Transperitoneal versus Retroperitoneal Suprarenal Cross-Clamping for Repair of Abdominal Aortic Aneurysm with a Hostile Infrarenal Aortic Neck

Visceral Artery Revascularization With the "Roof-Top" Approach: An Alternative Technique With Great Exposure of the Suprarenal Aorta

Due to the extensive collateral arterial network, symptomatic chronic mesenteric ischemia is a relatively uncommon condition and is associated with severe atherosclerotic disease of all major visceral arteries. Open surgical repair has been commonly used to restore blood supply to the visceral arteries, and the "roof-top" approach has been advocated as an alternative technique to traditional midline incision, mainly because of the great exposure of the suprarenal aorta that it offers. Roof-top approach, in other words, bilateral subcostal incision, is a totally abdominal approach to the suprarenal aorta, and as the title says, it is like a roof-top on the abdominal wall. We present a case of a female patient with intestinal angina that was deemed unsuitable for endovascular repair (ER) and was treated with open surgical repair utilizing the "roof-top" approach.

Surgical approaches in juxtarenal and pararenal aortic aneurysms repair

BACKGROUND

In this study, surgical tactic features and juxtarenal and pararenal treatment immediate results were analyzed depending on the use of various surgical approaches.

METHODS

Between 2015 and 2019, a total of 89 patients received surgical treatment, of which 52(58%) had juxtarenal aneurysms and 37 (42%) - pararenal aneurysms. During repairs, three types of surgical approaches were used: midline laparotomy, extended retroperitoneal approach and thoraco-phreno-retroperitoneal approach. The patients were divided into three groups accordingly.

RESULTS

At the immediate postoperative period, mortality rate equaled 2 (2.2%). The reasons were pulmonary embolism and sepsis. Statistically reliable data were obtained, confirming the advantages of midline laparotomic approach over the lateral retroperitoneal ones, which consisted in a shorter operative time, less pronounced pain syndrome, lesser blood loss, fewer postoperative days. The disadvantages were that enteroparesis occurred more often when the midline laparotomy was used in comparison to extended retroperitoneal or thoraco-phrenoretroperitoneal approaches.

CONCLUSION

Thus, open repairs of juxtarenal and pararenal aortic aneurysms have some specific technical and strategical features which are associated with intraoperative renal ischemia. During open surgical intervention, it is important to first consider the possibility of repair with midline laparotomy. However, lateral retroperitoneal approaches can also be used on a case-by-case basis noting their advantages and disadvantages.

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

BACKGROUND

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15-20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs.

METHODS

Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included.

RESULTS

All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6-54.2). Mean survival time was 51.4 months (95% CI: 48.6-54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025-1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225-4.553; P = .010) were substantially associated with in-hospital complications.

CONCLUSIONS

Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

Mid-Term Outcomes of Retroperitoneal and Transperitoneal Exposures in Open Aortic Aneurysm Repair

BACKGROUND

There have been a number of studies comparing perioperative outcomes of the retroperitoneal (RP) and transperitoneal (TP) approaches to open aortic aneurysm repair (OAR), many of which have shown conflicting results. There remains a paucity of data comparing these 2 exposures beyond 30 days. The purpose of this study was to evaluate the mid-term outcomes between RP and TP exposures in OAR.

METHODS

This is a retrospective review of elective OAR from a single institution from 2010 to 2014 with at least one year of follow-up. Patients with any prior aortic repair, prior midline TP or RP exposures, prior small bowel obstruction (SBO), or prior abdominal wall hernia repair were excluded. Patients' demographics, comorbidities, intraoperative details, and postoperative variables up to 5 years were compared. Primary outcomes were all-cause mortality, aortic or arterial reinterventions, incisional reinterventions, SBO or reintervention for SBO, and composite reintervention.

RESULTS

Of the 273 OARs identified, 136 OARs (86 TP and 50 RP exposures) met criteria for the study. The average follow-up was 43.4 months. Of the preoperative and intraoperative characteristics, patients with RP exposures were significantly more likely to be female (30% vs. 12.8%; P = .014) and to have larger aneurysm (6.1 ± 1.02 cm vs. 5.4 ± 1.01 cm; P < .001), tube graft (48% vs 19.8%; P < .001), and renal bypass (30% vs. 2.3%; P < .001). Patients with TP exposures were significantly more likely to have inferior mesenteric artery reimplantation (15.1% vs. 4%; P = .046), infrarenal clamping (65.9% vs. 22%; P < .001), and iliac aneurysm (36% vs. 4%; P < .001). During mid-term follow-up, there was not a difference in all-cause survival at 3 years (95.8% vs. 95.8%; P = .52). Although there were more incisional hernias in the TP group (48% vs. 8%; P < .001), there was no difference in incisional reinterventions (14% vs. 6%; P = .36). There were no differences in aortic or arterial reinterventions (5% vs. 4%; P = .86), SBO (7% vs. 0%; P = .99), intervention for SBO (3% vs. 0%; P = .99), or composite reinterventions (16% vs. 10%; P = .6) between the TP and RP exposures.

CONCLUSIONS

In mid-term follow-up, OAR through TP exposure had more incisional hernias compared with RP exposure. However, there is no difference in mortality or composite reinterventions between approaches.

Anatomical Considerations and Open Surgery to Treat Juxtarenal Abdominal Aortic Aneurysms

Introduction:

Historically, the open approach to the abdominal aorta has been transperitoneal (TP). In comparison, a retroperitoneal (RP) incision exposes the lateral wall of the suprarenal aorta for clamp application and midline structures such as the duodenum and pancreas are not encountered. Proximal clamp position for open repair of juxtarenal abdominal aortic aneurysm (JR-AAA) is suprarenal, supra-superior mesenteric, or supraceliac. While RP and TP approaches have previously been compared for physiological reasons, there are currently no randomized controlled trials comparing these methods from an anatomical perspective.

Aims:

The primary aim is to examine the evidence for adopting an RP approach for JR-AAA and compare it with TP approach from an anatomical perspective. The secondary aim is to assess optimum proximal clamp position and its effect on renal function and mortality for the 2 approaches.

Methods/Design:

Literature was reviewed searching databases Medline and Embase for studies on clamp positioning in JR-AAA repair using a TP or RP approach, up to December 2017.

Conclusions:

There is no clear evidence for the optimum cross-clamp position for open repair of JR-AAAs. More proximal clamps provide adequate operative space with the possible downside of increased afterload leading to visceral and renal ischemia. Clamps placed inferior to the superior mesenteric artery allow continued bowel and hepatic perfusion with the potential to cause trauma to the adjacent aortic branches during application. As far as the optimum approach is concerned, many series show a strong trend for RP as a more proximal clamp is required. Significant numbers develop renal failure after JR-AAA repair, with most recovering fully irrespective of the clamp position.

Renal protection in juxtarenal and suprarenal aortic aneurysm surgery

Among the most important factors driving morbidity and mortality after aortic surgery is post operative renal insufficiency. The attendant metabolic derangements greatly complicate surgical care, expedite arrhythmias, and can significantly prolong hospital stay and cost. This article seeds to define factors contributory to renal complications after aortic surgery and offers a review of techniques to protect renal mass from post operative declines.

Survival after repair of pararenal and paravisceral abdominal aortic aneurysms

OBJECTIVE

The objective of this study was to review our 27-year clinical experience with open proximal abdominal aortic aneurysm repairs, with a focus on long-term survival.

METHODS

A retrospective cohort study was undertaken of all patients who underwent proximal abdominal aortic aneurysm repair between 1986 and 2013 at a tertiary care referral center. Demographics, operative variables, complications, and 30-day mortality were analyzed. Postoperative acute kidney injury was analyzed by the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease)/Acute Kidney Injury Network criteria. Long-term survival was assessed through review of electronic medical records and the Social Security Death Index. Associations between demographics and complications were investigated to determine predictors of long-term survival.

RESULTS

The study identified 245 patients. Mean age was 71 years (range, 38-92 years); 69% were men, and 88% were white. Aneurysm type was juxtarenal in 127 patients (52%), suprarenal in 68 patients (28%), and type IV thoracoabdominal in 50 patients (20%). In-hospital mortality was 3.3% (eight patients), and 30-day mortality was 2.9% (seven patients). At least one major complication occurred in 64% of the patients, which included the following: acute kidney injury, 60% (persistent acute kidney injury at discharge, however, was 28%, and hemodialysis at discharge was 1.6%); major pulmonary complications, 22%; myocardial infarction, 4%; visceral ischemia, 2%; and paraplegia, 0.5%. Median follow-up was 54 months. Kaplan-Meier survival estimates were 70% at 5 years and 43% at 10 years. Variables associated with poorer survival included congestive heart failure (hazard ratio [HR], 3.5; P < .001), chronic obstructive pulmonary disease (HR, 1.8; P < .002), and increased aneurysm size at presentation (HR, 1.1; P < .013). Persistent stage 3 acute kidney injury was associated with poor long-term survival.

CONCLUSIONS

Open surgical repair of proximal abdominal aortic aneurysms can be performed with low mortality. Acute kidney injury is the most frequent complication, but the need for hemodialysis at discharge is low. Long-term survival is favorable. These data should assist in establishing benchmarks for endovascular repair of complex proximal abdominal aortic aneurysms.

Left retroperitoneal aortic aneurysm repair in patients unsuitable for endovascular treatment

BACKGROUND

This study aims to evaluate the contemporary outcome of left open retroperitoneal (RP) abdominal aortic surgery over a 7-year time period in patients with difficult anatomy unsuitable for endovascular aneurysm repair (EVAR).

METHODS

Eighty-four consecutive patients unsuitable for EVAR/FEVAR underwent left RP open aortic surgery. Of these, 44 (52%) required an infrarenal cross-clamp, 17 (20%) a suprarenal cross-clamp and 15 (18%) a supracoeliac cross-clamp. Eight (10%) were thoracoabdominal aneurysms.

RESULTS

There were four mortalities within 30 days (4.8%). Two occurred in patients with a supracoeliac cross-clamp, one in a suprarenal cross-clamp (total suprarenal mortality 10%) and one in an infrarenal cross-clamp. Four patients required prolonged ventilatory support (>10 days). Three patients (9%) from the suprarenal group developed post-operative renal dysfunction, one of these required permanent dialysis. Paralytic ileus occured in two patients (2%) and was secondary to ischaemia in both cases.

CONCLUSION

There will always remain a small group of patients best treated by open aortic surgery. By definition, these are complex, difficult cases and are decreasing in number. However, in vascular units regularly performing the RP approach, excellent results can be obtained. This series provides further evidence for centralization of vascular services.

Renal and abdominal visceral complications after open aortic surgery requiring supra-renal aortic cross clamping

PURPOSE

The aim of this study was to assess renal or abdominal visceral complications after open aortic surgery (OAS) requiring supra-renal aortic cross clamping (SRACC).

METHODS

We retrospectively reviewed the medical records of 66 patients who underwent SRACC. Among them, 17 followed supra-celiac aortic cross clamping (SCACC) procedure, 42 supra-renal, and 7 inter-renal aorta. Postoperative renal, hepatic or pancreatic complications were investigated by reviewing levels of serum creatinine and hepatic and pancreatic enzymes. Preoperative clinical and operative variables were analyzed to determine risk factors for postoperative renal insufficiency (PORI).

RESULTS

Indications for SRACC were 25 juxta-renal aortic occlusion and 41 aortic aneurysms (24 juxta-renal, 12 supra-renal and 5 type IV thoraco-abdominal). The mean duration of renal ischemic time (RIT) was 30.1 ± 22.2 minutes (range, 3 to 120 minutes). PORI developed in 21% of patients, including four patients requiring hemodialysis (HD). However, chronic HD was required for only one patient (1.5%) who had preoperative renal insufficiency. RIT ≥ 25 minutes and SCACC were significant risk factors for PORI development by univariate analysis, but not by multivariate analysis. Serum pancreatic and hepatic enzyme was elevated in 41% and 53% of the 17 patients who underwent SCACC, respectively.

CONCLUSION

Though postoperative renal or abdominal visceral complications developed often after SRACC, we found that most of those complications resolved spontaneously unless there was preexisting renal disease or the aortic clamping time was exceptionally long.

Retroperitoneal repair of abdominal aortic aneurysms offers postoperative benefits to male patients in the Veterans Affairs Health System

BACKGROUND

Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested.

METHODS

Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes.

RESULTS

A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03).

CONCLUSION

RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias.