Retroperitoneal Approach to AAA Repair

Report
Retroperitoneal Approach to AAA
Repair
George E. Hajjar MD. FRCSC
Division of Vascular and Endovascular
Surgery
University of Ottawa
Canada
Vascular and Endovascular Surg U of O
Canada
Ottawa Canada
The Nations Capital. Pop 990,000
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
• Advantages:
• Lesser post-op pain, easier respiratory
functions.
• Less third spacing and fluid shift.
• Less hypothermia
• Less bowel oedema, and transient ischemia
• Less post op ileus and need for NG suction
• Better exposure of suprarenal aorta
• The Aorta is a retroperitoneal structure
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair
• Advantages (Contd):
• Avoids going through intra-abdominal adhesions
and scarring
• Prevents development of intra-abdominal
adhesions and scarring
• Decreases the chances of duodenal injury, and
intramural haematoma
• Decreases the incidence of Aorto-duodenal fistula
development
• Possibly decreases length stay.
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
• Not widely used:
• Unfamiliarity with the approach
• Reserved for selective difficult cases
• Fear of incisional complications : muscle eventration
although it does occur it is well tolerated in this
patient population. No incisional hernias or
eviscerations.
• Fear of difficulty exposing associated iliac disease:
Right iliac aneurysm or femoral exposure if needed.
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
• Procedure of choice In
•
•
•
•
•
Hostile abdomen
Juxta-renal or supra-renal aneurysms
Horseshoe Kidney
Redo Aortic Surgery
Inflammatory aneurysms
• Avoided:
• If concurrent right renal repair is needed
• Left sided vena cava, other venous anomalies
• Ruptured aneurysm with large left sided haematoma
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Horseshoe kidney
• Requires Re-implanting renal branches to the isthmus
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Ruptured AAA
• Avoid left sided ruptures. Unless low down and neck is accessible
Vascular and Endovascular Surg U of O
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Redo Aortic Surgery
• Remote ABF. Proximal aortic aneurismal degeneration
Vascular and Endovascular Surg U of O
Canada
Right iliac aneurysms
• Mobilization of the retroperitoneum low down in the left pelvis
• Relaxing the upper incisional retractors
• Ligating and transecting the IMA , allows further aneurysm mobilization .
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Draining Lumbar vein
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair venous anomalies
Vascular and Endovascular Surg U of O
Canada
Suprarenal exposure
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Iliac Exposure
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Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Demographics:
251 consecutive Patients (2004-2012)
M : 195 F: 56
Age: 87-52 Av:71.5 Mean: 71
• Co morbidity:
CAD:
112
COPD: (1 or 2 puffers)
40
Diabetes:
44
Obesity: (BMI>30)
46
Hx of smoking:
230
HTN:
165
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair: our experience
• Aneurysm Characteristics:
• Primary:
246 patients
• Redo : 5 patients
1 pat. 1 yr post REVAR
2 pats. Secondary ADF, in a Type IV AAA post remote
aortic Sx.
1 pat. IAAs post ruptured AAA repair 4 years earlier
1 pat. Had an AAA 10 years post ABF end to side graft
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair: our experience
• Aneurysm Characteristics:
231
15
5
elective
acute /symptomatic
ruptured (3 acute, 2 chronic)
• Other findings:
2 horseshoe kidneys
6 inflammatory
89 IAA. 54 bilat. 15 R. 20 L.
46 patients had previous abdominal surgery.
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair: our experience
• Proximal control:
212 infrarenal
33 Suprarenal
6 Supraceliac, type IV AAA repair.
• Type of Repair:
136 Tube graft
89 AIs. 54 Bilat, 15 R, 20 L
24 ABFs.
2 pericardial patch aortic closures
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Additional procedures:
IMA re-implantation
Renal re-implantation /graft
2 horseshoe kidneys
1 accessory renal
3 left renal grafts.
AxBfem &aortic graft excision
Duodenal closure
5
6
2
2
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair: our experience
• Mortality:
• No intra-op mortality
• 30 day Mortality :
2 patients
1 cardiogenic shock
1 respiratory failure
• In hospital death :
2 patients
1 Ischemic colitis and MSOF
1 progressive renal failure, resp failure
• Total in hospital mortality:4 (1.6%)
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: Length of stay
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: Complications
• Cardiac:
Arrhythmias 12, (1 Pneumo: pacemaker)
CHF10, (1 needed mitral repair)
MI: 8 ( 2 required intervention)
• Renal:
20 transient rise in Creatinine
6 ARF: 2 hemofiltration only, 3 transient dialysis, 1 permanent
• Respiratory:
Exacerbation of COPD:5 ( 1 needed home O2)
1 PE
DVT
• Post-op bleed:
6 total. 4 no source was found. 2 splenectomy
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: Complications
• GI:
Ischemic colitis: 8 transient, 4 C.diff, 2 colectomies
UGI bleeding. 6 gastro duodenal erosions
( 1 required cauterization)
4 post-op ileus.
• Peripheral ischemia: 4 patients:
Ext iliac occlusion (1),
bilat SFA thrombosis post RAAA(1)
popliteal artery occlusion (thrombectomy and fasciotomy)
SFA atheroembolic disease
Acute occlusion of one ABF limb, required urgent revision
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair: Incisional complications
• 13 patients.
• Wound infection:6
2 proven cultures with purulent drainage
4 erythema. No culture Rx with Abx.
• Wound haematoma: 4
• Serosanguinous drainage: 3
• Late incisional complications:
1 Intercostal neuralgia(tip of 11th rib was excised
for higher exposure)
2 excision of Prolene knot
6 specific complaints about asymmetric bulge
needed reassurance
Vascular and Endovascular Surg U of O
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Conclusion
• Retroperitoneal approach for AAA repair is easily
feasible.
• Can be used in a variety of conditions including right iliac
aneurismal disease, aortoiliac disease.
• Approach of choice for hostile abdomens, redo aortic
surgery, inflammatory aneurysm, horseshoe kidney,
suprarenal aneurysms
• Does not provide access to right renal artery if needed
• Avoided in large left retroperitoneal haematomas and
ruptured AAA
Vascular and Endovascular Surg U of O
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Vascular and Endovascular Surg U of O
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