Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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STEP 3: OPERATIVE STEPS—AORTORENAL ENDARTERECTOMY

Endarterectomy is used in selected patients with bilateral focal orificial atherosclerotic RAS.

1. INCISION

The aorta is approached through a midline or transverse incision.

2. DISSECTION

The aorta is mobilized from the level of the celiac artery to the inferior mesentery artery. This requires division of the diaphragmatic crural fibers, and the dense neural tissue that surrounds the origins of the celiac and superior mesenteric and renal arteries.

This dissection should isolate a sufficient segment of aorta to allow safe placement of the proximal clamp above the renal or superior mesenteric arteries, if these vessels are so close that a clamp cannot be safely placed between them. The lumbar arteries are occluded with removable clips and clamps applied in sequence to the renal arteries, the superior mesenteric artery, and the infrarenal and suprarenal aorta.

A longitudinal arteriotomy is made extending from the left side of the superior mesentery orifice to below the renal arteries (Figure 88-4, A). The technique involves removal of the aortic intima in this section of the aorta. Once the aortic intima has been dissected proximally, each individual renal artery is approached. The aortic intima is grasped and gentle traction is applied, pulling to the opposite side. The renal ostial lesion is then dissected from the media by prolapsing the renal artery into the aorta (Figure 88-4, B).

Gentle advancement of the renal artery toward its orifice by the assistant facilitates feathering of the end point. The process is repeated on the contralateral side.

The distal intima of the aorta is divided and secured with interrupted 6-0 polypropylene tacking sutures (Figure 88-4, C). The arteries are flushed of atheromatous debris and air, and the arteriotomy is closed with running 4-0 polypropylene suture (Figure 88-4, D). The adequacy of the renal endarterectomy is evaluated by intraoperative duplex ultrasound. If any residual plaque is detected, a transverse arteriotomy is made in the affected renal artery, the plaque is extracted, and the distal end point is secured with tacking sutures. The arteriotomy is closed with interrupted 7-0 polypropylene sutures.

Left

renal artery

Abdominal aorta

Aortorenal plaque

A B

Left

renal artery

Completed Abdominal aorta; arteriotomy closure

Secured distal end point

Inferior vena cava

C D

FIGURE 88–4

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3. CLOSING

The closure of the abdomen is similar for both aortorenal bypass and renal endarterectomy. The retroperitoneum is closed with 2-0 Vicryl, and the incision is closed with running looped monofilament 1-0 PDS or polypropylene suture.

STEP 3: OPERATIVE STEPS—SPLENORENAL BYPASS

Both aortorenal bypass and renal endarterectomy may be contraindicated in elderly patients with severe aortoiliac occlusive or aneurysmal disease and multiple comorbidities. The presence of a dense fibrotic reaction from previous operations or renal angioplasty makes dissection difficult and increases the operative risk. The addition of an aortic bypass to renal revascularization, which may be indicated in younger patients, is associated with increased morbidity and mortality in older individuals. In these patients, alternative bypass procedures, such as splenorenal bypass for high-grade left RAS and hepatorenal bypass for disease on the right, should be considered. The more ischemic kidney is repaired first unless it is atretic.

Careful angiographic assessment of the hepatic and splenic arteries with anterior posterior and lateral views is imperative before undertaking these alternative renal revascularization procedures, because extensive plaque may be present in the donor vessels, which may not be detected on standard anterior posterior angiographic views.

For both splenorenal and hepatorenal bypass, the patient is positioned supine on the operating table with a sandbag elevating the affected side and prepped from nipple to knee.

1. INCISION

The abdomen is entered via a left subcostal incision that can be extended medially and laterally if necessary. The splenocolic ligament, spleen, and pancreas are reflected medially, and a self-retaining retractor is placed (Figure 88-5, A-B).

Divided splenic artery

Dividing left renal artery

Retracting left renal vein caudally

E

Splenic artery

Distal left renal artery

Completed splenorenal anastomosis

F

G

FIGURE 88–5, cont’d

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STEP 3: OPERATIVE STEPS—HEPATORENAL BYPASS

In patients with severe aortic atherosclerosis or aneurysmal degenerative disease and normal liver function with a high-grade right RAS, hepatorenal bypass should be considered.

1. INCISION

The abdomen is entered via a right subcostal incision (Figure 88-6, A).

Right subcostal incision

MC

A

FIGURE 88–6