Total laparoscopic juxtarenal abdominal aortic aneurysm repair

OBJECTIVES: This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair. METHODS: Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients. RESULTS: We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies. CONCLUSION: Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.     

Totally laparoscopic abdominal aortic aneurysm repair

On the basis of our previous animal and clinical experience with laparoscopic intra-abdominal vascular reconstructions, and due to the prevalence of abdominal aortic aneurysms (AAA), we have recently broadened our scope to tackle more difficult aortic surgery laparoscopically. We present a case report of our first clinical experience with laparoscopic AAA repair using specialized laparoscopic vascular instrumentation. The patient was an 84-year-old hypertensive male with a 7-cm asymptomatic infrarenal abdominal aortic aneurysm that was discovered incidentally. He presented with postcoronary artery bypass grafting and had moderate chronic obstructive pulmonary disease (COPD). A spiral computed tomograph (CT) angiogram revealed an adequate infrarenal neck and aneurysmal involvement of the proximal iliac arteries. An eight-port transabdominal technique was used with the patient in the supine position. Proximal and distal control was achieved without difficulty. The aneurysm was excluded using endoscopic stapling devices, and an aortobiiliac reconstruction was performed with a 16 × 9-mm bifurcated dacron graft. Estimated blood loss was 1000 ml, and the operative time was approximately 7 hours. The patient was ambulating without assistance on postoperative day 3. Total hospitalization was 7 days (delayed secondarily to postoperative ileus). Minimal quantities of narcotics were required for analgesia. At 6-months follow-up, the patient has palpable peripheral pulses and no complications related to surgery. This case report shows that a completely laparoscopic approach to the abdominal aortic aneurysm is possible using instrumentation specifically designed for laparoscopic vascular surgery. The exact role that laparoscopic techniques will hold in vascular surgery remains to be determined because these procedures are time consuming and technically difficult. Received: 2 December 1997/Accepted: 4 March 1998     

Totally laparoscopic abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) resection is a major surgical procedure performed frequently. As a minimal access procedure, laparoscopy has been shown in the field of general surgery to improve a patient's postoperative well-being and to shorten hospital stay. The same benefits could be expected from a laparoscopic approach for AAA repair. We report what we believe to be the first totally laparoscopic AAA repair performed according to the principles of endoaneurysmorrhaphy.     

Durability of benefits of endovascular versus conventional abdominal aortic aneurysm repair

PURPOSE: Endovascular abdominal aortic aneurysm (AAA) repair is reported to result in less initial patient morbidity and a shorter hospital length of stay (LOS) when compared with conventional AAA repair. We sought to examine the durability of this result during the intermediate follow-up interval. METHODS: The records of all admissions for all patients who underwent AAA repair during a 26-month interval were reviewed. RESULTS: Three hundred thirty-seven (337) patients underwent procedures to repair AAAs (163 open and 174 endovascular). Endovascular procedures were performed with a variety of devices (Talent, 108; Ancure, 36; AneuRx, 26; Zenith, 2; and Cordis, 2) and configurations (141 bifurcated and 33 aortomonoiliac). The mean follow-up period was 10.6 months (endovascular repair) and 12.3 months (open repair). LOS did not significantly vary by device (P =.24 to P =.92) or configuration (P =.24). The initial median LOS for procedures was significantly shorter (P =.009) for endovascular repairs (5 days) than for open procedures (8 days). However, the patients who underwent endovascular repair were more likely to be readmitted during the follow-up interval when compared with patients who underwent open procedure. The readmission-free survival rate after AAA repair at 12 months was 95% for patients for open AAA repair versus 71% for patients for endovascular repair (P <.001). If the total hospital days were compared, including the initial and all subsequent AAA-related admissions, there was no significant difference for mean LOS for patients who underwent endovascular versus open AAA procedures (11 days versus 13.6 days; P =.21). The patients for endovascular AAA repair most commonly needed readmission for treatment of endoleak (n = 31), wound infection (n = 12), and graft limb thrombosis (n = 9). Although women had similar LOS to men for endovascular repair (P =.44), they had longer initial LOS for open AAA repair (15 versus 10 days; P =.03). After endovascular repair, women were more likely than men to be readmitted by 12 months (51% versus 71% readmission-free survival rate; P =.03) and they had longer LOS on readmission (13.2 versus 5.2 days; P =.006). No gender differences were identified for patients after open AAA repair regarding readmission-free survival rate (P =.09) or LOS on readmission (P =.98). CONCLUSION: Although initial LOS was shorter for the patients who underwent endovascular as compared with conventional AAA repair, this advantage was lost during the follow-up interval because of frequent readmission for the treatment of procedure-related complications, chiefly endoleak. These readmissions frequently involved the performance of additional invasive procedures. Gender differences existed regarding LOS and the likelihood of complications after open and endovascular AAA repair.     

Total laparoscopic abdominal aortic aneurysms repair

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.     

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.     

Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.     

完全穿刺技术在腹主动脉瘤腔内修复术中的应用

目的 探讨应用Perclose ProGlide缝合器完全穿刺技术行腹主动脉瘤腔内修复术的安全性和有效性.方法 2008年5月至2010年4月,36例腹主动脉瘤患者完全穿刺下行腔内修复术治疗.其中男性30例,女性6例;平均年龄68岁.所应用的支架型血管包括:3例Endurant,13例Talent,20例Zenith.18～24 F的鞘管预置两把ProGlide,14～16 F的鞘管预置单把ProGlide.缝合动脉切口时取出鞘管并将线结下滑收紧.统计技术成功率、相关并发症及手术操作时间.术后3、6、9、12个月及其后每年进行CT血管造影随访.结果 20例局部麻醉,16例全身麻醉.68条股动脉共应用128把ProGlide,其中38条股动脉各应用2把,8条各应用3把,2条各应用4把,20条各应用1把.63条股动脉(63/68,92.6%)技术操作成功,2条中转切开缝合,3条出现血肿,无需手术处理.平均随访时间(12±3)个月.1例于术后3个月出现无症状的动脉夹层.结论 完全穿刺技术在腹主动脉瘤腔内修复术中的应用是安全和有效的.由于可能需要切开缝合,建议在杂交手术室中操作.     

Total laparoscopic infrarenal aortic aneurysm repair: preliminary results

OBJECTIVES: We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. MATERIAL AND METHODS: Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. CONCLUSION: These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.     

Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery

We performed a total laparoscopic reimplantation of the inferior mesenteric artery (IMA) during laparoscopic infrarenal aortic aneurysm repair. The postoperative course was uneventful, and angiograms showed a patent IMA after reimplantation. To our knowledge, total laparoscopic reimplantation of the IMA in human beings has not previously been described.     

Endoleaks following conventional open abdominal aortic aneurysm repair.

OBJECTIVE: to describe the complication of following conventional open abdominal aortic aneurysm (AAA) repair. DESIGN: prospective case study. SETTING: two specialist vascular surgical centres. PATIENTS AND METHODS: six patients who had successful conventional open AAA repair. RESULTS: six patients presented with back or abdominal pain or hypotension between one and eighteen months later. An endoleak at the distal anastomosis was noted in five of the cases and one endoleak at the proximal anastomosis. All six cases were successfully repaired; two of these patients required Dacron graft replacement, whilst in four cases only direct resuturing was needed. There was no evidence of infection. CONCLUSIONS: an endoleak is not a phenomenon confined to stent grafts. It should be considered in all patients who present with back or abdominal pain within eighteen months of open AAA repair. The combination of computed tomography (CT) scan and digital subtraction angiography is most useful for preoperative diagnosis.     

Endovascular versus "fast-track'' abdominal aortic aneurysm repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 +/-7.4 vs 158 +/-6.8 minutes, p<0.0001), with a greater volume of blood (1.8 +/-0.29 vs 0.32 +/-0.24 units, p=0.0005), colloid (565 +/-89 vs 32 +/-22 cc, p<0.0001), and crystalloid transfusions (4,625 +/-252 vs 2,627 +/-170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 +/-0.08 vs 1.8 +/-0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 +/-0.10 vs 0.87 +/-0.10 days, p=0.01), but floor (2.1 +/-0.23 vs 2.6 +/-0.21 days, p=0.17), and total hospital lengths of stay (2.8 +/-0.32 vs 3.4 +/-0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track (10,205 dollars +/-736 dollars vs 20,640 dollars +/- 1,206 dollars, p<0.0001) leading to greater overall hospital earnings (6,141 dollars +/- 1,280 dollars vs 107 dollars +/- 1,940 dollars, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.     

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

ObjectiveThe aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA).MethodsAll patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared.ResultsThe median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23).ConclusionsESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.     

Inflammatory abdominal aortic aneurysm: predictors of long-term outcome in a case-control study

BACKGROUND: Inflammatory abdominal aortic aneurysms (AAAs) are relatively rare clinical entities. The aim of this study is to ascertain the risk factors in patients with inflammatory AAAs and clarify which feature plays a role in determining the long-term outcome in these patients. METHODS: Between 1990 and 1997, 238 patients underwent surgery for an AAA at our institution, 17 (7.1%) of whom had the diagnosis of inflammatory type AAA. This group was matched in a case-control fashion to a group of 35 patients with similar characteristics of age, gender, and preoperative risk factors who were operated on for a noninflammatory AAA. All available clinical, pathologic, and postoperative variables were retrospectively reviewed, and the 2 groups were compared. In the inflammatory group, risk factor analysis was performed for poor outcome. RESULTS: All operations were performed through a standard transperitoneal median laparotomy. The 2 groups did not differ significantly in terms of clinical characteristics and preoperative risk factors Patients with inflammatory AAAs were significantly more symptomatic (100% vs 31%, P = .03) and had larger aneurysm size on admission (8.2 +/- 1.2 cm vs 6.1 +/- 0.4 cm, P = .04). In inflammatory AAAs, preoperative erythrocyte sedimentation rate was found to be significantly elevated (mean, 48 +/- 14 mm/h vs 8 +/- 3 mm/h, P = .01). Surgical morbidity and mortality rates did not differ between 2 groups. The intensive care unit and hospital stay periods were similar in both groups (2.2 days vs 1.8 days, P = .25, and 9.2 days vs 8.1 days, P = .35). Eight-year survival rates of inflammatory and noninflammatory groups were 60% and 74%, respectively (P = .01). Results from Cox proportional hazards model analysis showed that a high sedimentation rate after surgical intervention (P = .02), cardiovascular disease (P = .01), postoperative persisting fibrosis with ureteral entrapment (P = .01), and postoperative chronic renal failure (P = .02) were independent risk factors for death. Other surgical variables did not prove to be risk factors for long-term mortality. CONCLUSIONS: Although the preoperative characteristics may differ in patients with inflammatory type AAAs, they can be treated today with low morbidity and mortality rates. However, inflammatory process may continue postoperatively because of unknown reasons, and the study documented that persisting, postoperative inflammatory process with or without retroperitoneal fibrosis may place a patient at high risk for poor outcome. This is important information for the long-term management of these patients, and we believe that their follow-up protocols should be more comprehensive to further improve their long-term survival rates.     

Laparoscopic-assisted abdominal aortic aneurysm repair

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. There have been case reports of laparoscopic-assisted aortobifemoral bypass for occlusive disease. Because aneurysmal disease comprises the majority of aortic surgery, we pursued animal and cadaveric feasibility studies for laparoscopic-assisted abdominal aortic aneurysm (AAA) repair. We present a case report of the first clinical case performed under Institutional Review Board protocol using this technique. The patient was a 62-year-old male with a 6-cm infrarenal AAA. After obtaining a pneumoperitoneum, a modified fish retractor was used to exclude the bowel. Ten 11-mm ports provided access to laparoscopically dissect the neck of the aneurysm and the iliac vessels. Then, a 10-cm minilaparotomy was performed and standard vascular clamps were inserted via the port incisions. Standard aneurysmorraphy was performed with a polytetrafluoroethylene (PTFE) tube graft. Laparoscopy conferred three major benefits: better visualization of the aneurysm neck, less bowel manipulation, and avoidance of hypothermia. This case report illustrates the feasibility of laparoscopic-assisted aneurysm repair. Controlled human studies will define the role of laparoscopy in AAA surgery.     

Complex abdominal aortic aneurysm repair

ascular surgery is a challenging discipline and complex aneurysms can present an entire range of technical difficulties. To overcome these problems good technical skills are mandatory. However, it is also worth remembering a few basic rules: The simplest solution is often the best. All cases need careful planning, including that of the approach. A successful anastomosis requires good aortic tissue. Minimal dissection reduces morbidity.