Repairing the Royal Aorta

Music by Muzak was soft and low. Two Sleepy People and So Bears My Heart for You flowed over the operating room in Houston's Methodist Hospital. But the patient on the table, His Royal Highness Prince Edward Albert Christian George Andrew Patrick David, Duke of Windsor, was already going under the anesthetic. Baylor University's famed surgeon Dr. Michael E. DeBakey was scarcely listening as he performed an operation that only a few years ago would have seemed dangerous indeed. He slit open the 70-year-old duke's belly and cut down to the aorta, the body's main artery, on which he found a 4-in. section that had swollen into an aneurysm, much as an inner tube will balloon through a weakness in its rubber wall. In 67 min. of delicate surgery, Dr. DeBakey cut out the aneurysm and replaced it with a length of knitted Dacron tubing.

First Hint. The blood royal is no exception to the rule that blood flowing through the arteries exerts considerable pressure and needs strong-walled vessels to keep it in place. This is especially true of the aorta, largest of all arteries. It is a three-ply tube, about one inch in diameter where it descends through the abdomen, carrying blood for the lower organs and legs. The middle layer (the "media," to anatomists) is muscle, and it is a break in this layer that leads to aneurysms. In the vast majority of cases, the first cause of the break is unknown.* and the beginning of the aneurysm's growth may easily go undetected.

The duke had no hint of trouble until about four years ago. Then, during a routine checkup, Manhattan's Dr. Arthur Antenucci diagnosed an aneurysm that required watching. But it was too small at the time to justify the major surgery that would be involved in its removal. No special diet was needed, no drugs. How little distress the aneurysm caused the duke is shown by the fact that he was able to keep working steadily for most of this year on his movie, A King's Story.

No Rush. But this month the aneurysm grew rapidly. The elastic outer layer of the aorta was being stretched thinner and thinner, with increasing danger that it might burst and loose a fatal flood of blood into the abdominal cavity. Dr. Antenucci ordered X rays, which showed that the aneurysm had increased in size, and within a week had grown bigger than an orange. The beat of the blood pulsing through it could be felt by the doctor's hand. And it was in an especially dangerous location, below the branching of the kidney arteries (see diagram). It was time for surgery, but there did not seem to be much of a rush --the duke went to Houston by slow, jolting train.

For Dr. DeBakey, who developed the operation and has already done it 6,500 times, the procedure was routine. But alter he made a 6-in. incision through the duke's lean abdominal wall, the surgeon discovered that the aneurysm was even bigger than expected. 'The size of a small cantaloupe or large grapefruit," he reported. Instead of a simple balloon shape with a neat "stalk," it was "fusiform," with its base extending along the aorta. Worse, the wall of the aorta had eroded until it was on the point of rupturing.

Skin to Skin. The surgeons put a clamp on the aorta above the aneurysm and another below it. Next, Dr. DeBakey cut out the weakened, ballooning piece of aorta and stitched in the Dacron tube (a material devised to his own specifications). Then he and his assistants opened the clamps to let blood clot in the tiny interstices of the knit. Finally, they took the clamps off for good. It took only 67 min. from the first incision to the closing of the wound ("skin to skin," as surgeons call it). Within 3 1/2 hr the duke was chatting cheerily with his duchess.

By coincidence, a commoner of uncommon note (and a friend of the duke's) had the same operation the same day. In Los Angeles' Cedars of Lebanon Hospital, Gloria Morgan Vanderbilt, 60, had a fusiform aneurysm cut out by Dr. Joshua Fields, and got an even more extensive artery replacement. Her graft, made of nylon-Teflon-Dacron and shaped like an inverted 7, was attached at the top near the renal arteries. Its shorter branch was joined to the right iliac artery, and a longer branch on the left extended down into the thigh. At week's end, the patient was doing well.

In both cases, the graft will serve as a scaffolding on which the body will build its own tubing of living cells. This tissue by itself will not be as strong as the original muscle, but the combination of knit and tissue will be stronger. Barring unexpected complications, it will easily last as long as the patients live. And they should be able to get around as well as ever, with negligible discomfort.

* In sharp contrast with hemophilia, which Queen Victoria passed on to many of her descendants, the tendency to aortic aneurysms develops in later life and does not appear to be inherited.

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