Video Presentation: Open

Paravisceral Aneurysm

Background and Surgical

technique for a infrarenal

aneurysm with retroperitoneal

approach

April 2018, Elizabeth Ramos Duran, MD. Postdoctoral Scholar.

Vascular and Endovascular Surgery. University of Miami.

•

• No disclosures

OBJECTIVE

To give to a new generation of surgeons a tool to remember the Surgical technique of a Retroperitoneal Open Aneurysm Repair.

Background

• An abdominal aorticaneurysm (AAA) is apermanent, localizeddilation with ananteroposterior ortransverse diameter ≥3.0 cm.

Eur J Vasc Endovasc Surg (2011) 41, S1eS58

Background

• AAA most often involves the aortic segment between the renal and inferior mesenteric arteries.

• 5%: renal or visceral arteries.

• 40% of AAAs: associated with iliac artery aneurysm.

Open vs Endovascular Repair

• Dua et al: vascular trainees are expected to do half of the OAR cases that were done in 2010;by 2020, this number will drop to 20%.

• Required 30 cases for graduation and by 2011 there was an average of 21.7. By 2025 there will be 5.

• Next generation will require either a use of high-fidelity simulation systems, the creation of a dedicated open repair vascular fellowship or a combination of these approaches.

Retroperitoneal approach (RP)

• 1963, Rob: 500 patients undergoing aortic surgery for low-risk infrarenal aortic and iliac artery disease in which an anterolateral RP approach was described.

• Validated in 1968 by Stipa and Shaw: 45 patients undergoing RP AAA repair, with no deaths.

• Williams et al in 1980: proposed an extended approach with a posterolateral incision.

• In 2003, Shaw et al: specific modification to the posterolateral approach.

Retroperitoneal approach (RP)

ADVANTAGES:• Access to the abdominal aorta up to the

supraceliac level, without entering the peritoneum.

• Easier access to the juxtarenal or suprarenal aorta for aneurysms.

• Involves fewer dermatomes than a midline incision, therefore reducing postoperative pain.

• Some technical difficulties can be avoided in the case of patients with previous laparotomies or substantial abdominal fat.

Retroperitoneal approach (RP)

DISADVANTAGES:• The technique has a learning curve

and can initially appear less attractive than the TP approach

• Access to the right renal artery and right iliac artery are difficult.

• “Bulge” forming along the surgery scar in 11% to 23% of patients.

Surgical Planning

Position

Incision

Access to retroperitoneal space

Exposure of Aorta

Aortotomy

Ligation of Lumbar Arteries

Renal perfusion

Coselli (Texas) Cold Renal Perfusion Protocol:

• Moderate heparinization1mg/kg

• Intermittent cold renal perfusion:

1. Mannitol 12.5g/L

2. Methylprednisolone 125mg/L

3. Lactate ringer solution

4. Cool to 4C

5. Initial bolus 200-300cc per kidney

6. Intermittent infusion 100-150cc per kidney every 10-15 minutes while renal ischemia.

7. Avoid fluid overload

Proximal anastomosis

Renal anastomosis

Distal anastomosis

Something extra…

Small bowel Perfusion? Chest tube

Closure

Acknowledgements

• The department of Vascular and Endovascular Surgery at the University of Miami:Dr. Jorge Rey, Dr. Omaida Velasquez, Dr. Arash Bornak, Dr. Alberto Lopez and Dr. Stefan Kenel-Pierre.

References

• Ian M. Nordon, Robert J. Hinchliffe, Ian M. Loftus and Matt M. Thompson. Pathophysiology and epidemiology of abdominal aortic aneurysms,Nat. Rev. Cardiol. 8, 92–102 (2011).

• Helena Kuivaniemi, Evan J Ryer, James R Elmore & Gerard Tromp (2015) Understanding the pathogenesis of abdominal aorticaneurysms, Expert Review of Cardiovascular Therapy, 13:9, 975-987.

• F.L. Moll a, J.T. Powell b, G. Fraedrich c, F. Verzini d, S. Haulon e,M. Waltham f, J.A. van Herwaarden a, P.J.E. Holt g, J.W. van Keulen a,h,B. Rantner c, F.J.V. Schlo¨sser h, F. Setacci i, J.-B. Ricco j. Management of Abdominal Aortic Aneurysms ClinicalPractice Guidelines of the European Society for Vascular Surgery, Eur J VascEndovasc Surg (2011) 41, S1eS58.

• The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm, Chaikof, Elliot L. et al., Journal of Vascular Surgery , Volume 67 , Issue 1 , 2 - 77.e2.

• Anahita Dua, MD, MS, SreyRam Kuy, MD, MHS, Cheong J. Lee, MD, Gilbert R. Upchurch Jr, MD,and Sapan S. Desai, MD, PhD, MBA. Epidemiology of aorticaneurysm repair in the United States from 2000 to 2010, J Vasc Surg 2014;59:1512-7.

References

• K. Craig Kent, MD, Robert M. Zwolak, MD, Natalia N. Egorova, PhD, MPH,Thomas S. Riles, MD, Andrew Manganaro, MD, Alan J. Moskowitz, MD,Annetine C. Gelijns, PhD, and Giampaolo Greco, PhD, MPH. Analysis of risk factors for abdominal aorticaneurysm in a cohort of more than 3 million individuals, J Vasc Surg 2010;52:539-48.

• Anahita Dua, MD, MS, MBA, Gilbert R. Upchurch Jr, MD, Jason T. Lee, MD,d John Eidt, MD, and Sapan S. Desai, MD, PhD, MBA. Predicted shortfall in open aneurysmexperience for vascular surgery trainees,J Vasc Surg 2014;60:945-9.

• R.M. Greenhalgh (principal investigator), D.J. Allison, P.R.F. Bell, M.J. Buxton, P.L. Harris, B.R. Hopkinson, J.T. Powell, I.T. Russell, S.G. Thompson. Endovascular versus Open Repair of Abdominal Aortic Aneurysm, N Engl J Med 2010; 362:1863-1871.

• https://www.uptodate.com/contents/overview-of-abdominal-aortic-aneurysm?search=abdominal%20aortic%20aneurysm&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H91213737

• https://www.uptodate.com/contents/surgical-and-endovascular-repair-of-ruptured-abdominal-aortic-aneurysm?search=abdominal%20aortic%20aneurysm&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=10#H108751558

Thank you