Large intercostal arteriovenous aneurysm: successful - Thorax
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Thorax, 1978, 33, 406-408 Large intercostal arteriovenous aneurysm: successful surgical correction MICHAEL SWANK, DERWARD LEPLEY, JUN., DONALD C. MULLEN, ROBERT J. FLEMMA, AND LAWRENCE I. BONCHEK From the Department of Thoracic and Cardiovascular Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA Swank, M., Lepley, D., Jun., Mullen, D. C., Flemma, R. J., Bonchek, L. I. (1978). Thorax, 33, 406-408. Large intercostal arteriovenous aneurysm: successful surgical correction. A large aberrant systemic artery to superior vena cava communication associated with normal lungs and normal pulmonary arteries has never been reported. This lesion, its diagnosis, and successful surgical management are discussed. Several cases (Maier, 1954; Ferencz, 1961) of large systemic arteries supplying a hypoplastic lung with venous drainage to the superior vena cava (SVC) have been described but in each case the pul- monary arteries were small or absent. A retrospec- tive search and review of the British Anatomical Record failed to find a case report of a large aberrant systemic artery to superior vena cava communication associated with normal lungs and normal pulmonary arteries. Our case demonstrates this interesting lesion, its diagnosis and surgical management. Case history An 18-year-old white youth had been noted to have an asymptomatic harsh murmur along the left sternal border and scapular area at the age of 7 years. Cardiac catheterisation failed to show the sus- pected patent ductus arteriosus, and no other lesions were found. The presence of an arterio- venous fistula somewhere in the thoracic cavity or mediastinum was suspected. The patient remained asymptomatic, but be- cause of a persistent murmur he was recatheter- ised in January 1977. A chest radiograph showed a soft tissue density in the right paratracheal region. On physical examination he was found to have a regular sinus rhythm with a blood pressure of 130/70 mmHg in both arms. A grade IV/VI continuous murmur along the left sternal border radiated into the axilla and left scapular area. First and second heart sounds were normal. The remainder of the physical examination was unremarkable. Catheterisation and angiography showed the lesion illustrated in Figs. 1, 2, and 3. A large aberrant systemic artery arose from the descend- ing thoracic aorta about 6 cm distal to the origin of the left subclavian artery. It followed a cepha- lad, posterior course communicating with an en- larged upper right intercostal vein that emptied into the azygos vein and thence into the superior vena cava. The large opacified area was thought to be an intercostal arteriovenous aneurysm. A left-to-right shunt of 15-1 was calculated with a cardiac output of 10-7 I/min. Oxygen saturation in the superior vena cava was 89%. Saturation in the inferior vena cava was 84% and in the right ventricle 82%. All intracardiac pressures were normal. The patient was prepared for elective ligation of the arterial side of this large arteriovenous com- munication. The lesion was approached via a standard left posterolateral thoracotomy. The ab- errant arterial branch of the descending aorta arose posterolaterally about 6 cm distal to the left subclavian artery. It was about 1-5 cm in diameter and coursed superiorly and posteriorly (Fig. 4). There were no other abnormalities. The artery was tied and suture-ligated without difficulty (Fig. 5). Complete collapse of the vessel was noted, indi- cating no other significant arterial source. No murmur was heard in the immediate postoperative period. The patient had an uneventful postopera- tive course and was discharged on the seventh day after operation. 406 on 24 December 2018 by guest. Protected by copyright. http://thorax.bmj.com/ Thorax: first published as 10.1136/thx.33.3.406 on 1 June 1978. Downloaded from
Transcript of Large intercostal arteriovenous aneurysm: successful - Thorax
Thorax, 1978, 33, 406-408
Large intercostal arteriovenous aneurysm:
successful surgical correctionMICHAEL SWANK, DERWARD LEPLEY, JUN., DONALD C. MULLEN,ROBERT J. FLEMMA, AND LAWRENCE I. BONCHEK
From the Department of Thoracic and Cardiovascular Surgery, The Medical College of Wisconsin,Milwaukee, Wisconsin, USA
Swank, M., Lepley, D., Jun., Mullen, D. C., Flemma, R. J., Bonchek, L. I. (1978). Thorax, 33,406-408. Large intercostal arteriovenous aneurysm: successful surgical correction. A largeaberrant systemic artery to superior vena cava communication associated with normal lungs andnormal pulmonary arteries has never been reported. This lesion, its diagnosis, and successfulsurgical management are discussed.
Several cases (Maier, 1954; Ferencz, 1961) of largesystemic arteries supplying a hypoplastic lung withvenous drainage to the superior vena cava (SVC)have been described but in each case the pul-monary arteries were small or absent. A retrospec-tive search and review of the British AnatomicalRecord failed to find a case report of a largeaberrant systemic artery to superior vena cavacommunication associated with normal lungs andnormal pulmonary arteries. Our case demonstratesthis interesting lesion, its diagnosis and surgicalmanagement.
Case history
An 18-year-old white youth had been noted tohave an asymptomatic harsh murmur along theleft sternal border and scapular area at the age of7 years.
Cardiac catheterisation failed to show the sus-pected patent ductus arteriosus, and no otherlesions were found. The presence of an arterio-venous fistula somewhere in the thoracic cavityor mediastinum was suspected.The patient remained asymptomatic, but be-
cause of a persistent murmur he was recatheter-ised in January 1977. A chest radiograph showeda soft tissue density in the right paratrachealregion. On physical examination he was found tohave a regular sinus rhythm with a blood pressureof 130/70 mmHg in both arms. A grade IV/VIcontinuous murmur along the left sternal borderradiated into the axilla and left scapular area.First and second heart sounds were normal. The
remainder of the physical examination wasunremarkable.
Catheterisation and angiography showed thelesion illustrated in Figs. 1, 2, and 3. A largeaberrant systemic artery arose from the descend-ing thoracic aorta about 6 cm distal to the originof the left subclavian artery. It followed a cepha-lad, posterior course communicating with an en-larged upper right intercostal vein that emptiedinto the azygos vein and thence into the superiorvena cava. The large opacified area was thoughtto be an intercostal arteriovenous aneurysm. Aleft-to-right shunt of 15-1 was calculated with acardiac output of 10-7 I/min. Oxygen saturationin the superior vena cava was 89%. Saturation inthe inferior vena cava was 84% and in the rightventricle 82%. All intracardiac pressures werenormal.The patient was prepared for elective ligation of
the arterial side of this large arteriovenous com-munication. The lesion was approached via astandard left posterolateral thoracotomy. The ab-errant arterial branch of the descending aortaarose posterolaterally about 6 cm distal to the leftsubclavian artery. It was about 1-5 cm in diameterand coursed superiorly and posteriorly (Fig. 4).There were no other abnormalities. The artery wastied and suture-ligated without difficulty (Fig. 5).Complete collapse of the vessel was noted, indi-cating no other significant arterial source. Nomurmur was heard in the immediate postoperativeperiod. The patient had an uneventful postopera-tive course and was discharged on the seventh dayafter operation.
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Large intercostal arteriovenous aneurysm: successful surgical correction
Fig. 1 Catheter positioned at origin of systemicartery shows its connection with an 'aneurysmal'venous lake superiorly.
Fig. 2 Superior vena cava is filled after contrastmaterial empties from intercostal arteriovenousaneurysm via azygos vein.
Fig. 3 Subtraction film shows pointof origin (posterolateral aorta 6 cmdistal to left subclavian) and courseof aberrant systemic artery.
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Michael Swank et al.
Fig. 5 Artery is suture-ligated at its posterolateralorigin 6 cm distal to lef t subclavian artery. Tip ofclamp is cephalad.
Fig. 4 Black silk is aroundaberrant artery posterolaterallyjust superior to a largeintercostal artery. Tape isinferior and aorta is rotatedmedially.
This unusual case illustrates two points: (1) withpresent-day catheterisation techniques it shouldbe possible to define accurately any persistent,continuous murmur so that a properly plannedsurgical procedure can be carried out; and (2) inthe case of a large aortic to vena caval communi-cation with aneurysmal venous lakes, simple liga-tion of the arterial side of the fistula without dis-section of the angiomatous venous plexus is theprocedure of choice.
References
Ferencz, D. (1961). Congenital abnormalities of pul-monary vessels and their relation to malformationsof the lung. Pediatrics, 28, 993-1010.
Maier, H. C. (1954). Absence or hypoplasia of a pul-monary artery with anomalous systemic arteries tothe lung. Journal of Thoracic Surgery, 28, 145-162.
Requests for reprints to: Derward Lepley, Jun., M.D.,9800 West Bluemound Road, Milwaukee, Wisconsin53226, USA.
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