advanced as contraindicating arterial repair. The data from this series suggest that such propagation of a thrombus is unlikely provided the collateral circulation is adequate, for extension of a thrombus is not apt to occur if the circulation proximal and distal to the site of repair is kept active by collateral blood flow. In one patient in whom thrombosis occurred, the occluded segment was excised and the thrombus sharply limited to the immediate area of repair. Furthermore, the chance of thrombosis occurring, or of its propagation if it should occur, can be lessened considerably by the use of anticoagulants.
There was recurrence of an arteriovenous fistula in one patient in this series-the fistula was simply transfixed and ligated in continuity, a procedure which appears to be unwise. No aneurysms developed at the site of repair in any instance. Should this unfortunate event take place it appears likely that it would occur within the first few weeks or months after operation and not years later when atherosclerotic changes might add an additional hazard to its extirpation. Under such circumstances it would seem that the original procedure could still be looked upon as justifiable; such patients should be able to withstand surgical cure of the aneurysm with no more risk than would have been entailed had the artery been ligated at the original operation.
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It was the opinion at this center that while the patient may have been subjected to certain additional hazards, these hazards are minimal and of little practical concern provided the collateral circulation is adequate, no collateral vessels are sacrificed, and anticoagulants are used. Altogether there seems every justification for performing reparative or restorative procedures instead of arterial ligation whenever such methods can be applied. Certainly the results of successful repair are superior to those of any method which necessitates sacrificing the continuity of the affected artery.
