Large intercostal arteriovenous aneurysm: successful - Thorax

transcript

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.

on 24 Decem

ber 2018 by guest. Protected by copyright.

http://thorax.bmj.com

horax: first published as 10.1136/thx.33.3.406 on 1 June 1978. Dow

nloaded from

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.

on 24 Decem

nloaded from

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.

on 24 Decem

nloaded from

Large intercostal arteriovenous aneurysm: successful - Thorax

Documents