Advantages of using the midline incision right retroperitoneal approach for abdominal aortic aneurysm repair

This study was conducted to compare the midline incision right retroperitoneal approach for repairing abdominal aortic aneurysms (AAA) with the transperitoneal approach. The intra- and postoperative course of 15 patients who underwent AAA repair using the transperitoneal approach between 1987 and 1991 and another 15 patients who underwent AAA repair using the retroperitoneal approach between 1991 and 1994 were evaluated. The incidence of postoperative wound complications was also assessed. There was no operative or hospital death in either group. Although a significantly longer interval was required from the incision to the aortic clamp using the extraperitoneal method, there were no statistical differences in the aortic clamping time, total operation time, or blood loss between the two groups. On the other hand, there was a statistically significant improvement in bowel function and a significant reduction in the length of postoperative hospitalization following the extraperitoneal procedure. Furthermore, no wound complications such as those associated with the left flank incision developed after the extraperitoneal procedure. Thus, we recommend the midline incision right retroperitoneal approach for AAA as it does not involve muscle division and is associated with fewer complications.     

Open repair for pararenal abdominal aortic aneurysm: the strategy and pitfalls for safe surgery

Pararenal abdominal aortic aneurysm (PRAAA) includes two types of AAA : juxtarenal (JRAAA) and suprarenal (SRAAA). JRAAA is defined as aneurysms that extend up to but do not involve the renal arteries, necessitating suprarenal aortic clamping for repair. SRAAA is defined as aneurysms that extend up to the superior mesenteric artery, involving one or both renal arteries to be repaired. The surgical repair of PRAAAs requires more extensive aortic exposure and may result in ischemic injury to kidneys and visceral organs with higher morbidity and mortality compared with infrarenal AAAs. The four approaches to PRAAA repair are: 1) midline abdominal incision, transperitoneal, left renal vein divided or mobilized; 2) midline abdominal incision, transperitoneal, left medial visceral rotation technique 3) left flank incision, retroperitoneal; and 4) thoracoabdominal incision, thoracoretroperitoneal approach. The four positions of proximal clamping are: 1) suprarenal; 2) interrenal; 3) supramesenteric; and 4) supraceliac aorta. The surgical strategy should be determined based on computed tomography and magnetic resonance angiography imaging, and severe atherosclerotic or calcified aorta should never be clamped to prevent lethal embolic complications. Although developing fenestrated endovascular technology can be used in some cases of PRAAA repair, open surgery with thorough preoperative assessment and careful utilization of techniques to prevent visceral and renal ischemic injury is safe, effective, and durable and remains the gold standard for repair.     

A new incision for retroperitoneal approach to the aorta

A new incision for retroperitoneal approach to the abdominal aorta is described. The incision extends from alongside the rectus abdominis muscle across the costal arch over the 7-8th intercostal space. In the upper part only the skin and muscles are divided, allowing wide opening of the incision. The approach is muscle-sparing, since fibers of the transverse abdominal muscle are incised only in the upper part. It permits a good approach even for high aortic reconstruction.     

Extraperitoneal approach for repair of inflammatory abdominal aortic aneurysm

Inflammatory abdominal aortic aneurysms are characterized by dense perianeurysmal fibrosis involving the adjacent organs. Attempts to isolate the aneurysm can lead to operative injuries of these structures, thus increasing the rates of complications and mortality. In the last 12 years 45 patients with inflammatory abdominal aortic aneurysms underwent aneurysm resection at the Department of Vascular Surgery of the University of Rome. The aneurysm was resected through a standard, midline transperitoneal approach in 39 patients, through a thoracophrenolaparotomy in two patients, and through a left-flank extraperitoneal approach in the last four patients. The extraperitoneal approach simplified aneurysm dissection and aortic clamping with no cases of postoperative morbidity or death. In addition, we reviewed the CT scan findings of 12 patients surgically treated for inflammatory abdominal aortic aneurysm. The amount of fibrosis in the anterior wall of the aneurysm was greater than in the left posterolateral aspect (p = 0.008). We conclude that the left-flank extraperitoneal approach is the most anatomically advantageous route for repair of inflammatory abdominal aortic aneurysm.     

Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms

Emergency surgery is the only effective treatment of ruptured abdominal aortic aneurysms, even though morbidity and mortality rates remain high. We have studied the feasibility of left retroperitoneal aortic exposure in these cases in an effort to reduce postoperative complications. Over a 33 month period, 29 patients underwent emergency surgery for either a ruptured or symptomatic infrarenal abdominal aortic aneurysm. Of 13 patients with ruptured aneurysms, 4 underwent repair through a midline transperitoneal approach (3 deaths) whereas the remaining 9 were repaired through the retroperitoneal exposure (1 death). Supraceliac aortic clamping through the same incision prior to aneurysm exposure maintained hemodynamic integrity. The remaining 16 patients with symptomatic aneurysms were all treated through the retroperitoneal exposure (3 deaths). In the retroperitoneal groups, the cause of death was cardiac in two patients, hypertensive stroke in one, and necrotizing pancreatitis in one. Morbidity consisted of prolonged intubation, respiratory distress syndrome, and thrombophlebitis in one patient each and acute tubular necrosis in two patients. We believe that the left retroperitoneal approach is a useful option in the emergent treatment of abdominal aortic aneurysms.     

Giant size abdominal aortic aneurysm repair using open proximal anastomosis under hypothermic circulatory arrest: a report of two cases

Hypothermic total circulatory arrest and open proximal anastomosis techniques are not commonly used in abdominal or juxtarenal abdominal aortic aneurysm repair. Proximal aortic clamping is usually adequate for surgical repair of abdominal aortic pathologies. We present two cases of giant-sized abdominal aortic aneurysms, one was juxtarenal and one was a Crawford type IV thoracoabdominal aneurysm, that were repaired by using open proximal anastomosis under hypothermic total circulatory arrest and a transabdominal approach. This technique may be useful for both thoracoabdominal and large abdominal aortic aneurysms because it offers the opportunity to not clamp the aorta and operate in bloodless surgical field.     

Two patients with horseshoe kidney and ruptured abdominal aortic aneurysm

Renal anomalies present a challenge to surgeons who repair aortic aneurysms; horseshoe kidneys occur in 1 out of 400 people in the general population. The degree of fusion, accessory blood supply and ureteric anomalies all affect the approach to aneurysm repair in the elective or emergency setting. The authors report two patients with ruptured abdominal aortic aneurysms, who were found at operation to have a horseshoe kidney. In both cases a thick renal isthmus was found crossing the aorta between the inferior mesenteric artery and the bifurcation. The kidney was preserved intact, accessory blood supply was controlled from inside the aorta and the aneurysm was repaired with a Dacron graft. One patient underwent ureterolysis; although renal failure subsequently developed, it was likely related to prolonged preoperative hypotension. The other patient recovered without complications.     

Treatment of abdominal aortic aneurysm by exclusion and bypass: an analysis of outcome

Abdominal aortic aneurysm is conventionally treated by aneurysmorrhaphy with inlying graft. Alternatively, division of the aorta, with suture closure of the distal aorta and outflow vessels (exclusion of the aneurysm), and end-to-end proximal to distal bypass may be performed. However, the long-term fate of this operation has not been determined. Specifically, concern exists that the excluded blood filled aneurysm may not thrombose or may be the source of late sepsis. During an 8-year period we have treated 280 abdominal aortic aneurysms (urgent and elective) by exclusion of the abdominal aortic aneurysm sac and bypass via the posterolateral retroperitoneal approach. Mean age was 70 years (range, 44 to 88), with 217 men and 63 women. Preoperative CT scanning and aortography were performed to assess arterial anatomy. Seventy tube grafts and 260 bifurcation grafts were used. Thirty-day mortality rate was 4%. Estimated blood loss was 731 +/- 52 ml; mean transfusion requirements were 456 +/- 82 ml. The minor complication rate was 6%, and it is of great interest that there were no cases of ischemic colitis requiring colectomy. Aneurysm sacs thrombosed except in two anticoagulated patients who required further treatment. No late infections occurred. Five-year bypass patency rate was 98%. These data demonstrate that this method of treatment effectively minimized operative dissection and blood loss and therefore is a viable alternative for the management of abdominal aortic aneurysms.     

Single-stage surgery for distal aortic arch aneurysm and infrarenal abdominal aortic aneurysm through anterolateral approach.

A 58-year-old man with a distal aortic arch aneurysm (DAA) associated with an infrarenal abdominal aortic aneurysm (AAA) successfully underwent a single-stage replacement of the aneurysms. A left anterolateral thoracotomy was used for replacement of the DAA, which was performed using profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion. An extraperitoneal approach in conjunction with a lateral abdominal incision was employed for replacement of the AAA. The combination of an anterolateral thoracotomy and a lateral abdominal incision is useful in combined surgery for DAA and AAA.     

Endovascular grafting for the treatment of abdominal aortic aneurysms.

Endovascular repair of an aortic aneurysm will allow aneurysm exclusion using a graft passed inside the aorta either percutaneously or from a small groin incision. Morbidity and mortality associated with this procedure should be decreased considerably. The first grafting systems currently being developed will be appropriate for repair of aneurysms of the abdominal and descending thoracic aorta that can be repaired using tube grafts. Several research groups have shown that endovascular grafting of the aorta can be accomplished successfully.     

Congenital abdominal aortic aneurysm in the infant: case report and review of the literature

Congenital abdominal aortic aneurysms are a distinct entity from acquired aortic aneurysms. The authors present the case of a 6-week-old boy with a 6-cm aneurysm involving the abdominal aorta and common iliac arteries. Three other cases of congenital aortic aneurysms are reviewed, and an approach to these rare patients is discussed. J Pediatr Surg 36:657-658.     

Selection of the approach to the surgical treatment of diseases of the abdominal aorta]

The article discusses results of using in clinic different operative accesses in surgical treatment of occlusive-stenotic injuries and aneurysms of the abdominal aorta in 224 patients. Full medial laparotomy was used in 22 patients, extraperitoneal access--in 27 patients, extraperitoneal C. Rob access--in 122 patients, extended +thoraco-phreno-lumbotonic access--in 5 patients, the developed extraperitoneal access--in 48 patients. The advantages of the proposed method as compared with the pararectal method and C. Rob's one were experimentally confirmed. Choice of the operative access depending on the kind and spread of the pathological alterations in the abdominal aorta and the presence of complications were shown to be expedient.     

New perspectives for the treatment of thoracic aortic aneurysm with self-expanding endoprostheses. Preliminary experience.

We present our preliminary experience with the application of covered aortic stents to treat aneurysms and dissections of the thoracic artery, a technique that was developed in 1996. Seven selected patients were treated with World Medical Talent bare spring tip endoprostheses and followed up for a total of 67 months. All prostheses were implanted at the Parma General Hospital Cardiovascular Department. Seven patients, average age 57.8 years, range 44-73 years, were treated; a total of 11 prosthetic segments were implanted. Aortic pathologies included: 2 isthmic atherosclerotic aneurysms, 2 chronic dissections, 1 acute dissection, 1 thoracic aneurysm associated with an aneurysm of the abdominal aorta below the renal arteries. Dilation diameters ranged from 6-9 cm, lengths from 4-12 cm. All patients underwent computerized tomography and angiography before stent implantation. The procedure was carried out in an operating room with the patient under general anesthesia and in controlled hypotension. In 2 cases the common iliac artery, prepared for the extraperitoneal route by application of a No. 10 Dacron introducer sheath, was used as the insertion site; in 4 cases the common femoral artery was used, in the case of the double aneurysm the traditional surgical route was used to correct the abdominal aneurysm, and the thoracic aneurysm was repaired through the abdominal prosthesis. All patients were released in good condition; thrombosis of the aneurysm surrounding the graft was immediate in all cases except one which required the application of a second segment shortly after the initial procedure. There were no major complications; one case of iatrogenic dissection of the femoral artery used as the access site required a prosthetic bypass. No implant-related complications were observed during follow-up. Our initial experience has been favorable and demonstrates that stents can be utilized for aortic pathologies of varying etiologies; we had no mortality or major complications, and hospital stays were short. Long term results must be confirmed before the therapeutic potential of this technique can be fully evaluated.     

Cellular, enzymatic, and genetic factors in the pathogenesis of abdominal aortic aneurysms

Aneurysms of the abdominal aorta occur with atherosclerosis or connective tissue disorders. Changes of three components of aortic media, smooth muscle cells, elastin, and collagen, which could contribute to medial weakening, are discussed. Smooth muscle cells cultured from the aging abdominal aorta (normal, atherosclerotic, or aneurysmal) have limited replicative potential at five to six cell doublings, whereas cells from aneurysmal thoracic aorta undergo more than 20 cell doublings in culture. The elastin content is much reduced in aneurysms and this is associated with an increase in elastase activity of medial homogenates to 17.8 U/ng of deoxyribonucleic acid (DNA) compared with 8.3 and 4.4 U/ng of DNA in atherosclerotic and normal aorta, respectively. An elastinolytic enzyme has been purified from aneurysmal aorta and appears to have different properties from human leukocyte elastase. Ruptured aneurysms are associated with an increased total collagenase activity but the increase could be stimulated by, or result from, an influx of inflammatory cells and does not necessarily have a causal significance. In patients with a family history of aneurysm there appears to be a decreased content of type III collagen in aortic media: 24% +/- 4% compared with 32% +/- 5% in most aneurysms. Familial aneurysms are most common in women, and preliminary results suggest that a polymorphic variant of the type III collagen gene, defined by restriction enzyme digest, may be associated with aneurysmal disease in women. The genetic approach may define causal mechanisms predisposing patients to aneurysmal dilatation.     

Fate of aneurysms of the distal arch and proximal descending thoracic aorta after transaortic endovascular Stent-Grafting

BACKGROUND: The purpose of this study was to evaluate the midterm results of transaortic stent-grafting for distal aortic arch aneurysms or proximal descending aortic aneurysms and the feasibility of this method for thoracic aortic aneurysm repair. METHODS: Twenty-three patients with true distal aortic arch aneurysms or proximal descending thoracic aortic aneurysms were repaired with the stent-graft introduced through the incision on the proximal arch aorta. Follow-up computed tomography was performed every 6 months in 21 surviving patients. The maximum dimension of the excluded aneurysmal space and the maximum aneurysmal diameter were measured and evaluated to determine whether the aneurysmal space decreased or disappeared after this alternative procedure. RESULTS: There was 1 hospital death (4.3%) due to cerebral embolism. Another patient died of pneumonia 1 year after surgery. Twenty-one patients (91%) survived during the follow-up period, but 1 patient (4.3%) suffered from paraplegia. The follow-up period ranged from 12 to 62 months (average, 34.3 +/- 15.2). There were no instances of aneurysmal rupture during the follow-up period. Postoperative serial computed tomography scans showed disappearance or significant shrinkage of the excluded aneurysmal space in 20 of 21 patients (95%), except for the one patient with endoluminal leakage. CONCLUSIONS: Transaortic endovascular stent-grafting was an effective alternative approach to treating distal aortic arch aneurysms or proximal descending aortic aneurysms. The excluded aneurysm disappeared or shrunk after successful placement of the stent-graft.     

The right retroperitoneal approach for abdominal aortic surgery

Retroperitoneal exposure of the abdominal aorta is usually performed through a left flank incision. An alternative approach to the abdominal aorta is described utilizing a right flank incision. Indications for the use of the right retroperitoneal approach during surgery for aortic aneurysms include right renal artery stenosis, right iliac artery aneurysm, need for simultaneous cholecystectomy, multiple or recent intraabdominal procedures, and sigmoid colostomy. A series of 17 patients is presented to illustrate the utility of this approach. There was one operative death in an emergent patient; the cause of death was not related to the method of aortic exposure. The remaining patients recovered quickly. The anatomic advantages and limitations of this exposure are discussed. We believe that retroperitoneal aortic exposure is superior to midline transperitoneal exposure. Aortic exposure utilizing a right retroperitoneal approach is a useful option in the surgical armamentarium.     

Anatomic exposures in thoracoabdominal aortic surgery

Thoracoabdominal aortic aneurysm repair requires exposure of long segments of the aorta. This often results in large, debilitating incisions that can compromise pulmonary physiology significantly and result in severe pain. Preoperative preparation and positioning of the patient as well as careful planning of the incision based on the individual's anatomy are required for successful aortic exposure. Alternative approaches such as varying the skin incision location and performing submuscular dissection can reduce postoperative discomfort. Rib resection and double thoracotomy may be needed to expose enough aorta to allow safe proximal and distal control. Improved understanding of the pathophysiology of postoperative complications may alter the approach to aortic and visceral vessel exposure and reattachment. In addition, endovascular technology continues to advance, allowing for more applications in thoracic aortic disease. A combined open and endovascular approach to thoracic aortic aneurysms may minimize the morbidity and mortality by decreasing the physiologic insult normally incurred by long thoracoabdominal incisions.     

Surgical treatment of pararenal aortic aneurysms in the elderly

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.     

Atrophy of the abdominal wall muscles after extraperitoneal approach to the aorta

OBJECTIVE: We retrospectively assessed computed tomography (CT) scans to determine degree of anterolateral abdominal muscle atrophy in patients who underwent infrarenal aortic repair with 2 kinds of incisions for the extraperitoneal approach. METHODS: CT scans obtained before surgery and final scans obtained 2 to 100 months after surgery were assessed in 12 patients with paramedian incision (PM group) and 27 patients with flank incision (F group) who could be followed up at our hospital. We considered muscle thickness before surgery on the incision side to be 100% thickness (baseline value), and we calculated, by measuring the incision side after surgery, the corrected percent thickness (CPT%), which represents percentage of remaining muscle thickness that has escaped incision-induced atrophy. CT scans obtained at the level of the third (L3) and fifth (L5) lumbar vertebrae and the center of the sacrum (S) were selected for CPT% measurement. RESULTS: Duration from surgery to final CT scan was 2 to 65 months (mean +/- SD, 34.33 +/- 21.38 months) in PM group and 3 to 96 months (27.85 +/- 20.74 months) in F group. In PM group, mean CPT% values of the rectus abdominis muscle were 55.83 +/- 21.65% at L3, 35.50 +/- 10.79% at L5, and 31.92 +/- 11.00% at S; these values were statistically much smaller than baseline (P <.01). Mean CPT% values of the lateral abdominal muscles were not statistically different from baseline. In F group, mean CPT% values of the rectus abdominis muscle were 82.19 +/- 23.15% at L5 and 64.41 +/- 31.34% at S; these values were statistically smaller than baseline (P <.01). Mean CPT% values of the lateral abdominal muscles were 87.59 +/- 22.30% at L3 and 84.59 +/- 26.90% at L5; these values were statistically smaller than baseline (P <.05). CONCLUSIONS: Paramedian incision induced severe rectus abdominis muscle atrophy. Although flank incision induced various degrees of atrophy in both muscles, some patients had no muscle atrophy. These data indicate that further anatomic investigation into the relation between flank incision and abdominal wall innervation may contribute to prevention of muscle atrophy after flank incision.     

Aortic transection and diverting bypass as treatment of repetitive recurrent abdominal aortic false aneurysm rupture in a patient with Behcet's disease

Abdominal aortic false aneurysms in patients with Behcet's disease have been reported frequently and repaired successfully by various procedures; however, anastomotic false aneurysms have often been reported to occur after the operation. In this article, we report a case of four-time repetitive, recurrent suprarenal abdominal aortic false aneurysm ruptures that lasted for 7 years. The location of this aneurysm was not easy to repair not only by open surgical procedures but by endovascular stent because the aortic defect was too close to the visceral arterial branches. The last operation consisted of primary repair of aortic defect, transection of abdominal aorta at the level of supraceliac aorta with end closure, and a thoracic aorta to abdominal aorta bypass with Dacron graft. An 8-year follow-up revealed no more abdominal aortic aneurysm recurrence.