SURGICAL TECHNIQUE FOR SUPRARENAL ANDTHORACOABDOMINAL TYPE IV AORTIC ANEURYSMS R. Halpern, S. Baila, H Moldovan, Isabela Oprea, Florentina Matache, Mihaela Craciun, S. Bubenek
Clinical presentation First Pt. 65 yo: Abdominal and lumbar pain and Syncope 1 day before hospitalization Second Pt. 59 yo: pulsatile abdominal mass - 10 months before hospitalization and lumbar pain - 1 month before hospitalization Third Pt. 58 yo: abdominal pain - onset 2 weeks before hospitalization
Lab tests All patients had normal PREOPERATIVE BP, HT, Hb, L, ureea, creatinin and glucose levels
Patient position Operative position right lateral decubitus hips rotated 20-30 ° table angulated in the middle left arm elevated Peridural and general anesthesia with nonselective intubation Urinary catheter, invasive left radial artery monitoring, large bore venous lines and cell saver set up From: http://www.or-live.com/memorialhermann/1234/event Dr. Hazim J. Safi, Memorial Hermann Hospital, Huston, Texas
Axillary Artery Canulation and Materials Systemic heparinisation 70-100 UI heparin / Body weight Canulation of right axillary artery and set up the shunt Synthetic graft on axillary artery in termino-lateral fashion Arterial canula inserted into graft 4 retrograde canulas Medtronic Connecting tubes
Operative Approach Thoracic approach 8th intercostal space - control of the distal thoracic aorta for rapid clamping of aorta in case bursting bleeding at the time of retroperitoneal approach of abdominal aorta Phrenotomy Retroperitoneal approach - continuing the oblique incision to below the umbilicus Approach to the infra diaphragmatic aorta by rotation to right of the spleen, left kidney and abdominal viscera Splitting of the left crus of the diaphragm Clamping of the aorta below diaphragm Sursa: http://www.or-live.com/memorialhermann/1234/event Aneurysm incision to the visceral level of Dr. Hazim J. Safi, Memorial Hermann Hospital, Huston, aorta Texas
Continuous axilo-visceral shunt Clamping of axillary artery distal the canula Identification and canulation of renal arteries, superior mesenteric and celiac trunk ostia Starting continuous perfusion of visceral arteries from right axillary artery using the shunt
Proximal anastomosis Preparing the anastomotic site at suprarenal aorta Bevel the proximal end of the graft Anastomosis between the graft and visceral portion of the aorta with 3.0 polipropilene suture (Clamping time 45-60 min) At the end of anastomosis taking off the canulas Distal anastomosis between graft and Aorta Femural arteries
Postoperative course Uneventful Discharged after 7-10 day post op. With normal creatinin, TGO, TGP levels It was a spike in Creatinin, TGO and TGP levels on 2, 3 postop day up to 1.3 creatinin, 400 U/l TGO and 130 U/l TGP Presence of intestinal motility during 2-3 day after surgery No respiratory or bleeding complications
Types of Aortic Aneurysms Juxtarenal aortic aneurysms (3-20% of AAA) Thoracoabdominal type IV aneurysms (Crawford classification) (4% of TAA) Infrarenal aortic aneurysm with hostile infrarenal aortic neck (friability, calcification) (unknown %)
The standard treatment of these types of aortic aneurysms is open surgical repair until fenestrated endografts will be improved. Hybrid procedures could be also an option This type of surgery is technically more demanding and characterized by problems related to: suprarenal aortic control renal, hepatic and intestinal ischemia larger surgical dissection associated with bleeding problems which may be followed by an increased operative mortality and morbidity rate.
Abdominal Aortic Aneurysm Classification ProximalType II≥15 mm neck A: Distal extension down to aortic bifurcation need for bifurcated endografts Type I Type II B: Type III Proximal neck ≥15 mm Proximal neck ≥15 mm Proximal neck <15 mm Distal cuff ≥10 mm Aneurysmal involvement of Distal expansion adapted for tubular endograft the proximal iliacal arteries demands open surgery need for bifurcated endograft Type II C: Proximal neck ≥15 mm Schumacher H, Eckstein HH, Distal extension down to iliac Kallinowski, F, Allenberg JR bifurcation (1996) Morphometry and classification in abdominal inappropriate for aortic aneurysms. J Endovasc endografting Surg 4:39–44 demands open surgery
Juxtarenal Aortic Aneurysm Abdominal Aortic Aneurysm that do not have an infrarenal aortic neck andwhere the aortic diameter is normal at the level of celiac axis.
Juxtarenal Aortic Aneurysm Classification Type A aneurysm of interrenal aorta extending on suprarenal aorta; the dilatation develops at the posterior aortic wall Type B infrarenal aortic aneurysm with normal interrenal aorta and aneurysm of one or two renal artery origin. Type C juxtarenal aorta with normal interregnal aorta and absence of aneurysm at renal arteries. Ayari R, Paraskevas N, Rosset E, Ede B, Branchereau A. Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification. Eur J Vasc Endovasc Surg. 2001 Aug;22(2):169-74.
Key points Retroperitoneal approach Suprarenal or supravisceral aortic clamping Renal and intestinal continuous perfusion (protection) with a passive shunt from right axillary artery Beveled proximal anastomosis the tip on the level of celiac trunk the heel - infrarenal Patch insertion of visceral arteries origins into graft - “Carrel patch” for visceral arteries implantation (in type IV thoracoabdominal aneurysms)
Retroperitoneal approach 1952 - Dubost - was the first to replace an aneurysm of the abdominal aorta used a retroperitoneal approach Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta. Reestablishment of the continuity by a preserved human arterial graft, with result after five months. Arch Surg 1952; 64:405-408. 1963 - Rob - first to give a detailed description of the antero-lateral retroperitoneal advantages easier postoperative course disadvantages such as limited exposure. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963; 53:87-89. 1980 – Williams - described the extended retroperitoneal approach allows a better exposure not only of the infrarenal but also the pararenal and even suprarenal aorta. Williams GM, Ricotta J, Zinner M, et al. The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery 1980; 88:846-855.
Retroperitoneal approach May provide less physiologic insult and a smoother postoperative course. less ventilatory support and tolerated enteral feedings quicklyChang BB, Shah DM, Paty PS, Kaufman JL, Leather RP. Can the retroperitoneal approach be used for ruptured abdominal aortic aneurysms? J Vasc Surg 1990;11:326-30.Gregorio A. Sicard, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Reportof a prospective randomized trial J Vasc Surg 1995;21 Facilitate proximal abdominal aortic exposure and anastomosis, especially in large, pararenal aneurysms or in situations unfavorable to a transabdominal approach. Suited to those that pose significant technical challenges.Shepard AD, Tollefson DF, Reddy DJ, Evans JR, Elliott JP Jr, Smith RF, Ernst CB Left flank retroperitoneal exposure: a technical aid to complex aortic reconstruction. : J Vasc Surg. 1991 Sep;14(3):283-91 Adequate exposure to the proximal right renal artery can be obtained with acceptable mortality and morbidity.Shah DM, Darling RC 3rd, Chang BB, Paty PS, Leather RP, Lloyd WE Access to the right renal artery from the left retroperitoneal approach. : Cardiovasc Surg. 1996 Dec;4(6):763-5.
Where to clamp? Above the diaphragm Adamkiewicz – risk for paraplegia In case of ruptured infradiaphragmatic aneurysms After control – move the clamp at a more distal level Between diaphragm and celiac artery Hepatic, intestinal and renal ischemia Division of crura (Crawford) Between renal artery and superior mesenteric artery Renal ischemia Potential pancreatic tissue damage and bleeding
Risk Factors for Supravisceral Aortic Clamping Time – speed of suture Preexisting visceral disease renal failure hepatic failure Methods for renal protection
Is there a cut-off for clamping time? Renal failure remains a common complication after complex aortic surgery, which greatly increases the risk of mortality. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17(2):357–368. Bicknell CD, Cowan AR, Kerle MI, Mansfield AO, Cheshire NJ, Wolfe JH. Renal dysfunction and prolonged visceral ischaemia increase mortality rate after suprarenal aneurysm repair. Br J Surg 2003;90(9):1142–1146. Martin GH, O’Hara PJ, Hertzer NR, Mascha EJ, Krajewski LP, Beven EG, Clair DG, Ouriel K. Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome. J Vasc Surg 2000;31(5):851–862.
Renal protection Schwartz et al. found in a retrospective review of 58 patients, all with TAA IV, that renal failure did not occur if preoperative renal function was normal.A renal ischaemic time of up to 45-50 min seems safe Sarac TP, Clair DG, Hertzer NR, Greenberg RK, Krajewski LP, O’Hara PJ, Ouriel K. Contemporary results of juxtarenal aneurysm repair. J Vasc Surg 2002;36(6):1104– 1111. Breckwoldt WL, Mackey WC, Belkin M, O’Donnell TF. The effect of suprarenal cross- clamping on abdominal aortic aneurysm repair. Arch Surg 1992;127:520–524. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17(2):357–368.
Medication of Renal Protection Cold perfusion with Ringer’s lactate - Svensson et al. PGE1Reiher L, Vosberg H, Sandmann. Kidney protection in preventing post-ischaemic renal failure during thoracoabdominal aortic aneurysm repair: does prostaglandin E1 together with cooling provide more protection than cooling alone? Vasa 2001 Feb;30(1):21-3 Manitol and adequate IV volume Adenosine.Haruko Sugino, Hideyo Shimada and Kanji Tsuchimoto. Role of Adenosine in Renal Protection Induced by a Brief Episode of Ischemic Preconditioning in Rats Jpn. J. Pharmacol. 87 (2), 134-142 (2001) Fenoldapam Calcium Channel BlokersDan Tzivoni End Organ Protection by Calcium-Channel Blockers Clin. Cardiol. 24, 102–106 (2001)
Approaches to Renal ProtectionA. Aoki, K. Sangawa; Repair of a Pararenal Abdominal Aortic Aneurysm with Bilateral Renal Artery StenosisUsing a Rapid Infusion Pump for Renal Perfusion: Report of a Case. Surg Today (2008) 38:751–755
Approaches to Renal Protection Renal perfusion using a roller pump supplied with venous blood from a central venous catheter under medium-level heparinization to feed two perfusion balloon catheters Pichlmaier M, Hoy L, Wilhelmi M, Khaladj N, Haverich A, Teebken OE. Renal perfusion with venous blood extends the permissible suprarenal clamp time in abdominal aortic surgery. J Vasc Surg. 2008 Jun;47(6):1134-40. Epub 2008 Apr 3.
Protection for Mesenteric Ischemia Bicknell et al. found a significantly higher mortality rate in patients who had visceral ischemia for 40–59 min (27%) than in those with ischaemia for <40 min (9%). Vermeulen et al. also observed a higher complication rate if mesenteric ischaemia was longer than 60 min.Methods of reducing visceral ischemia: selective visceral artery perfusion using extracorporeal circulation shunting of the visceral arteries via a side-arm of the graft. The rationale is relatively weak for using adjunct therapy to reduce visceral ischemia in uncomplicated repair of TAA IV with a single proximal anastomosis including the visceral arteries. If a separate proximal end-to-end anastomosis is anticipated, mesenteric shunting is probably beneficial and recommended. (C.-M. Wahlgren and E. Wahlberg)
Conclusions Advantages No need of pumping system No stress about clamping time – increased safety Drawbacks: Increasing operative time due to axilary canulation Increasing operative cost due to canulas Cannot be applied when is associated axillary artery atheromatosis
Conclusions There is a need for large scale trial in order to determine: the precise safety of the method the utility and indications of the method
Special thanks toVictor Pavel – perfusionist nurse