[26] There are now before the profession three methods of repairing arteries—by invagination, by suture of the two outer coats, by the through-and-through method—each of which has its advantages and disadvantages. The presence of sutures in the interior of the vessel does not seem to produce coagulation, even though the intima of the vessel is injured by the passage of the same. Nevertheless sutures must be kept out of the blood stream. Liability to secondary hemorrhage is reduced if a double line of sutures can be used.
LIGATION OF ARTERIES.
Arteries are exposed and ligated in their continuity for the purpose of controlling hemorrhage, either for temporary or permanent purposes. The results of permanent ligature have been described in the chapter on Wounds. The application of a ligature should be so made as to thoroughly break up the intima without serious injury to the other coats of the vessel. Coagulation and organization of the thrombus soon produce a permanent occlusion and obliteration. It is a mistake to endeavor to tie the ligature too tightly. Hardened catgut or freshly boiled silk make the best ligature material. It is seldom a difficult matter to find the desired artery upon the normal individual or upon a cadaver. In some cases in practise the tissues through which search must be made will be found infiltrated with blood or otherwise altered, and the discovery of and attack upon the vessel may be thus made very trying. The vessel when exposed in its continuity will be recognized by the sense of touch rather than that of sight, and almost the entire maneuver may be made, by touch alone, by one whose tactile sensibility has been well trained and without any clear view of the vessel. The arteries which are thus exposed have their own sheaths, especially the larger ones, which should be opened with care, not alone to avoid injury to the vessel itself, but in order that the amount of separation may be as slight as possible, as the sheath is necessary for support and for nutrition. Having exposed the vessel and divided the sheath the ligature is introduced with a blunt, curved needle attached to a handle, and known as an aneurysm or artery needle. It is made to carry the ligature, or it is so insinuated and brought out from behind the vessel that the ligature may be threaded into its eye. Caution should be exercised that nothing but the artery itself is included; this is especially necessary in the neck, where the relations between the large vessels and the nerves are very intimate. As a general rule the needle should not be threaded until after it has been passed. The knot should be tied in the depths of the wound, and the vessel should not be disturbed by efforts to secure the knot. If the operation have been done as it should it will not be necessary to drain such a wound, but it may be closed by buried and superficial sutures. When one of the limbs has been involved in this operation it should be kept absolutely at rest, in a somewhat elevated position, and warm applications made, in order that the warmth previously maintained by the free circulation of arterial blood may not be allowed to drop too low.
Innominate Artery.
—The innominate had been tied between thirty-five and forty times, up to 1905. A number of patients have survived the operation, and died within a few weeks of cardiac and arterial disease. Some have progressed a number of weeks, with rapid recovery from the operation and temporary improvement sufficient to justify this operation in apparently favorable cases. This vessel and the carotid also should be tied, in order that the resulting clot may be more perfect and that there should be no return pressure made upon the aneurysmal sac. The incision is made along the anterior border of the sternomastoid down to the clavicle and then along the inner third of this bone, thus forming a flap whose free edges are 10 Cm. in length. The sternal and clavicular heads of the sternomastoid are divided, while the sternohyoid and sternomastoid are separated from the sternum, care being taken especially of the anterior jugular vein, which may be double ligated, if necessary, and, in the deeper dissection, of the pneumogastric and the recurrent laryngeal nerves, which wind around the innominate, and the phrenic, which is in close relation with it. In view of the great engorgement which the aneurysm may produce in the veins of the neck it would be a great help in this operation to follow Crile’s suggestion for removal of goitres, placing the patient in the semi-upright position and having him wear the pneumatic suit, in order that, by suitable pressure from without, the blood pressure may be kept at the proper degree, while, at the same time, the veins of the neck are emptied by gravity. The carotid, having been found, is traced downward and will lead to the innominate and the sac. When the ligature is ready to be drawn tight the table should be lowered and the pneumatic pressure in the suit reduced.
Obviously the deeper the surgeon dissects the more difficulties he will encounter. The innominate artery is crossed by the left innominate vein, which may be in the way, while all the other vessels may be so much disturbed as to alter their relations and make their recognition difficult. The gradual progress of the aneurysm may have caused the tissues to become matted to each other and thus lose their identity. The innominate having been found is traced downward behind the sternum and a suitable base is sought for the ligature. This search may be aided by changing the position of the patient’s head, and with the assistance of artificial light. In the depths of the wound the veins, the vagus, and the pleura can only be avoided by care in keeping the point of the artery needle in contact with the artery. If necessary gentle traction on the carotid trunk may aid by lifting the sac and making its isolation more easy.
As suggested by Bardenheuer the upper end of the sternum may be removed with sufficient of the inner end of the clavicle to facilitate approach. This has been done in this country by Burrell. The aneurysm needle is passed from without inward and from below upward, in order to avoid injury to the pleura. An artery needle made with a flexible tip, which may be bent to suit the exigencies of the case, will make the most difficult part of the work more easy. The ligature should not be tied too tightly, and for this purpose silk is the preferable material. Strips of ox aorta and other animal materials have been used, but if the knot is not too tight no harm will be done to the artery wall.[27]
[27] Sheen (Annals of Surgery, July, 1905) reports a successful case, his method being as follows: Median incision from the cricoid to one inch below the sternal notch, exposure of the carotid and innominate, then a silk ligature carried around the innominate distally and tied with Balance’s stay-knot; pulsation ceased, to later reappear. A second similar operation also failed. A third operation was performed through a five-inch transverse incision above the clavicle, the artery being twice ligated proximally. Sheen advises that ligature should always be of silk, that the incision should be central, with horizontal and vertical division of the manubrium; that the carotid should also be tied; that two ligatures be placed; that drainage is inadvisable, and that next to sepsis as a cause of death stand cerebral lesions. Statistics are thirty-six cases of ligature, with a mortality of 78 per cent.
As stated above, the common carotid should also be tied at the conclusion of the other ligation. These cases should be drained with a few strands of catgut. Absolute rest is an essential of the after-treatment.