Challenging Arterial Reconstructions: 100 Clinical Cases

By Sachinder Singh Hans

This book presents 100 challenging cases encountered in vascular surgery practice that were selected from the author’s vascular registry of 7,000 vascular reconstructions (endovascular and open). Chapters include difficult surgical problems of patients with aortic, visceral and peripheral arterial aneurysms, with expert management of mycotic, inflammatory and ruptured aneurysms and major complications like aorto-duodenal fistula, graft infection or inferior vena cava injury. These reconstructions are representative of the “real world” experience of vascular surgery in the United States, and the selection of cases were based on either difficulty with case selection, or complex operative or an endovascular technique. The natural history of vascular reconstructions often leads to secondary reconstructions, which are far more complex and therefore are included in significant numbers in this text. Both good and unsatisfactory results have been included and the lessons learned from thepoor outcomes are emphasized. Invited commentaries from leading experts in the field have been added to a few chapters offering an alternate viewpoint in the management of patients with complex pathology.

Challenging Arterial Reconstructions: 100 Clinical Cases serves as an invaluable resource to vascular surgeons that are learning or regularly performing open surgical or endovascular interventions.

• Language: English
• Publisher: Springer
• Release date: May 18, 2020
• ISBN: 9783030441357

Book preview

Part IOpen Repair of Intact Abdominal Aortic Aneurysm

© Springer Nature Switzerland AG 2020

S. S. HansChallenging Arterial Reconstructionshttps://doi.org/10.1007/978-3-030-44135-7_1

1. Symptomatic Proximal Anastomotic Pseudoaneurysm of Suprarenal Aorta

Sachinder Singh Hans¹  

(1)

Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinical Assistant Professor at Wayne State, University School of Medicine, Clinton Township, MI, USA

Sachinder Singh Hans

Email: [e-mail]

Keywords

Proximal anastomotic pseudoaneurysm of suprarenal arterySpinal drainage

History

A 37-year-old white male was admitted to the hospital on February 13, 1981, with the history of low back pain and abdominal pain of 3-week duration. This patient was first seen January 1972 by an ophthalmologist with a 2-week history of blurred vision. At that time his blood pressure was found to be 240/140 mm Hg, with grade IV retinopathy. A comprehensive evaluation for hypertension in 1972 was compatible with idiopathic malignant hypertension. Twenty-four-hour urinary VMA was 9.2 (normal). Renal vein renin assay was 4000 ngE/hr in the right and 5900 ngE/hr. in the left (normal up to 275 ngE/hr). An intravenous pyelogram revealed mild hydronephrosis due to left ureteropelvic junction obstruction. From 1972 until 1980, the patient’s blood pressure was well controlled. In May 1973, the patient suffered right monoparesis involving the right upper extremity and speech difficulty, from which he recovered in 3–6 months. He has been on propranolol 30 mgm q.i.d., hydrochlorothiazide 50 mgm b.i.d., spironolactone 25 mgm q.d., and guanethidine 10 mgm q.d.

In September 1980, during the stress of his father’s severe illness, the patient decided to discontinue his medication and later developed confusion and hallucinations. He was admitted to the psychiatric service with probable diagnosis of acute psychotic reaction.

Physical Examination

The patient’s height was 5′7″, with body weight of 90 pounds. Examination of the heart showed apex beat was outside the midclavicular line. The lungs were unremarkable. Examination of the abdomen revealed a large, pulsatile abdominal aortic aneurysm, upper limit of which could be reached with great difficulty. He had excellent femoral, popliteal, and pedal pulses.

Laboratory studies revealed hemoglobin 12.5 gm and a hematocrit of 37.8%, BUN 23 mgm/dl, and creatinine 1.4 mgm/dl.

Chest X-ray revealed cardiomegaly ; EKG showed evidence of left ventricular hypertrophy. Ultrasound of the aorta revealed a large, abdominal aortic aneurysm with a transverse diameter of 10–12 cm. A retrograde aortogram performed through the right femoral artery revealed large abdominal aortic aneurysm, arising very close to the origin of the renal arteries and abruptly assuming its largest transverse diameter in its proximal portion (Fig. 1.1).

../images/480270_1_En_1_Chapter/480270_1_En_1_Fig1_HTML.png

Fig. 1.1

Aortography showing large abdominal aortic aneurysm

The patient was taken to the operating room on February 22, 1981. A very large aortic aneurysm with focal, thinned-walled protrusions was noted on the anterior wall (Fig. 1.2). The left renal vein was mobilized, and left testicular vein was ligated, and silastic vessel loop was passed around the left renal vein. The proximal aortic clamp was applied above the left renal vein but just distal to the renal artery obliquely. Distal control of the aneurysm was obtained at the common iliac artery level. The aneurysm was large, 10 cm in diameter, and contained a large amount of thrombus (Fig. 1.3). The aneurysm was resected and reconstructed with an aorto-bi-iliac graft (18 × 9 mm) woven Dacron. The patient was discharged on postoperative day 7 in satisfactory condition.

../images/480270_1_En_1_Chapter/480270_1_En_1_Fig2_HTML.jpg

Fig. 1.2

Intraoperative picture of aneurysm

../images/480270_1_En_1_Chapter/480270_1_En_1_Fig3_HTML.png

Fig. 1.3

Operative specimen showing thrombus

The patient was seen 13 years later with back pain that had been present for several weeks and was admitted to the hospital where he underwent a CTA. CTA showed normal-sized aorta from the diaphragm down to the celiac and superior mesenteric arteries. The aorta then dilated up to a lumen of around 10 cm with a large anastomotic false aneurysm. There was contrast in the right renal artery but no contrast seen into the left renal artery going into the left kidney. The aorto-bi-iliac graft that had previously been placed was patent from below the aneurysm down to both iliacs. There was a slight iliac enlargement distal to the right limb of the aortoiliac graft. The arterial runoffs were normal.

Angiography showed a large juxtarenal abdominal aortic aneurysm measuring 10 cm × 10 cm in AP/transverse diameter. Right renal artery begins adjacent to cephalad border of aneurysm. The left renal artery likely originates from the aneurysm, and there is a probably occlusion of the left renal artery. The aorto-bi-iliac graft is patent.

Procedure

The patient was taken to the operating room and was placed in the lateral retroperitoneal position with the left side up. Arterial line, Swan-Ganz catheter, and Foley catheter were placed. A spinal drain was placed.

A retroperitoneal incision was made from the previous paramedian incision below the umbilicus laterally over the tenth rib onto the chest. The chest was opened. The diaphragm was opened in a circumferential fashion approximately 2 cm lateral to its insertion on the chest wall. The retroperitoneal dissection was continued medially toward the aorta. The kidney and ureter were elevated on the medial portion of the incision, and dissection was carried posterior to that down to the aorta.

The subdiaphragmatic aorta was identified. The inferior pulmonary ligament was dissected free to allow exposure of this segment of the aorta. Proximal control was obtained by dissection posterior and anterior to the aorta above the diaphragm.

Next, the large pulsatile mass beneath the kidney was dissected free. The aortic hiatus was dissected free, and the crus of the diaphragm was dissected. The dissection was carried down, and the origin of the celiac artery was identified.

Next, the left renal artery was identified and was dissected back to its origin off the aorta. The kidney was dissected off this large pseudoaneurysm. The entire lateral aspect of the aneurysm was exposed.

The spinal fluid was drained (approximately 50 cc’s), and papaverine was placed into the spinal canal. Next, the supradiaphragmatic aortic clamp was placed. After the aorta was cross-clamped, the false aneurysm was opened up using electrocautery and scissors. Upon opening the large anastomotic aneurysm in the lower portion of the aneurysm, the old woven graft was identified. There was a broken suture sitting inside the aneurysm. The aortic graft had completely become unincorporated with the aorta, and the large aneurysm was surrounding the free end of the graft inside the lumen.

The right renal, left renal, and SMA orifices were identified. Irrigating Fogarty catheters were placed in these orifices and helped control bleeding. Iced Lactated Ringer’s solution was then infused into all these, both renal arteries and SMA, to help preserve the renal and the intestines. The proximal aorta was debrided, and it was felt that a graft could be sutured to the orifice of the SMA and right renal. A 20 millimeter Gortex graft was then brought onto the field, and this was sutured in placed with 3-0 cardiovascular Prolene suture. The beveled anastomosis was performed proximally including the SMA inferiorly and the right renal artery.

After the proximal anastomosis was completed, a silver clip was placed at the proximal anastomosis. Clamps were placed distally and flow was restored to the celiac, SMA, and right renal. After flow was restored, it was noted the clamp time was 33 minutes. The Dacron graft was sized at the appropriate length and sutured in an end to end fashion to the remotely placed Dacron graft using 3-0 cardiovascular Prolene in a simple running fashion.

Prior to completion of the anastomosis, anterograde and retrograde bleeding was performed. The anastomosis was tied. The flow was restored to the legs.

A 6 millimeter PTFE (W.L. Gore, Newark, DE) side graft, which had previously been sutured onto the graft prior to being placed in the patient, was cut to the appropriate length and bypass graft and then sutured end to the end of the left renal artery. The kidney was small, approximately 8 cm, but renal artery was patent. A 1 millimeter probe was easily passed through the first branch of the renal artery. The renal artery was then sutured in an end-to-end fashion with a 6-0 Prolene simple running suture. After this was sutured into place, the anastomosis was tied, and flow was restored to the kidney. There was a good Doppler signal in both branches of the renal artery.

The patient developed some evidence of coagulopathy, and coagulation factors were replaced, and the patient was warmed. After hemostasis was obtained, the aneurysm sac was closed over the aortic graft with interrupted 3-0 Vicryl sutures. The pleura was closed over the thoracic aorta with interrupted 3-0 Vicryl sutures. Next, the diaphragm was closed with interrupted 2-0 Prolene interrupted horizontal mattress sutures. After the diaphragm was closed, the intercostal stitches were placed with a #2 doubled PDS suture. The chest tube was placed through an anterior incision above the operative incision. A #32 French chest tube was placed posteriorly and was tied in place with a 2-0 silk. After the chest tube was in adequate place, the intercostal stitches were tied, and the diaphragm was approximated.

There was palpable pulse in renal arteries, celiac artery, and superior mesenteric artery. Dressings were applied. Chest tube was connected to water seal. The patient was then transferred to the intensive care unit in satisfactory condition. Patient was subsequently discharged in satisfactory condition and lost to follow-up 4 years later.

Discussion

Proximal anastomotic pseudoaneurysms after AAA repair are uncommon as compared to distal iliac and femoral anastomotic aneurysms. Hallet et al. reported nine para-anastomotic aneurysms at a median follow-up of 6.1 years and three at the proximal aortic anastomosis [1]. Conrad et al. reported six visceral segment aneurysms, three of which underwent open repair among 152 patients who underwent surveillance with imaging studies following open AAA repair [2].

A proximal aortic para-anastomotic pseudoaneurysm developed in six patients (2.9%) in a retrospective study of 208 patients who survived elective open repair of infrarenal aortic aneurysm [3]. Crawford et al. reported a long-term outcome of open repair of AAA. During a 15-year follow-up, late complications occurred in 26 (3.2%) patients with anastomotic pseudoaneurysms in 23 patients and secondary aortoenteric fistula in the remaining 3 patients [4]. Following an open AAA repair, an anastomotic aneurysm or aneurysmal dilatation of adjacent visceral segment and/or iliac arteries may occur in 1%, 5%, and 20% at 5, 10, and 15 years, respectively. Therefore CTA abdomen and pelvis should be obtained every 5 years after open repair.

All patients with proximal para-anastomotic pseudoaneurysms do not need repair. Repair of such aneurysms is dictated by their size (>5.5 cm) and coexisting medical comorbidities. When indicated, retroperitoneal flank approach is preferred. The role of endovascular repair with branched endografts is not clearly defined in the management of para-anastomotic pseudoaneurysms. In patients undergoing repair of type IV thoracoabdominal aneurysm, continuous cold perfusion of the left kidney can be carried out during performing of distal anastomosis [5, 6]. Postischemic renal dieresis occurs commonly when suprarenal clamp time exceeds 30 minutes. Patients should have adequate volume replacement. Postoperatively, a spinal cord protection protocol is maintained for at least 24 hours in all patients treated with a lumbar drain [5, 6]. This case illustrates the importance of careful follow-up with imaging studies, as well as adequate treatment of hypertension. It is possible that uncontrolled blood pressure in this case led to rapid enlargement of juxtarenal AAA before the first operation and probably played a role in the development of proximal para-anastomotic pseudoaneurysm.

Invited Commentary from Charles W. Acher, MD

What is striking about this patient is his age of 37 at the time of his first aneurysm repair. Even with such severe malignant hypertension, which was diagnosed and treated 10 years previously, it is unusual to develop an aneurysm at this age without some underlying genetic molecular disorder which we can now test for but was unavailable at the time of either aneurysm repair. A smoking history was not mentioned but would be present in most of these patients. His mental decompensation in 1980 after stopping his medications might very well have been hypertensive encephalopathy, or encephalopathy may have contributed, but it also raised the question of how consistent he was in controlling his blood pressures in the decade preceding and after his initial aneurysm surgery with what was undoubtedly a hypertensive stroke in 1973, a year after diagnosing his hypertension. Also, in 1981 he already had hypertensive nephropathy with diminished renal function, and he may have been malnourished from aneurysm-related anorexia with a BMI of 14.1. All of these factors may have contributed to his subsequent aneurysm/pseudoaneurysm 13 years later.

The actual repair of his aneurysm/pseudoaneurysm in 1994 appears to have gone flawlessly and demonstrates several points which are important in planning and executing such a complicated repair even today and were ahead of their time in 1994. The use of a spinal drain was not done in most centers in 1994. We reported the largest clinical series up to that time of 40 TAAA patients in 1989 with experience since 1986 showing an 80% reduction in spinal cord injury, but general acceptance of spinal drains did not really take hold until Coselli’s randomized trial in 1999 [7]. In 1994 we would have drained CSF, but in a surgery like this today, we might avoid the spinal drain but use the rest of our spinal cord protection protocol which is hypothermia (32–33 °C), proximal hypertension, steroids and naloxone, plus aggressive volume resuscitation with blood (cell saver and bank) and FFP. We would use spinal drainage for a true Crawford type 4 TAAA in most cases. Renal cooling with iced saline was also not standard in 1994 but is the best strategy for renal protection. We always advocated rapid renal cooling (over 2–4 minutes) with 300–400 infusion of LR with 12.5 gm and 1000 units of heparin/liter at 4C into each kidney [6]. This is very protective with permanent dialysis-dependent renal failure in 0.8% of our patients and was confirmed by a randomized trial by Lamaire and Coselli [8]. Also I think it was important to investigate the left kidney and revascularize for maximum renal preservation if the renal artery was not occluded as suggested by the pre-op imaging. The cold renal perfusion is important in attaining moderate hypothermia (32–33 °C) which is end-organ (kidney, bowel, liver) protection during aortic reconstruction [9]. We do not reverse hypothermia with active warming (no bare huggers) and allow patients to rewarm on their own over several hours in the ICU. This intentional hypothermia has not resulted in increased bleeding or postoperative bleeding because we are very aggressive with volume and factor replacement during the surgery and patients are on an FFP drip at 75 cc per hour until the next day. We feel this hypothermia is protective of the spinal cord in more extensive replacements until the axial collateral network defined so elegantly by Etz and Griepp improves blood flow to the cord [10]. In this case that is not as important because of the limited aortic replacement but is important for the bowel and liver which we do not perfuse directly.

There are a few other technical points that have changed since 1994 when we exposed and closed in much the same way as described. We do extraperitoneal exposure now and have for the last 20 years if the incision is in the 7th intercostal space or lower, and we close the diaphragm with a running double-stranded 0 PDS suture and not interrupted Ethibond. In 5th and 6th interspace incisions, we still may need interrupted Ethibond for the last third of the diaphragm which are tied after the chest wall is approximated. In addition to a chest tube, we also drain the retroperitoneum with a 10 flat JP drain with a ReliaVac reservoir which maintains a constant -80 mmhg suction to minimize fluid and blood from accumulating in the retroperitoneum and has a one-way valve so reservoir contents don’t reflux back into the drain. Just as important as the surgical repair are the anesthetic protocols which are standardized in our unit. All of these cases are done by cardiovascular anesthesiologists who follow the protocols that have been developed from basic science and experience and modified by consensus as new information comes to light that has strong scientific foundation. Postoperative ICU protocols are also important to optimize cardiac function, hemodynamics, oxygen delivery, and tissue perfusion. These protocols have been agreed upon by the anesthesiologists, surgeons, and intensivists who we co-manage with daily while in the ICU with face-to-face interactions.

Reading about this case brought back memories of those patients we treat successfully who disappear into the ether of time and we wonder what happened to them. Did all that work result in a longer and better life? It also brings home the reason we try so hard to maintain contact with these patients so we can better understand the long-term success or failure of our efforts.

References

1.

Hallett JW, Marshall DM, Petterson TM, Gray DT, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25(2):277–84; discussion 285–286.PubMed

2.

Conrad MF, Crawford RS, Pedraza JD, Brewster DC, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg. 2007;46(4):669–75.PubMed

3.

Crawford ES, Saleh SA, Babb JW, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period. Ann Surg. 1981;193(6):699–709.PubMedPubMedCentral

4.

Biancari F, Ylönen K, Anttila V, Juvonen J, Romsi P, Satta J, Juvonen T. Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study. J Vasc Surg. 2002;35(1):87–93.PubMed

5.

Shepard AD. Proximal abdominal aortic aneurysm repair in endovascular reconstruction. In: Hans SS, Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton: CRC Press; 2018. p. 213–20.

6.

Wynn MM, Acher C, Marks E, Engelbert T, Acher CW. Post operative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp technique and 4°C renal perfusion. J Vasc Surg. 2015;61(3):611–22.PubMed

7.

Acher CW, Wynn MM, Archibald J. Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms. Surgery. 1990;108(4):755–61; discussion 61–2.PubMed

8.

Coselli JS, LeMaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002;35(4):631–9.PubMed

9.

Koksoy C, LeMaire SA, Curling PE, et al. Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood. Ann Thorac Surg. 2002;73(3):730–8.PubMed

10.

Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM, Griepp RB. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg. 2011;141(4):1029–36.PubMedPubMedCentral

© Springer Nature Switzerland AG 2020

S. S. HansChallenging Arterial Reconstructionshttps://doi.org/10.1007/978-3-030-44135-7_2

2. Repair of Juxtarenal Abdominal Aortic Aneurysm with Aortorenal Bypass

Sachinder Singh Hans¹  

(1)

Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinical Assistant Professor at Wayne State, University School of Medicine, Clinton Township, MI, USA

Sachinder Singh Hans

Email: [e-mail]

Keywords

Juxtarenal AAAAortic clamp injurySimultaneous aortorenal bypass graft

Physical Examination

A 68-year-old male was scheduled for open repair of a 5.0 cm abdominal aortic aneurysm (AP/transverse diameter) in February 2005. The aneurysm was juxtarenal with associated 2.8 cm bilateral common iliac artery aneurysms and a 2.0 cm left hypogastric artery aneurysm (Fig. 2.1a). Preoperative aortography showed accessory left lower pole renal artery (Fig. 2.1b). Medical comorbidities included history of atrial flutter, hypertension, and post-thrombotic syndrome involving both lower extremities.

../images/480270_1_En_2_Chapter/480270_1_En_2_Fig1_HTML.png

Fig. 2.1

(a, b) Aortography showing abdominal aortic aneurysm and bilateral iliac aneurysm with accessory left lower pole renal artery . Because of large amount of thrombus in the abdominal aortic aneurysm, aortogram only shows the contrast-filled lumen

Procedure

Through midline transperitoneal incision , AAA was exposed to mobilize. Following application of the Bookwalter retractor, and mobilization of the ligament of Treitz, the left renal vein was ligated close to the inferior vena cava. The aneurysm arose at the level of the left renal artery and was saccular with a bulge to the left. Left crus of the diaphragm was divided by electrocautery. Both common iliac artery aneurysms were mobilized along with mobilization of the origin of the hypogastric and external iliac artery. Aorta was clamped above the left renal artery and below the right renal artery following systemic heparinization. Proximal anastomosis was performed using 22 × 11 mm knitted Dacron graft (Meadox, Boston Scientific, Marlborough, MA) in two layers, with the first layer of interrupted horizontal mattress suture on pledgets with 3-0 cardiovascular polypropylene (Ethicon, Somerville, NJ) and a second layer of continuous suture. As the proximal clamp was released, there was excessive bleeding at the 7 o’clock position of the suture line. Reapplication of the clamp a few cm proximally resulted in a tear of the aorta. A #24 Foley balloon catheter was introduced through the left limb of the Dacron graft and inflated at the supraceliac level. Left renal artery was transected at its origin from the aorta. Proximal stump of the renal artery was suture ligated, and deep bites into the left lateral wall of the aorta were taken using horizontal mattress sutures of 3-0 cardiovascular Prolene on pledgets. Bio-glue (Cryolife, Kennesaw, GA) was applied to achieve hemostasis. A 6 mm PTFE graft (W.L. Gore, Newark, DE) was anastomosed to the main body of the Dacron graft on the left side just above the bifurcation of the graft taking out a small disc of Dacron graft using 5-0 cardiovascular polypropylene and distally was anastomosed end to end to the divided left renal artery. The left lower pole renal artery was reimplanted into the left limb of the Dacron graft using 5-0 CV polypropylene as well. The left hypogastric aneurysm was excised, and back bleeding was controlled with 4-0 CV polypropylene suture. Because of severe calcific disease in the left external iliac artery, left limb of the graft was anastomosed to the left common femoral artery in an end-to-side fashion. Left common iliac aneurysm was opened, and its wall was partially removed, and proximal left external iliac artery was ligated. On the right side, anastomosis of the right limb of the Dacron graft was performed end to end to the common iliac artery at the bifurcation after removal of the aneurysm. The patient received 600 cc of blood from the cell saver, and 1 unit of PRBCs was given to the patient. Patient’s post-op course was complicated by respiratory failure which improved with ventilatory support.

The patient was extubated on the third postoperative day. The patient had transient renal dysfunction . Postoperative aortography showed patent aortoiliac and femoral graft and patent left aortorenal bypass (Figs. 2.2 and 2.3). Patient did well and underwent repair of 3.5 cm left femoral anastomotic aneurysm 8 years after the original procedure. The patient later expired from complications of Alzheimer’s dementia in 2017.

../images/480270_1_En_2_Chapter/480270_1_En_2_Fig2_HTML.png

Fig. 2.2

(a, b) Aortography showing aortic bifurcation graft and left aortorenal bypass

../images/480270_1_En_2_Chapter/480270_1_En_2_Fig3_HTML.png

Fig. 2.3

Left femoral anastomotic aneurysm

Discussion

Operative repair of juxtarenal AAA is a technically challenging operation. In absence of the need to visualize distal right common iliac artery (as was the case for this patient due to 2.5 cm right iliac aneurysm), a left flank retroperitoneal approach is increasingly used for open repair of proximal complex AAA in patients with need to explore the aorta proximal to the renal arteries, redo aortic surgery, AAAs in the presence of a horseshoe kidney, hostile abdomen with prior osteotomies, or inflammatory AAA. A concomitant renal artery bypass became necessary as proximal aortic clamp resulted in tear of the aorta above the renal arteries [1]. Because of the improvement in medical management of renovascular hypertension, concomitant renal artery bypass with open AAA is rarely indicated. In order to perform suprarenal dissection via transperitoneal approach, mobilization of left renal vein or ligation of left renal vein close to the inferior vena cava preserving gonadal and adrenal vein as venous outflow from the kidneys is necessary. Mobilization of the left renal vein without division often requires ligation of adrenal vein and gonadal vein. In addition, the left crus of the diaphragm needs to be divided to gain proximal aortic exposure.

Follow-up aortography showed satisfactory proximal anastomosis, patent left aortorenal bypass, occluded lower pole renal artery reimplantation (Fig. 2.2), and an anastomotic aneurysm involving the graft and left femoral artery. Though not always possible, either tube graft (aorto-aortic) or aortoiliac anastomosis should be preferred as femoral anastomosis may result in increased incidence of surgical site infection, lymphoceles, and late development of anastomotic aneurysms [1]. Repair of left femoral anastomotic aneurysm was performed by interposition of an 8 mm knitted Dacron graft. A left flank approach through 9th or 10th ICS, 9th ICS for paravisceral extent IV thoracoabdominal aneurysms, and 10th ICS for pararenal aortic aneurysms is preferable [1]. Renal, visceral, and occasionally spinal cord ischemia may occur with prolonged proximal clamping [1]. Renal artery reconstruction at the time of open repair of paravisceral aneurysm is associated with increased incidence of acute renal failure and mortality [2, 3]. Minimizing renal ischemia time to less than 40 minutes is important in reducing the risk of acute kidney injury. Before aortic cross clamping above the suprarenal or supraceliac level, hemodynamics need to be optimized. Mannitol 25 g is administered 30 minutes prior to aortic cross clamping, though its benefit in preventing renal dysfunction has not been proven. Deery et al. reported from vascular surgery group of New England registry for the repair of complex AAA (defined by need of suprarenal or supraceliac clamping) had higher perioperative mortality (3.2% compared to 1.2% standard infrarenal AAA repair) [4]. Renal or visceral ischemia independently predicted cardiac, respiratory, and renal complications according to results of their study [4].

Invited Commentary from Timothy J. Nypaver, MD

This operative management of a juxtarenal aneurysm highlights many of the intraoperative and postoperative challenges and complications that can and do occur with standard open repair. In addition, juxtarenal aneurysms are now frequently managed via endovascular means with use of fenestrated grafts and alternate techniques , including extension of the landing zone more proximally with renal preservation via chimney or snorkel grafts into the renal arteries [5]. This has resulted in less operative exposure for both vascular surgeons and trainees, and the intraoperative rescue maneuvers , clearly demonstrated in this case, are becoming less familiar to practicing vascular surgeon. The author should be congratulated with this difficult case, managing a proximal clamp site tear and avulsion of a renal artery with the following critical maneuvers: proximal balloon control (inserted through a limb of the vascular graft), reimplantation of the avulsed renal artery, implantation of an accessory renal artery, and successful management of a bleeding proximal anastomosis. This was accomplished with minimal blood transfusions and complete operative management and correction of existing aneurysms (the common iliac and the hypogastric aneurysm). In doing so, the patient has been rewarded with a durable operative repair, one that lasted up to his death 12 years later from non-aortic causes. This case also indirectly highlights the potential benefits of endovascular repair with its less invasive nature and its reduced operative risk and morbidity. While this patient recovered from this challenging operative management with transient respiratory failure (3 days) and reversible renal dysfunction, other patients, frailer or those with more significant comorbidities, may not have been able to do so. Thus, careful consideration should always be given to each approach, endovascular or open, so that the vascular surgeon hopefully can select the right operation for the right patient. While each approach is complementary, it is recognized, as with standard infrarenal abdominal aortic aneurysm operations, that endovascular repair will become the more commonly performed and the probable favored approach for repair of juxtarenal aneurysms [6].

The author has appropriately pointed out the significant benefits of the left flank retroperitoneal approach . If an open repair is to be undertaken for a juxtarenal or suprarenal aneurysm, for a paravisceral extent IV thoracoabdominal aneurysms, or for a proximal type I endoleak or other complications related to infrarenal endografting, a left flank retroperitoneal approach is preferred. If necessary, the first 1–2 cm of the right renal artery can be dissected and exposed, and in addition, the right common iliac artery can be exposed distally allowing either an anastomosis to the mid to distal common iliac or alternately allowing for ligation of the common iliac with the bypass limb then routed to the femoral level. Retroperitoneal abdominal aortic aneurysm has been associated with lower estimated blood loss and less fluid requirement within the first 24 hours following operation than transperitoneal repair [7]. In addition, the left flank retroperitoneal approach allows more facile access to the suprarenal, supramesenteric, and supraceliac levels, all performed thru the same visual plane. Once open repair is selected for a juxtarenal aneurysm, the decision for transperitoneal versus retroperitoneal is often based upon the surgeon’s preference and experience and, as illustrated in this example, whether the right iliac artery is extensively involved with the disease process.

References

1.

Shepard AD. Proximal abdominal aortic aneurysm repair. In: Hans SS, Shepard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton: CRC Press; 2018. p. 213–20.

2.

Ultee KHJ, Soden PA, Zettervall SL, McCallum JC, Siracuse JJ, Alef MJ, Vascular Study Group of New England. Perioperative effect of concomitant procedures during open infrarenal abdominal aortic aneurysm repair. J Vasc Surg. 2016;64(4):934–940.e1.Crossref

3.

Wooster M, Back M, Patel S, Tanious A, Armstrong P, Shames M. Outcomes of concomitant renal reconstruction during open paravisceral aortic aneurysm repair. J Vasc Surg. 2017;66(4):1149–56.Crossref

4.

Deery SE, Lancaster RT, Baril DT, Indes JE, et al. Contemporary outcomes of open complex abdominal aortic aneurysm repair. J Vasc Surg. 2016;63(5):1195–200.Crossref

5.

Lee JT, Greenberg JI, Dalman RL. Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg. 2012;55:935–46.Crossref

6.

Soler R, Bartoli MA, Faries C, et al. Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms. J Vasc Surg. 2019;70(3):683–90.Crossref

7.

Nypaver TJ, Shepard AD, Reddy DJ, et al. Repair of pararenal abdominal aortic aneurysms: an analysis of operative management. Arch Surg. 1993;128:803–13.Crossref

© Springer Nature Switzerland AG 2020

S. S. HansChallenging Arterial Reconstructionshttps://doi.org/10.1007/978-3-030-44135-7_3

3. Abdominal Aortic Aneurysm Repair in a Patient with Celiac Artery Occlusion and a Large Inferior Mesenteric Artery

Sachinder Singh Hans¹  

(1)

Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinical Assistant Professor at Wayne State, University School of Medicine, Clinton Township, MI, USA

Sachinder Singh Hans

Email: [e-mail]

Keywords

AAA with large IMA, mesenteric collaterals, Carrel patch

Physical Examination

A 75-year-old male with history of hypertension, nicotine abuse, and now chronic back pain underwent CTA evaluation of the abdomen for a large pulsatile mass in his abdomen. A 7.4 cm infrarenal AAA with 80% stenosis of the celiac artery, 40% stenosis of the superior mesenteric artery, and an enlarged inferior mesenteric artery with a collateral vessel between the celiac and IMA (Fig. 3.1) was demonstrated. Patient had not had any symptoms of intestinal angina.

../images/480270_1_En_3_Chapter/480270_1_En_3_Fig1_HTML.png

Fig. 3.1

(a, b) CTA showing iliac artery stenosis. Mild stenosis of SMA and large AAA

Procedure

Patient was taken to the hybrid room for possible endovascular or open repair. An aortogram performed via the left femoral artery sheath revealed a large collateral artery in the upper abdomen communicating with the IMA (Fig. 3.2). Because of the risk of development of bowel infarction due to the coverage of the IMA with EVAR, it was decided to perform open repair. Through a midline laparotomy incision, AAA was explored, and a large collateral artery joining the IMA was identified. Open repair of the AAA with 20 mm tube graft was performed. Origin of the IMA and its first few centimeters were mobilized and reimplanted into the Dacron graft as a carrel patch (Fig. 3.3). Postoperative course was uneventful except for the development of transient atrial fibrillation and encephalopathy which improved gradually. Postoperative CTA showed satisfactory graft placement and patent IMA with mild to moderate stenosis (Fig. 3.4). Patient was seen in 6 months later in the clinic and in a satisfactory condition.

../images/480270_1_En_3_Chapter/480270_1_En_3_Fig2_HTML.png

Fig. 3.2

(a–c) Aortogram showing AAA with a large mesenteric collateral joining the IMA

../images/480270_1_En_3_Chapter/480270_1_En_3_Fig3_HTML.png

Fig. 3.3

Intraoperative picture showing reimplanted IMA as Carrel patch

../images/480270_1_En_3_Chapter/480270_1_En_3_Fig4_HTML.png

Fig. 3.4

(a–c) Postoperative CTA images showing patent aortic graft with mild stenosis of the origin of the reimplanted IMA

Discussion

Complications of colon ischemia following open or endovascular aneurysm repair are rare. Patients undergoing open AAA repair with prior colon resection or a large IMA with arc of Riolan with associated celiac and SMA occlusive disease are more likely to develop the dreaded complication of ischemic colitis due to ligation of the IMA. Coverage of the IMA during endovascular repair of AAA in such patients may also result in ischemic colitis. In a recent retrospective analysis by Lee et al, IMA reimplantation during open AAA repair was associated with higher incidence of ischemic colitis [1]. However, the patient population under study did not demonstrate enlarged mesenteric collaterals suggesting need for IMA reimplantation. In the case described above, patient had a large collateral between the celiac with inferior mesenteric artery. The IMA reimplantation was thought to be a good option for prevention of bowel ischemia. The large collateral in this patient was not the arc of Riolan, which connects the middle colic (branch of SMA) to the IMA. This large collateral was a novel collateral from the celiac artery to the left upper colic artery of the IMA. An endovascular option with preservation of the IMA using a single fenestration in the back-table modification of the stent can be used occasionally in high-risk patients [2].

Invited Commentary from Mitchell Ross Weaver, MD

This case illustrates the importance of fully evaluating a patient’s anatomy beyond only determining if there are adequate proximal and distal landing zones for an endograft to seal and adequate access for delivering the device. Coverage of the inferior mesenteric artery is a mandatory step in the endovascular treatment of abdominal aortic aneurysms for all commercially available abdominal aortic endograft systems, and even with this the incidence of clinically relevant postoperative mesenteric ischemia is very low. As well as in open surgical repair of abdominal aortic aneurysms, the inferior mesenteric artery is routinely ligated except in circumstances where it was patent preoperatively and has poor back bleeding following the aortic reconstruction. In this case however, given the large size of the inferior mesenteric artery and the mesenteric occlusive disease noted in the celiac and superior mesenteric arteries, one must assume that if flow is not preserved in the inferior mesenteric artery, mesenteric ischemia and bowel infarction will follow.

For this patient the inferior mesenteric artery patency was preserved by an open aortic aneurysm repair and reimplantation of the inferior mesenteric artery. While each patient’s anatomy is unique to them, in some patients other options may be to intervene either with endoluminal or open interventions on the celiac or superior mesenteric arteries to preserve adequate mesenteric blood flow. Nevertheless, this case does stress the importance of case planning and being mindful of the physiological effects caused by the anatomic changes of surgical intervention, whether open or endovascular.

References

1.

Lee KB, Lu J, Macsata RA, Patel D, Yang A, Ricotta JJ, Amdur RL, Sidawy AN, Nguyen BN. Inferior mesenteric artery reimplantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair. J Vasc Surg. 2019;69(6):1825–30.

2.

Correa JC, Mantese V, Jacobs DL. Stent graft treatment of abdominal aortic aneurysm with preservation of the inferior mesenteric artery. J Vasc Surg. 2014;60(4):118–9.Crossref

© Springer Nature Switzerland AG 2020

S. S. HansChallenging Arterial Reconstructionshttps://doi.org/10.1007/978-3-030-44135-7_4

4. Abdominal Aortic Aneurysm Repair in a Patient with a Pelvic Kidney

Sachinder Singh Hans¹  

(1)

Medical Director of Vascular and Endovascular Services, Henry Ford Macomb Hospital, Clinical Assistant Professor at Wayne State, University School of Medicine, Clinton Township, MI, USA

Sachinder Singh Hans

Email: [e-mail]

Keywords

Abdominal aortic aneurysmPelvic kidney

Physical Examination

A 66-year-old white male with chronic obstructive pulmonary disease was found to have an 8-cm-wide asymptomatic abdominal aortic aneurysm by physical examination. Ultrasound of the abdominal aorta confirmed that the aneurysm was 8 cm in transverse diameter, and, in addition, there was a suggestion of a pelvic midline mass. Retrograde aortogram revealed the infrarenal location of the aneurysm with a normal left kidney and left renal artery. The right kidney was located in the pelvis with its blood supply arising from the lower abdominal aorta either at its bifurcation or from the origin of common iliac artery (Fig. 4.1); this distinction could not be made with certainty on arteriogram. Pulmonary function tests revealed severe obstructive lung defects, and a chest X-ray showed mild obstructive lung disease.

../images/480270_1_En_4_Chapter/480270_1_En_4_Fig1_HTML.png

Fig. 4.1

Aortogram showing abdominal aortic aneurysm, pelvic kidney and its arterial supply from aorta or common iliac artery

Procedure

On exploration the aneurysm had a short neck and was 8 cm in transverse diameter. The aneurysm was mobilized along with the blood supply to the pelvic kidney arising 1 cm anterior and superior to the origin of the slightly dilated common iliac arteries. The right renal vein from the pelvic kidney joined the right common iliac vein. The aorta was clamped below the left renal artery, and the aneurysm was excised under systemic heparinization. A 19 × 9.5 mm USCI woven bifurcated Dacron graft was sutured in place after both renal arteries to the pelvic kidney had been mobilized and cuff preserved with each common iliac artery. Both renal arteries to the pelvic kidney were flushed with heparinized ice-cold saline after the aneurysm had been opened. Proximal anastomosis was performed with 4-0 cardiovascular Prolene. Distally, each common iliac artery and the attached renal artery proximal to it were joined in a common elliptical anastomosis to the Dacron limb on either side also using 4-0 cardiovascular Prolene (Fig. 4.2). Total clamp time was 30 minutes. Postoperative renal blood flow and scan showed normal blood flow to the left kidney as well as to the right pelvic kidney (Fig. 4.3). The patient was discharged after 8 days in good condition.

../images/480270_1_En_4_Chapter/480270_1_En_4_Fig2_HTML.png

Fig. 4.2

Operative photograph showing Dacron