Laparoscopic-assisted abdominal aortic aneurysmectomy

PURPOSE: The technical elements and early results of laparoscopic-assisted abdominal aortic aneurysmectomy are described. METHODS: From February 1997 to May 1999, 60 patients underwent elective laparoscopic surgery for infrarenal abdominal aortic aneurysm. Patients ranged in age from 53 to 87 years (mean age, 70.6 years). The mean aneurysm size was 5.7 cm (range, 4.4-8.0 cm). All patients underwent aortography and computed tomography scanning preoperatively. Patients were not deemed candidates for the procedure when visceral arterial abnormalities requiring surgical treatment were present or an aortic aneurysm neck shorter than 0.5 cm was found. A risk-stratification system was used as a means of quantitating risk factors and excluding high-risk patients. Aortic reconstruction was performed with retroperitoneal laparoscopy, with the patient in a modified right lateral decubitus position. An Endo TA 30 and an Endo TA 60 laparoscopic staplers (US Surgical, Norwalk, Conn) were used in occluding the common iliac arteries and aneurysm sac. Laparoscopic hemoclips were used as a means of occluding the lumbar arteries and other branches of the aneurysm sac. An aortobifemoral or aortobi-iliac bypass grafting procedure was performed by means of the laparoscope to position the graft and visualize the end-to-end aorta-to-graft anastomosis, with distal anastomoses performed through counter incisions. RESULTS: Three patients died within 30 days of surgery (mortality rate, 5.0%). Complications included left ureteral injury (1), postoperative myocardial infarction (1), ileofemoral deep venous thrombosis (1), acute renal failure (2), colon ischemia (1), and infected graft limb requiring revision (1). The mean operative time was 7.7 hours, and the mean aortic cross-clamping time was 112 minutes. Compared with a contemporary consecutive series of 100 patients undergoing open transabdominal or retroperitoneal aneurysmectomy performed by the same group of surgeons, the laparoscopic patients had decreased length of stays in the intensive care unit and the hospital, with less need for ventilator support, earlier resumption of a regular diet, and an earlier return to normal activity. At the follow-up examinations, all bypass grafts were patent. CONCLUSION: Laparoscopic-assisted aneurysmectomy is safe and effective and can be performed with good results. The longer operation time required is well tolerated in patients who are at good and moderate risk. Prior training in laparoscopic aortic surgery is necessary for surgeons to obtain the required level of expertise needed to perform these procedures. With these caveats, the results of our study suggest that laparoscopic-assisted aortic aneurysmectomy is appropriate for moderate-to-good risk (American Society of Anesthesiologists class of III or lower) operative candidates meeting standard criteria for aneurysm resection in whom preoperative computed tomography scan and biplane arteriography demonstrate a proximal aneurysm neck of 0.5 cm or larger and no need for visceral or internal iliac artery reconstruction. A randomized trial would be required to confirm the benefits of this procedure over open aneurysmectomy.     

Combined abdominal aortic aneurysmectomy and other abdominal operations.

BACKGROUND AND AIM: Co-existence of intra-abdominal non-vascular disease with an abdominal aortic aneurysm (AAA) poses a difficult surgical challenge. MATERIAL AND METHODS: Review of hospital records of 602 patients undergoing elective surgery for AAA during a 9-year period identified 61 (10.3%) patients with a co-existent intra-abdominal non-vascular disease requiring surgery. RESULTS: The concomitant operations were 26 cholecystectomies, 11 inguinal hernia repairs, 2 small bowel resections, 5 left and 5 right hemicolectomies and 1 low anterior resection for colorectal carcinoma, 1 gastrectomy for gastric carcinoma, 5 nephrectomies, one salvage cystectomy for renal carcinoma and 1 left liver lobectomy for hepatrocellular carcinoma. Additional procedures for benign diseases prolonged the operative time by a mean of 35 (range 20-105) minutes and the major operations for malignancy by 120 (range 60-225) minutes. The overall hospital mortality and morbidity rates in the whole series of AAA (n = 602) remained as low as 0.66% and 13.6% respectively. There was no mortality and only two complications occurred in patients undergoing the combined procedure (n = 61). During a follow up period of 4-70 months, no graft infections were detected. CONCLUSION: In selected patients, the one stage approach is safe and effective. Attention should be given to the technical details and the rules of antisepsis. In elderly patients with AAA, a co-existent malignancy should be actively excluded.     

Successful simultaneous renal transplantation and abdominal aortic aneurysmectomy.

At the time of related donor renal transplantation, a 49-year-old man with chronic glomerulinephritis was found to have a large fusiform aneurysm involving the internal and external iliac arteries, the abdominal aorta, and both common iliac arteries. Transplantation and abdominal aneurysmectomy using a standard Dacron bifurcation graft were successfully carried out. This patient has had no associated complications and is currently five years after transplantation and aneurysmectomy, with excellent renal function. It is believed that transplantation may now be offered to an older age group of patients with end-stage renal disease in whom atherosclerosis wll have developed as a natural process of aging.     

Determinants of cardiovascular stability during abdominal aortic aneurysmectomy (AAA)

Patients undergoing abdominal aortic aneurysmectomy (AAA) develop depressed cardiac function during aortic clamping. The importance of volume status and thromboxane (Tx) mediated declines in cardiac contractility in determining this event was studied. In a blinded fashion, patients received the cyclo-oxygenase inhibitor ibuprofen 12 mg/kg by mouth (n = 11) or a placebo (n = 15), 1.5 hours prior to surgery. In the placebo group levels of 6-keto-PGF1 alpha, the hydrolysis product of prostacyclin (PGI2) rose from 20 +/- 10 to 1170 +/- 80 pg/ml (p less than 0.05) soon after incision. Concentrations of TxB2, the stable hydrolysis product of TxA2, were unchanged until 30 minutes after the aorta was clamped when arterial TxB2 concentrations rose from 90 +/- 20 to 230 +/- 30 pg/ml (mean +/- SEM) (p less than 0.05). A pulmonary source for PGI2 and TxA2 was indicated by the observation that arterial 6-keto-PGF1 alpha and TxB2 levels exceeded those in pulmonary arterial blood by 180 +/- 50 and 110 +/- 30 pg/ml, respectively (p less than 0.05). Levels of TxB2 in circulating platelets remained unchanged from baseline in the placebo group. During aortic clamping, cardiac index (CI) fell 0.7 +/- 0.2 1/min X m2 (p less than 0.05) in placebo treated patients, and there was a 6% decline in plasma contractility as bioassayed with a rat papillary muscle (p less than 0.05). Placebo patients entered surgery with a PAWP greater than or equal to 10 mmHg (mean 13 mm). Ibuprofen suppressed production of TxB2, such that 30 minutes after aortic clamping TxB2 was 70 +/- 30 pg/ml, a value lower than control patients (p less than 0.05). Further, plasma no longer depressed contractility of the papillary muscle. Five patients given ibuprofen had an initial pulmonary arterial wedge pressure (PAWP) of 10 mmHg or greater (mean 12 mmHg). During aortic clamping there was an insignificant decrease in CI of 0.2 +/- 0.1 1/min X m2. This was in contrast to the CI decrease in six other ibuprofen treated patients of 0.9 +/- 0.2 1/min X m2 whose PAWP at the start of surgery was less than 10 mmHg (mean 6 mmHg) (p less than 0.05), and to placebo patients whose initial PAWP was greater than or equal to 10 (p less than 0.05). Platelet counts fell from 185,000 to 121,000/mm3 in placebo patients (p less than 0.05), but did not fall when ibuprofen was given. Creatinine concentrations were unaffected by ibuprofen. Blood replacement in placebo and ibuprofen patients was similar, 1.90 +/- 0.20 and 0.65 +/- 0.15 1, respectively. Results indicate that CI will not decrease during AAA if sufficient volume is given before surgery to increase PAWP above 10 mmHg, and secondly, if TxB2 synthesis is inhibited.     

Effects of ulinastatin on pulmonary artery pressure during abdominal aortic aneurysmectomy

STUDY OBJECTIVE: Abdominal aortic aneurysmectomy (AAAectomy) results in a general ischemia-reperfusion syndrome accompanied by an acute rise in pulmonary artery pressure (PAP). We examined whether ulinastatin, a urinary trypsin inhibitor, prevents ischemia-reperfusion injury and increase in PAP after aortic unclamping (XU) during AAAectomy. DESIGN: Prospective study. SETTING: Public, university-affiliated hospital. PATIENTS: Sixteen patients (11 males and 5 females) scheduled for AAAectomy. INTERVENTIONS AND MEASUREMENTS: The patients received 300000 IU of ulinastatin intravenously before XU (n = 8) or no additional treatment (n = 8) (control). Heart rate, central venous pressure, PAP, pulmonary arterial wedge pressure, arterial pressure, mixed venous oxygen saturation (Sv(O2)), and cardiac output were monitored. Arterial and mixed venous blood samples were analyzed for pH, Pa(CO2), Pa(O2), hemoglobin, and oxygen saturation, and the physiological shunt function (Qs/Qt) were calculated. Plasma concentrations of malondialdehyde, myeloperoxidase, granulocyte elastase, alpha1-antitrypsine, and thromboxane B2 and the stable hydrolysis products of thromboxane A2 were measured. Measurements were conducted before aortic crossclamping (XC) (baseline) and at 10, 30, and 60 minutes after XU. MAIN RESULTS: A significant increase in PAP was observed 10 minutes after XU in the control group but not in the ulinastatin group. At 60 minutes after XU, Qs/Qt values had increased in the control group but had decreased in the ulinastatin group. There were no significant changes in malondialdehyde, thromboxane B2, granulocyte elastase, and alpha1-antitrypsine levels after XU in either group. A significant decrease in the plasma level of myeloperoxidase after XU was found in both groups. CONCLUSIONS: The present study demonstrated that ulinastatin prevents increase in PAP and shunting after XU during AAAectomy.     

Chronic lymphocytic leukemia complicating abdominal aortic aneurysmectomy

Patients with abdominal aortic aneurysms may present with a variety of special clinical problems. An unusual case of coexistent aortic aneurysm, atherosclerotic occlusive disease, and chronic lymphocytic leukemia in a 77-year-old man is presented.     

Thoracoabdominal aneurysm resection after previous infrarenal abdominal aortic aneurysmectomy.

Thoracoabdominal aneurysms in 51 patients were repaired over 5 years ending in February 1991. Fourteen (27%, 14 of 51) patients had a prior infrarenal aneurysm resection (PRA); their data are analyzed separately. The average age of patients who had undergone PRA was 67 years (range: 56 to 86 years). The mean aneurysm diameter was 8.6 cm (range: 5 to 12 cm), and the mean time interval between initial aneurysm surgery and subsequent resection of the thoracoabdominal aneurysm was 8.5 years (range: 2 to 17 years). Three patients in the PRA group were operated on emergently, two because of clinical evidence of rupture; the other patients underwent elective repair. Early mortality (30 days) in the PRA group was significantly related to age (72 years or older versus younger than 72 years: 75% versus 10%, p = 0.04), proximal extent of aneurysm (above diaphragm versus below diaphragm: 50% versus 0%, p = 0.05), ruptured aneurysm (ruptured versus nonruptured: 100% versus 16%, p = 0.06), and a cardiac history of myocardial infarction (57% versus 0%, p = 0.03), congestive heart failure (66% versus 0%, p = 0.01), or arrhythmia (80% versus 0%, p = 0.005). Similar results were seen with the entire group of patients with thoracoabdominal aneurysms except that the proximal extent of the aneurysm was not related to mortality. These results demonstrate that thoracoabdominal aneurysm resection after prior infrarenal aneurysmectomy is not associated with increased mortality or morbidity.     

Maintenance of cardiodynamics with aspirin during abdominal aortic aneurysmectomy (AAA).

The importance of prostacyclin (PGI2) and thromboxane (Tx) medication of depressed cardiac performance during abdominal aortic aneurysm operative surgery was studied by contrasting the effects of 650 mg aspirin administered 12 hours before operation to that of a placebo. In 11 patients who received a placebo, the stable metabolite of PGI2, 6-keto-PGF1 alpha rose from 0.050 +/- 0.032 eta grams/ml to 0.419 +/- 0.257 eta grams/ml (p less than 0.01) 30 minutes after the skin incision. The stable metabolite of TxA2, TxB2 did not increase until the aorta was clamped when TxB2 rose from 0.089 +/- 0.054 eta grams/ml to 0.193 +/- 0.138 eta grams/ml (p less than 0.05); this was prior to blood transfusion. During aortic clamping cardiac output decreased 27% (p less than 0.001). In vitro testing of patient plasma showed: 1) depressed developed tension (Tpd) of a rat papillary muscle by 16% (p less than 0.05); 3) reduction of Ca++-ATPase and Mg++-ATPase activity in a rat myocardial subfraction of sarcoplasmic reticulum (p less than 0.05); 3) reduction of Ca++-ATPase in a rat myocardial subfraction of myofibrils (p less than 0.01). Aspirin administered to 11 patients produced no measurable changes in blood loss or fluid requirements. Aspirin lowered preoperative 6-keto-PGF1 alpha and TxB2 levels (p less than 0.01) and prevented an increase of either agent during operation. The low Tx levels were associated with a stable cardiac output during aortic clamping. Further, plasma obtained from aspirin-treated patients did not depress papillary muscle contractility nor decrease ATPase activity of either myocardial subfraction. The observation that TxB2 when added to a papillary muscle or myocardial subfractions, did not decrease Tpd or ATPase suggests that TxB2 plays an indirect role in altering cardiac muscle activity. The results indicate that Txs modulate cardiac depression, which can be prevented with 650 mg aspirin before operation.     

Juxtarenal abdominal aneurysmectomy.

The term juxtarenal abdominal aneurysm is used to describe an aneurysm whose neck is level or adjacent to the origin of one or both renal arteries. Misinterpretation of these appearances could result in the operation being abandoned with the erroneous diagnosis of suprarenal aneurysm. We report 38 patients with a median age of 66 who underwent juxtarenal aneurysm repair, 18 of whom had been diagnosed as having an abdominal aneurysm extending above the renal arteries. Computed tomography, duplex scanning and selective aortography in 7 cases, failed to reveal the true nature of the aneurysm owing to the upper part of the sac lying over the origin of the renal arteries, resulting in aortic tortuosity at this point. The true extent of the aneurysm was best demonstrated by aortography performed in the lateral position. The operations were undertaken through a long midline incision. The aorta is cross-clamped at the supra-renal level and the proximal anastomosis is performed from inside the aneurysm at the level of the renal arteries. The occluding clamp is subsequently re-positioned over the graft ensuring restoration of renal flow and the distal anastomosis is completed in a routine manner. Associated renal artery disease in three hypertensive patients was simultaneously reconstructed. Unfavourable anatomical conditions led to re-implantation of the renal artery in one case and transection with interposition of a vein graft in another. 95% of the patients survived to leave hospital.     

Independence of renin production and hypertension in abdominal aortic aneurysmectomy

Seventeen patients undergoing elective repair of abdominal aortic aneurysm were examined to determine the causal mechanism for postoperative hypertension. In nine patients who had elevated systemic pressure after surgery, there were no correlations between mean arterial pressure and values of peripheral renin activity or angiotensin II. Further, no relation was demonstrated between systemic pressure and the volumes of crystalloid, colloid infused or milliequivalents of sodium administered preand intraoperatively. Postoperative arterial pressure correlated best with the preoperative value.     

Surgical approach to combined coronary revascularization and abdominal aortic aneurysmectomy

Combined repair of peripheral vascular disease and myocardial revascularization has become accepted treatment in selected patients. Two of our patients underwent such a procedure. One patient suffered an intraoperative dissection of the ascending aorta following myocardial revascularization. Ascending aortic replacement and vein graft reimplantation was accomplished as well as repair of the abdominal aortic aneurysm. Because of this experience we recommend that following myocardial revascularization, aortic cannulation be maintained during repair of the abdominal aortic aneurysm. This allows immediate access to cardiopulmonary bypass should untoward cardiovascular events occur during aneurysm repair.     

Chylous ascites following abdominal aortic aneurysmectomy. Management with total parenteral hyperalimentation.

Chylous ascites may follow operative injury to retroperitoneal lymphatics. When possible, early reoperation has been advised. This report describes a patient with chylous ascites following emergency abdominal aortic aneurysmectomy. Because the patient was not a candidate for reoperation, total parenteral hyperalimentation was employed in management. This approach resulted in a successful outcome.     

Combining abdominal aortic aneurysmectomy with gastrointestinal or biliary surgery

A retrospective study was undertaken to compare the morbidity and mortality of patients who had simultaneous abdominal aortic aneurysm (AAA) resection and gastrointestinal (GI) or biliary surgery with patients who had AAA resection alone. This series consisted of 89 patients who underwent surgery over a 6-year period (January, 1980 through December, 1985) at St. Elizabeth Hospital Medical Center. The patients were separated into three groups: group 1 had elective AAA resection; group 2 had AAA resection and a GI or biliary procedure simultaneously; and group 3 had resection of a ruptured AAA. The patients in groups 1 and 2 were similar with respect to sex, age, surgeons, estimated blood loss, operative time, preoperative risk factors and hospital stay. The patients in group 3 had shorter preoperative and longer postoperative hospital stays, were older, and had greater preoperative risk. The morbidity and mortality of the patients in group 2 were consistently the same or less than that of patients in group 1, even when individual surgeons and preoperative risk factors were compared. The patients in group 3 had a significantly higher morbidity and mortality. This article reviews the literature on management of patients with simultaneous AAA and other intraabdominal pathology and presents a suggested approach to treatment.     

Routine aortography before abdominal aortic aneurysmectomy: A prospective study

Routine preoperative arteriography was studied prospectively in 104 patients with abdominal aortic aneurysms. The patients were from the private practice of 11 vascular surgeons. Information regarding patient clinical status was gathered and compared with aortographic and intraoperative findings. Special attention was focused on the question of operation modification as dictated by aortographic findings. The surgeons were further asked whether the information gained from surgical exploration was equal to that obtained from arteriography. It is concluded that because of low yield of benefit, economic considerations, time delay, and minor but distinct risks of the procedure, arteriography should be used selectively rather than routinely in such patients.