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Procedure
5
Procedure
The patient was taken to the operating room and
was placed in the lateral retroperitoneal position
with the left side up. Arterial line, Swan-Ganz
catheter, and Foley catheter were placed. A spinal
drain was placed.
A retroperitoneal incision was made from the
previous paramedian incision below the umbilicus laterally over the tenth rib onto the chest. The
chest was opened. The diaphragm was opened in
a circumferential fashion approximately 2cm lateral to its insertion on the chest wall. The retroperitoneal dissection was continued medially
toward the aorta. The kidney and ureter were
elevated on the medial portion of the incision,
and dissection was carried posterior to that down
to the aorta.
The subdiaphragmatic aorta was identied.
The inferior pulmonary ligament was dissected
free to allow exposure of this segment of the
aorta. Proximal control was obtained by dissection posterior and anterior to the aorta above the
diaphragm.
Next, the large pulsatile mass beneath the kidney was dissected free. The aortic hiatus was dissected free, and the crus of the diaphragm was
dissected. The dissection was carried down, and
the origin of the celiac artery was identied.
Next, the left renal artery was identied and
was dissected back to its origin off the aorta. The
kidney was dissected off this large pseudoaneurysm. The entire lateral aspect of the aneurysm
was exposed.
The spinal uid was drained (approximately
50cc’s), and papaverine was placed into the spinal canal. Next, the supradiaphragmatic aortic
clamp was placed. After the aorta was crossclamped, the false aneurysm was opened up
using electrocautery and scissors. Upon opening
the large anastomotic aneurysm in the lower portion of the aneurysm, the old woven graft was
identied. There was a broken suture sitting
inside the aneurysm. The aortic graft had completely become unincorporated with the aorta,
and the large aneurysm was surrounding the free
end of the graft inside the lumen.
The right renal, left renal, and SMA orices
were identied. Irrigating Fogarty catheters were
placed in these orices and helped control bleeding. Iced Lactated Ringer’s solution was then
infused into all these, both renal arteries and
SMA, to help preserve the renal and the intestines. The proximal aorta was debrided, and it
was felt that a graft could be sutured to the orice
of the SMA and right renal. A 20 millimeter
Gortex graft was then brought onto the eld, and
this was sutured in placed with 3-0 cardiovascular Prolene suture. The beveled anastomosis was
performed proximally including the SMA inferiorly and the right renal artery.
After the proximal anastomosis was completed, a silver clip was placed at the proximal
anastomosis. Clamps were placed distally and
ow was restored to the celiac, SMA, and right
renal. After ow was restored, it was noted the
clamp time was 33 minutes. The Dacron graft
was sized at the appropriate length and sutured in
an end to end fashion to the remotely placed
Dacron graft using 3-0 cardiovascular Prolene in
a simple running fashion.
Prior to completion of the anastomosis,
anterograde and retrograde bleeding was performed. The anastomosis was tied. The flow
was restored to the legs.
A 6 millimeter PTFE (W.L. Gore, Newark,
DE) side graft, which had previously been sutured
onto the graft prior to being placed in the patient,
was cut to the appropriate length and bypass graft
and then sutured end to the end of the left renal
artery. The kidney was small, approximately
8cm, but renal artery was patent. A 1 millimeter
probe was easily passed through the rst branch
of the renal artery. The renal artery was then
sutured in an end-to-end fashion with a 6-0
Prolene simple running suture. After this was
sutured into place, the anastomosis was tied, and
ow was restored to the kidney. There was a good
Doppler signal in both branches of the renal
artery.
The patient developed some evidence of coagulopathy, and coagulation factors were replaced,
and the patient was warmed. After hemostasis
was obtained, the aneurysm sac was closed over
6
1 Symptomatic Proximal Anastomotic Pseudoaneurysm ofSuprarenal Aorta
the aortic graft with interrupted 3-0 Vicryl
sutures. The pleura was closed over the thoracic
aorta with interrupted 3-0 Vicryl sutures. Next,
the diaphragm was closed with interrupted 2-0
Prolene interrupted horizontal mattress sutures.
After the diaphragm was closed, the intercostal
stitches were placed with a #2 doubled PDS
suture. The chest tube was placed through an
anterior incision above the operative incision. A
#32 French chest tube was placed posteriorly and
was tied in place with a 2-0 silk. After the chest
tube was in adequate place, the intercostal
stitches were tied, and the diaphragm was
approximated.
There was palpable pulse in renal arteries,
celiac artery, and superior mesenteric artery.
Dressings were applied. Chest tube was connected to water seal. The patient was then transferred to the intensive care unit in satisfactory
condition. Patient was subsequently discharged
in satisfactory condition and lost to follow-up
4years later.
Discussion
Proximal anastomotic pseudoaneurysms after
AAA repair are uncommon as compared to distal
iliac and femoral anastomotic aneurysms. Hallet
etal. reported nine para-anastomotic aneurysms
at a median follow-up of 6.1years and three at
the proximal aortic anastomosis [1]. Conrad etal.
reported six visceral segment aneurysms, three of
which underwent open repair among 152 patients
who underwent surveillance with imaging studies following open AAA repair [2].
A proximal aortic para-anastomotic pseudoaneurysm developed in six patients (2.9%) in a
retrospective study of 208 patients who survived
elective open repair of infrarenal aortic aneurysm
[3]. Crawford etal. reported a long-term outcome
of open repair of AAA.During a 15-year follow up, late complications occurred in 26 (3.2%)
patients with anastomotic pseudoaneurysms in
23 patients and secondary aortoenteric stula in
the remaining 3 patients [4]. Following an open
AAA repair, an anastomotic aneurysm or aneurysmal dilatation of adjacent visceral segment
and/or iliac arteries may occur in 1%, 5%, and
20% at 5, 10, and 15years, respectively. Therefore
CTA abdomen and pelvis should be obtained
every 5years after open repair.
All patients with proximal para-anastomotic
pseudoaneurysms do not need repair. Repair of
such aneurysms is dictated by their size (>5.5cm)
and coexisting medical comorbidities. When
indicated, retroperitoneal ank approach is preferred. The role of endovascular repair with
branched endografts is not clearly dened in the
management of para-anastomotic pseudoaneurysms. In patients undergoing repair of type IV
thoracoabdominal aneurysm, continuous cold
perfusion of the left kidney can be carried out
during performing of distal anastomosis [5, 6].
Postischemic renal dieresis occurs commonly
when suprarenal clamp time exceeds 30minutes.
Patients should have adequate volume replacement. Postoperatively, a spinal cord protection
protocol is maintained for at least 24hours in all
patients treated with a lumbar drain [5, 6]. This
case illustrates the importance of careful follow up with imaging studies, as well as adequate
treatment of hypertension. It is possible that
uncontrolled blood pressure in this case led to
rapid enlargement of juxtarenal AAA before the
rst operation and probably played a role in the
development of proximal para-anastomotic
pseudoaneurysm.
Invited Commentary fromCharles
W.Acher, MD
What is striking about this patient is his age of 37
at the time of his rst aneurysm repair. Even with
such severe malignant hypertension, which was
diagnosed and treated 10 years previously, it is
unusual to develop an aneurysm at this age without some underlying genetic molecular disorder
which we can now test for but was unavailable at
the time of either aneurysm repair. A smoking
history was not mentioned but would be present
in most of these patients. His mental decompensation in 1980 after stopping his medications
might very well have been hypertensive encephalopathy, or encephalopathy may have contributed,
but it also raised the question of how consistent
he was in controlling his blood pressures in the
Invited Commentary fromCharles W.Acher, MD
7
decade preceding and after his initial aneurysm
surgery with what was undoubtedly a hypertensive stroke in 1973, a year after diagnosing his
hypertension. Also, in 1981 he already had hypertensive nephropathy with diminished renal function, and he may have been malnourished from
aneurysm-related anorexia with a BMI of 14.1.
All of these factors may have contributed to his
subsequent aneurysm/pseudoaneurysm 13 years
later.
The actual repair of his aneurysm/pseudoaneurysm in 1994 appears to have gone awlessly and
demonstrates several points which are important
in planning and executing such a complicated
repair even today and were ahead of their time in
1994. The use of a spinal drain was not done in
most centers in 1994. We reported the largest clinical series up to that time of 40 TAAA patients in
1989 with experience since 1986 showing an 80%
reduction in spinal cord injury, but general acceptance of spinal drains did not really take hold until
Coselli’s randomized trial in 1999 [7]. In 1994 we
would have drained CSF, but in a surgery like this
today, we might avoid the spinal drain but use the
rest of our spinal cord protection protocol which
is hypothermia (32–33 °C), proximal hypertension, steroids and naloxone, plus aggressive volume resuscitation with blood (cell saver and bank)
and FFP.We would use spinal drainage for a true
Crawford type 4 TAAA in most cases. Renal cooling with iced saline was also not standard in 1994
but is the best strategy for renal protection. We
always advocated rapid renal cooling (over
2–4minutes) with 300–400 infusion of LR with
12.5 gm and 1000units of heparin/liter at 4C into
each kidney [6]. This is very protective with permanent dialysis- dependent renal failure in 0.8%
of our patients and was conrmed by a randomized trial by Lamaire and Coselli [8]. Also I think
it was important to investigate the left kidney and
revascularize for maximum renal preservation if
the renal artery was not occluded as suggested by
the pre-op imaging. The cold renal perfusion is
important in attaining moderate hypothermia (32–
33°C) which is end-organ (kidney, bowel, liver)
protection during aortic reconstruction [9]. We do
not reverse hypothermia with active warming (no
bare huggers) and allow patients to rewarm on
their own over several hours in the ICU. This
intentional hypothermia has not resulted in
increased bleeding or postoperative bleeding
because we are very aggressive with volume and
factor replacement during the surgery and patients
are on an FFP drip at 75cc per hour until the next
day. We feel this hypothermia is protective of the
spinal cord in more extensive replacements until
the axial collateral network dened so elegantly
by Etz and Griepp improves blood ow to the
cord [10]. In this case that is not as important
because of the limited aortic replacement but is
important for the bowel and liver which we do not
perfuse directly.
There are a few other technical points that
have changed since 1994 when we exposed and
closed in much the same way as described. We do
extraperitoneal exposure now and have for the
last 20years if the incision is in the 7th intercostal space or lower, and we close the diaphragm
with a running double-stranded 0 PDS suture and
not interrupted Ethibond. In 5th and 6th interspace incisions, we still may need interrupted
Ethibond for the last third of the diaphragm
which are tied after the chest wall is approximated. In addition to a chest tube, we also drain
the retroperitoneum with a 10 at JP drain with a
ReliaVac reservoir which maintains a constant
-80 mmhg suction to minimize uid and blood
from accumulating in the retroperitoneum and
has a one-way valve so reservoir contents don’t
reux back into the drain. Just as important as the
surgical repair are the anesthetic protocols which
are standardized in our unit. All of these cases are
done by cardiovascular anesthesiologists who
follow the protocols that have been developed
from basic science and experience and modied
by consensus as new information comes to light
that has strong scientic foundation. Postoperative
ICU protocols are also important to optimize cardiac function, hemodynamics, oxygen delivery,
and tissue perfusion. These protocols have been
agreed upon by the anesthesiologists, surgeons,
and intensivists who we co-manage with daily
while in the ICU with face-to-face interactions.
Reading about this case brought back memories of those patients we treat successfully who
disappear into the ether of time and we wonder
what happened to them. Did all that work result
in a longer and better life? It also brings home the
8
1 Symptomatic Proximal Anastomotic Pseudoaneurysm ofSuprarenal Aorta
reason we try so hard to maintain contact with
these patients so we can better understand the
long-term success or failure of our efforts.
References
1. Hallett JW, Marshall DM, Petterson TM, Gray DT,
et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a
36-year population-based experience. J Vasc Surg.
1997;25(2):277–84; discussion 285–286.
2. Conrad MF, Crawford RS, Pedraza JD, Brewster DC,
etal. Long-term durability of open abdominal aortic
aneurysm repair. J Vasc Surg. 2007;46(4):669–75.
3. Crawford ES, Saleh SA, Babb JW, Glaeser DH,
Vaccaro PS, Silvers A. Infrarenal abdominal aortic
aneurysm: factors inuencing survival after operation performed over a 25-year period. Ann Surg.
1981;193(6):699–709.
4. Biancari F, Ylönen K, Anttila V, Juvonen J, Romsi P,
Satta J, Juvonen T.Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up
study. J Vasc Surg. 2002;35(1):87–93.
5. Shepard AD. Proximal abdominal aortic aneurysm
repair in endovascular reconstruction. In: Hans SS,
Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction:
a practical approach. Boca Raton: CRC Press; 2018.
p.213–20.
6. Wynn MM, Acher C, Marks E, Engelbert T, Acher
CW. Post operative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp
technique and 4°C renal perfusion. J Vasc Surg.
2015;61(3):611–22.
7. Acher CW, Wynn MM, Archibald J.Naloxone and
spinal uid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms.
Surgery. 1990;108(4):755–61; discussion 61–2.
8. Coselli JS, LeMaire SA, Koksoy C, Schmittling ZC,
Curling PE. Cerebrospinal uid drainage reduces
paraplegia after thoracoabdominal aortic aneurysm
repair: results of a randomized clinical trial. J Vasc
Surg. 2002;35(4):631–9.
9. Koksoy C, LeMaire SA, Curling PE, etal. Renal perfusion during thoracoabdominal aortic operations:
cold crystalloid is superior to normothermic blood.
Ann Thorac Surg. 2002;73(3):730–8.
10. Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM,
Griepp RB.The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrice. J Thorac Cardiovasc
Surg. 2011;141(4):1029–36.
Repair ofJuxtarenal Abdominal
ab
Aortic Aneurysm withAortorenal
Bypass
2
Physical Examination
A 68-year-old male was scheduled for open repair of
a 5.0cm abdominal aortic aneurysm (AP/transverse
diameter) in February 2005. The aneurysm was juxtarenal with associated 2.8 cm bilateral common
iliac artery aneurysms and a 2.0cm left hypogastric
artery aneurysm (Fig.2.1a). Preoperative aortography showed accessory left lower pole renal artery
(Fig.2.1b). Medical comorbidities included history
of atrial utter, hypertension, and post- thrombotic
syndrome involving both lower extremities.
Procedure
Through midline transperitoneal incision, AAA
was exposed to mobilize. Following application
of the Bookwalter retractor, and mobilization of
the ligament of Treitz, the left renal vein was
Fig. 2.1 (a, b) Aortography showing abdominal aortic
aneurysm and bilateral iliac aneurysm with accessory left
lower pole renal artery. Because of large amount of throm-
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_2
bus in the abdominal aortic aneurysm, aortogram only
shows the contrast-lled lumen
9
10
ab
2 Repair ofJuxtarenal Abdominal Aortic Aneurysm withAortorenal Bypass
ligated close to the inferior vena cava. The aneurysm arose at the level of the left renal artery and
was saccular with a bulge to the left. Left crus of
the diaphragm was divided by electrocautery.
Both common iliac artery aneurysms were mobilized along with mobilization of the origin of the
hypogastric and external iliac artery. Aorta was
clamped above the left renal artery and below the
right renal artery following systemic heparinization. Proximal anastomosis was performed using
22 × 11 mm knitted Dacron graft (Meadox,
Boston Scientic, Marlborough, MA) in two layers, with the rst layer of interrupted horizontal
mattress suture on pledgets with 3-0 cardiovascular polypropylene (Ethicon, Somerville, NJ) and
a second layer of continuous suture. As the proximal clamp was released, there was excessive
bleeding at the 7 o’clock position of the suture
line. Reapplication of the clamp a few cm proximally resulted in a tear of the aorta. A #24 Foley
balloon catheter was introduced through the left
limb of the Dacron graft and inated at the supraceliac level. Left renal artery was transected at its
origin from the aorta. Proximal stump of the renal
artery was suture ligated, and deep bites into the
left lateral wall of the aorta were taken using horizontal mattress sutures of 3-0 cardiovascular
Prolene on pledgets. Bio-glue (Cryolife,
Kennesaw, GA) was applied to achieve hemostasis. A 6 mm PTFE graft (W.L. Gore, Newark,
DE) was anastomosed to the main body of the
Dacron graft on the left side just above the bifurcation of the graft taking out a small disc of
Dacron graft using 5-0 cardiovascular polypropylene and distally was anastomosed end to end
to the divided left renal artery. The left lower pole
renal artery was reimplanted into the left limb of
the Dacron graft using 5-0 CV polypropylene as
well. The left hypogastric aneurysm was excised,
and back bleeding was controlled with 4-0 CV
polypropylene suture. Because of severe calcic
disease in the left external iliac artery, left limb of
the graft was anastomosed to the left common
femoral artery in an end-to-side fashion. Left
common iliac aneurysm was opened, and its wall
was partially removed, and proximal left external
iliac artery was ligated. On the right side, anastomosis of the right limb of the Dacron graft was
performed end to end to the common iliac artery
at the bifurcation after removal of the aneurysm.
The patient received 600cc of blood from the cell
saver, and 1 unit of PRBCs was given to the
patient. Patient’s post-op course was complicated
by respiratory failure which improved with ventilatory support.
The patient was extubated on the third postoperative day. The patient had transient renal dysfunction. Postoperative aortography showed
patent aortoiliac and femoral graft and patent left
aortorenal bypass (Figs.2.2 and 2.3). Patient did
Fig. 2.2 (a, b) Aortography showing aortic bifurcation graft and left aortorenal bypass
Discussion
Fig. 2.3 Left femoral anastomotic aneurysm
well and underwent repair of 3.5cm left femoral
anastomotic aneurysm 8years after the original
procedure. The patient later expired from complications of Alzheimer’s dementia in 2017.
Discussion
Operative repair of juxtarenal AAA is a technically challenging operation. In absence of the
need to visualize distal right common iliac
artery (as was the case for this patient due to
2.5cm right iliac aneurysm), a left ank retroperitoneal approach is increasingly used for
open repair of proximal complex AAA in
patients with need to explore the aorta proximal
to the renal arteries, redo aortic surgery, AAAs
in the presence of a horseshoe kidney, hostile
abdomen with prior osteotomies, or inammatory AAA.A concomitant renal artery bypass
became necessary as proximal aortic clamp
resulted in tear of the aorta above the renal
arteries [1]. Because of the improvement in
medical management of renovascular hypertension, concomitant renal artery bypass with open
AAA is rarely indicated. In order to perform
suprarenal dissection via transperitoneal
approach, mobilization of left renal vein or
ligation of left renal vein close to the inferior
11
vena cava preserving gonadal and adrenal vein
as venous outow from the kidneys is necessary. Mobilization of the left renal vein without
division often requires ligation of adrenal vein
and gonadal vein. In addition, the left crus of
the diaphragm needs to be divided to gain proximal aortic exposure.
Follow-up aortography showed satisfactory
proximal anastomosis, patent left aortorenal
bypass, occluded lower pole renal artery reimplantation (Fig.2.2), and an anastomotic aneurysm involving the graft and left femoral
artery. Though not always possible, either tube
graft (aorto-aortic) or aortoiliac anastomosis
should be preferred as femoral anastomosis
may result in increased incidence of surgical
site infection, lymphoceles, and late development of anastomotic aneurysms [1]. Repair of
left femoral anastomotic aneurysm was performed by interposition of an 8 mm knitted
Dacron graft. A left flank approach through
9th or 10th ICS, 9th ICS for paravisceral
extent IV thoracoabdominal aneurysms, and
10th ICS for pararenal aortic aneurysms is
preferable [1]. Renal, visceral, and occasionally spinal cord ischemia may occur with prolonged proximal clamping [1]. Renal artery
reconstruction at the time of open repair of
paravisceral aneurysm is associated with
increased incidence of acute renal failure and
mortality [2, 3]. Minimizing renal ischemia
time to less than 40 minutes is important in
reducing the risk of acute kidney injury.
Before aortic cross clamping above the suprarenal or supraceliac level, hemodynamics need
to be optimized. Mannitol 25g is administered
30 minutes prior to aortic cross clamping,
though its benefit in preventing renal dysfunction has not been proven. Deery etal. reported
from vascular surgery group of New England
registry for the repair of complex AAA
(defined by need of suprarenal or supraceliac
clamping) had higher perioperative mortality
(3.2% compared to 1.2% standard infrarenal
AAA repair) [4]. Renal or visceral ischemia
independently predicted cardiac, respiratory,
and renal complications according to results
of their study [4].
12
2 Repair ofJuxtarenal Abdominal Aortic Aneurysm withAortorenal Bypass
Invited Commentary fromTimothy
J.Nypaver, MD
This operative management of a juxtarenal aneurysm highlights many of the intraoperative and
postoperative challenges and complications that
can and do occur with standard open repair. In
addition, juxtarenal aneurysms are now frequently managed via endovascular means with
use of fenestrated grafts and alternate techniques,
including extension of the landing zone more
proximally with renal preservation via chimney
or snorkel grafts into the renal arteries [5]. This
has resulted in less operative exposure for both
vascular surgeons and trainees, and the intraoperative rescue maneuvers, clearly demonstrated
in this case, are becoming less familiar to practicing vascular surgeon. The author should be congratulated with this difcult case, managing a
proximal clamp site tear and avulsion of a renal
artery with the following critical maneuvers:
proximal balloon control (inserted through a limb
of the vascular graft), reimplantation of the
avulsed renal artery, implantation of an accessory
renal artery, and successful management of a
bleeding proximal anastomosis. This was accomplished with minimal blood transfusions and
complete operative management and correction
of existing aneurysms (the common iliac and the
hypogastric aneurysm). In doing so, the patient
has been rewarded with a durable operative
repair, one that lasted up to his death 12years
later from non-aortic causes. This case also indirectly highlights the potential benets of endovascular repair with its less invasive nature and
its reduced operative risk and morbidity. While
this patient recovered from this challenging
operative management with transient respiratory failure (3days) and reversible renal dysfunction, other patients, frailer or those with
more signicant comorbidities, may not have
been able to do so. Thus, careful consideration
should always be given to each approach, endovascular or open, so that the vascular surgeon
hopefully can select the right operation for the
right patient. While each approach is complementary, it is recognized, as with standard
infrarenal abdominal aortic aneurysm operations, that endovascular repair will become the
more commonly performed and the probable
favored approach for repair of juxtarenal aneurysms [6].
The author has appropriately pointed out the
signicant benets of the left ank retroperitoneal approach. If an open repair is to be undertaken for a juxtarenal or suprarenal aneurysm,
for a paravisceral extent IV thoracoabdominal
aneurysms, or for a proximal type I endoleak or
other complications related to infrarenal endografting, a left ank retroperitoneal approach is
preferred. If necessary, the rst 1–2cm of the
right renal artery can be dissected and exposed,
and in addition, the right common iliac artery
can be exposed distally allowing either an anastomosis to the mid to distal common iliac or
alternately allowing for ligation of the common
iliac with the bypass limb then routed to the femoral level. Retroperitoneal abdominal aortic
aneurysm has been associated with lower estimated blood loss and less uid requirement
within the rst 24hours following operation than
transperitoneal repair [7]. In addition, the left
ank retroperitoneal approach allows more facile access to the suprarenal, supramesenteric,
and supraceliac levels, all performed thru the
same visual plane. Once open repair is selected
for a juxtarenal aneurysm, the decision for transperitoneal versus retroperitoneal is often based
upon the surgeon’s preference and experience
and, as illustrated in this example, whether the
right iliac artery is extensively involved with the
disease process.
References
1. Shepard AD. Proximal abdominal aortic aneurysm
repair. In: Hans SS, Shepard AD, Weaver MR, Bove
PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca
Raton: CRC Press; 2018. p. 213–20.
2. Ultee KHJ, Soden PA, Zettervall SL, McCallum JC,
Siracuse JJ, Alef MJ, Vascular Study Group of New
England. Perioperative effect of concomitant procedures during open infrarenal abdominal aortic aneurysm repair. J Vasc Surg. 2016;64(4):934–940.e1.
References
13
3. Wooster M, Back M, Patel S, Tanious A, Armstrong
P, Shames M.Outcomes of concomitant renal reconstruction during open paravisceral aortic aneurysm
repair. J Vasc Surg. 2017;66(4):1149–56.
4. Deery SE, Lancaster RT, Baril DT, Indes JE,
et al. Contemporary outcomes of open complex
abdominal aortic aneurysm repair. J Vasc Surg.
2016;63(5):1195–200.
5. Lee JT, Greenberg JI, Dalman RL.Early experience
with the snorkel technique for juxtarenal aneurysms. J
Vasc Surg. 2012;55:935–46.
6. Soler R, Bartoli MA, Faries C, etal. Fenestrated endovascular aneurysm repair and open surgical repair for
the treatment of juxtarenal aortic aneurysms. J Vasc
Surg. 2019;70(3):683–90.
7. Nypaver TJ, Shepard AD, Reddy DJ, etal. Repair of
pararenal abdominal aortic aneurysms: an analysis of
operative management. Arch Surg. 1993;128:803–13.
Abdominal Aortic Aneurysm
Repair inaPatient withCeliac
Artery Occlusion andaLarge
Inferior Mesenteric Artery
3
Physical Examination
A 75-year-old male with history of hypertension, nicotine abuse, and now chronic back pain
underwent CTA evaluation of the abdomen for
a large pulsatile mass in his abdomen. A 7.4cm
infrarenal AAA with 80% stenosis of the celiac
artery, 40% stenosis of the superior mesenteric
artery, and an enlarged inferior mesenteric
artery with a collateral vessel between the
celiac and IMA (Fig. 3.1) was demonstrated.
Patient had not had any symptoms of intestinal
angina.
ab
Procedure
Patient was taken to the hybrid room for possible endovascular or open repair. An aortogram performed via the left femoral artery
sheath revealed a large collateral artery in the
upper abdomen communicating with the IMA
(Fig.3.2). Because of the risk of development
of bowel infarction due to the coverage of the
IMA with EVAR, it was decided to perform
open repair. Through a midline laparotomy
incision, AAA was explored, and a large collateral artery joining the IMA was identied.
Fig. 3.1 (a, b) CTA showing iliac artery stenosis. Mild stenosis of SMA and large AAA
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_3
15