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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
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3 Abdominal Aortic Aneurysm Repair inaPatient withCeliac Artery Occlusion andaLarge Inferior…
abc
Fig. 3.2 (a–c) Aortogram showing AAA with a large mesenteric collateral joining the IMA
Patient was seen in 6months later in the clinic
and in a satisfactory condition.
Discussion
Complications of colon ischemia following open
or endovascular aneurysm repair are rare. Patients
undergoing open AAA repair with prior colon
resection or a large IMA with arc of Riolan with
associated celiac and SMA occlusive disease are
more likely to develop the dreaded complication
of ischemic colitis due to ligation of the IMA.
Coverage of the IMA during endovascular repair
of AAA in such patients may also result in ischemic colitis. In a recent retrospective analysis by
Lee et al, IMA reimplantation during open AAA
repair was associated with higher incidence of
ischemic colitis [1]. However, the patient population under study did not demonstrate enlarged
mesenteric collaterals suggesting need for IMA
Fig. 3.3 Intraoperative picture showing reimplanted
IMA as Carrel patch
Open repair of the AAA with 20mm tube graft
was performed. Origin of the IMA and its rst
few centimeters were mobilized and reimplanted into the Dacron graft as a carrel patch
(Fig.3.3). Postoperative course was uneventful
except for the development of transient atrial
brillation and encephalopathy which
improved gradually. Postoperative CTA
showed satisfactory graft placement and patent
IMA with mild to moderate stenosis (Fig.3.4).
reimplantation. In the case described above,
patient had a large collateral between the celiac
with inferior mesenteric artery. The IMA reimplantation was thought to be a good option for
prevention of bowel ischemia. The large collateral
in this patient was not the arc of Riolan, which
connects the middle colic (branch of SMA) to the
IMA.This large collateral was a novel collateral
from the celiac artery to the left upper colic artery
of the IMA. An endovascular option with
preservation of the IMA using a single fenestration in the back-table modication of the stent can
be used occasionally in high-risk patients [2].
References
17
abc
Fig. 3.4 (a–c) Postoperative CTA images showing patent aortic graft with mild stenosis of the origin of the reimplanted
IMA
Invited Commentary fromMitchell
Ross Weaver, MD
This case illustrates the importance of fully evaluating a patient’s anatomy beyond only determining if there are adequate proximal and distal
landing zones for an endograft to seal and adequate access for delivering the device. Coverage
of the inferior mesenteric artery is a mandatory
step in the endovascular treatment of abdominal
aortic aneurysms for all commercially available
abdominal aortic endograft systems, and even
with this the incidence of clinically relevant postoperative mesenteric ischemia is very low. As
well as in open surgical repair of abdominal aortic aneurysms, the inferior mesenteric artery is
routinely ligated except in circumstances where
it was patent preoperatively and has poor back
bleeding following the aortic reconstruction. In
this case however, given the large size of the inferior mesenteric artery and the mesenteric occlusive disease noted in the celiac and superior
mesenteric arteries, one must assume that if ow
is not preserved in the inferior mesenteric artery,
mesenteric ischemia and bowel infarction will
follow.
For this patient the inferior mesenteric artery
patency was preserved by an open aortic aneurysm repair and reimplantation of the inferior
mesenteric artery. While each patient’s anatomy
is unique to them, in some patients other options
may be to intervene either with endoluminal or
open interventions on the celiac or superior mesenteric arteries to preserve adequate mesenteric
blood ow. Nevertheless, this case does stress the
importance of case planning and being mindful
of the physiological effects caused by the anatomic changes of surgical intervention, whether
open or endovascular.
References
1. Lee KB, Lu J, Macsata RA, Patel D, Yang A, Ricotta
JJ, Amdur RL, Sidawy AN, Nguyen BN. Inferior
mesenteric artery reimplantation does not decrease
the risk of ischemic colitis after open infrarenal
abdominal aortic aneurysm repair. J Vasc Surg.
2019;69(6):1825–30.
2. Correa JC, Mantese V, Jacobs DL. Stent graft treat-
ment of abdominal aortic aneurysm with preservation of the inferior mesenteric artery. J Vasc Surg.
2014;60(4):118–9.
Abdominal Aortic Aneurysm
Repair inaPatient withaPelvic
Kidney
4
Physical Examination
A 66-year-old white male with chronic obstructive
pulmonary disease was found to have an 8-cmwide asymptomatic abdominal aortic aneurysm by
physical examination. Ultrasound of the abdominal aorta conrmed that the aneurysm was 8cm in
transverse diameter, and, in addition, there was a
suggestion of a pelvic midline mass. Retrograde
aortogram revealed the infrarenal location of the
aneurysm with a normal left kidney and left renal
artery. The right kidney was located in the pelvis
with its blood supply arising from the lower
abdominal aorta either at its bifurcation or from
the origin of common iliac artery (Fig.4.1); this
distinction could not be made with certainty on
arteriogram. Pulmonary function tests revealed
severe obstructive lung defects, and a chest X-ray
showed mild obstructive lung disease.
Procedure
On exploration the aneurysm had a short neck and
was 8 cm in transverse diameter. The aneurysm
was mobilized along with the blood supply to the
Fig. 4.1 Aortogram showing abdominal aortic aneurysm, pelvic kidney and its arterial supply from aorta or common
iliac artery
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_4
19
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Fig. 4.2 Operative photograph showing Dacron graft in
place and loops around two renal arteries supplying the
pelvic kidney, being anastomosed to the iliac limb of the
graft as a cuff in common with iliac arteries
4 Abdominal Aortic Aneurysm Repair inaPatient withaPelvic Kidney
pelvic kidney arising 1cm anterior and superior to
the origin of the slightly dilated common iliac
arteries. The right renal vein from the pelvic kidney joined the right common iliac vein. The aorta
was clamped below the left renal artery, and the
aneurysm was excised under systemic heparinization. A 19 × 9.5 mm USCI woven bifurcated
Dacron graft was sutured in place after both renal
arteries to the pelvic kidney had been mobilized
and cuff preserved with each common iliac artery.
Both renal arteries to the pelvic kidney were
ushed with heparinized ice-cold saline after the
aneurysm had been opened. Proximal anastomosis
was performed with 4-0 cardiovascular Prolene.
Distally, each common iliac artery and the attached
renal artery proximal to it were joined in a common elliptical anastomosis to the Dacron limb on
either side also using 4-0 cardiovascular Prolene
(Fig. 4.2). Total clamp time was 30 minutes.
Postoperative renal blood ow and scan showed
normal blood ow to the left kidney as well as to
the right pelvic kidney (Fig.4.3). The patient was
discharged after 8days in good condition.
Fig. 4.3 Scan showing normal glucoheptonate renal
blood ow and I-hippuran uptake in pelvic kidney as well
as left kidney
Discussion
CT angiography and preoperative arteriography
are essential diagnostic procedures for careful
operative planning of such cases [1]. The pelvic
kidney was rotated with its pelvis lying inferiorly.
Careful surgical dissection enabled us to recognize
two renal arteries to the pelvic kidney arising just
above the origin of the common iliac arteries to
supply the hilum of the pelvic kidney. Complete
mobilization of the arterial supply to the pelvic
kidney made it possible to reduce the ischemic
time to less than 40 minutes. If, on freeing the
aneurysm the artery to the pelvic kidney is found
to arise from the aneurysm itself or from the bifurcation of the common iliac artery, this artery
should be reimplanted into the Dacron graft [1]. A
similar situation may arise in a patient with
abdominal aortic aneurysm and a prior renal transplant. Campbell etal. used in situ renal perfusion
and performed successful aneurysmectomy in a
young renal transplant patient. Ex vivo renal perfusion is hazardous because of the risk to injury to
the renal parenchyma, its blood supply, and the
ureter. Aneurysmectomy with the use of a shunt
from the proximal aorta to the common iliac artery
as a means of providing blood ow to a transplanted kidney was described by Sterioff and
Parks [2]. This approach may be technically difcult in arteriosclerotic vessels, and there is a potential for distal embolization. An axillofemoral graft
is an attractive alternative provided blood supply
References
21
of the pelvic kidney is from the distal portion of
the common iliac artery. Shons etal. used an axillofemoral bypass to preserve a functioning renal
transplant after excision of a mycotic abdominal
aortic aneurysm in a diabetic patient [3].
Schneider and Cronenweff described temporary perfusion of a pelvic kidney during repair of
AAA and iliac aneurysms [4]. Pelvic renal ischemia was limited by a “double proximal clamping” technique and by placement of a temporary
shunt from the body of the aortic graft into the
pelvic renal artery during completion of two distal anastomoses [4]. A custom-made fenestrated
endograft with prior prototype information has
been described for the repair of a large AAA with
right pelvic kidney in a patient with multiple
comorbidities [5]. A hybrid technique was successfully performed in a patient with aortoiliac
aneurysm and a congenital solitary pelvic kidney
by performing right external iliac artery to two
renal arteries (to the solitary kidney) using a
bifurcated Dacron graft followed by coil embolization of the hypogastric artery and a standard
endovascular aneurysm repair [6].
In our patient arterial supply to pelvic kidney
arose close to the origin of the common iliac
artery, and as such an axillofemoral graft would
not have maintained renal perfusion. Systemic
heparinization before aortic clamping, ushing of
the renal arteries with heparinized ice-cold saline
after opening the aneurysm, and reestablishment
of arterial ow to such a kidney are important
steps in preserving renal function in such cases.
Invited Commentary fromMitchell
Ross Weaver, MD
The presence of renal anomalies such as a pelvic
kidney or a horseshoe kidney can be a formidable
challenge when it comes to the need for abdomi-
nal aortic aneurysm repair. Several factors of the
altered anatomy contribute to this. These include
positioning in the pelvis with limited space, often
multiple as opposed to a single renal artery that
will require reconstruction, and abnormal course
of the ureters which may place them at greater
risk for injury. Thus, careful study of the preoperative imaging is a must to identify and then
plan for reconstruction of the renal arteries, as
well as plan for the most advantageous approach
be that transperitoneal or retroperitoneal.
Additional adjuncts to consider include the use of
cold renal perfusion or temporary renal shunting
to avoid the effects of likely longer renal ischemia times in these cases.
References
1. Campbell DA Jr, Lorber MI, Arneson WA, Kirsh MM,
Turcotte JG, Stanley JC.Renal transplant protection
during abdominal aortic aneurysmectomy with a
pump-oxygenator. Surgery. 1981;90:559–62.
2. Sterioff S, Parks L. Temporary vascular bypass for
perfusion of a renal transplant during abdominal aneurysmectomy. Surgery. 1977;82(5):558–60.
3. Shons AR, DeShazo CV, Rattazzi L, Najarian
JS. Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg. 1976;132(1):97–9.
4. Schneider JR, Cronenwett JL. Temporary perfusion
of a congenital pelvic kidney during abdominal aortic
aneurysm repair. J Vasc Surg. 1993;17(3):613–7.
5. Majumder B, Perera AH, Browning N, MacGregor
M, Chapman A.Fenestrated endograft as a new perspective for the treatment of infrarenal abdominal
aortic aneurysm with a congenital pelvic kidney-a
case report and review of literature. Ann Vasc Surg.
2017;45:266.e1–4.
6. Malinowski MJ, Al-Nouri O, Hershberger R,
Halandras PM, Aulivola B, Cho JS.Abdominal aortic
aneurysm associated with congenital solitary pelvic
kidney treated with novel hybrid technique. Ann Vasc
Surg. 2014;28(6):1566.e7–10.
Open Repair ofAbdominal Aortic
Aneurysm inaPatient withDouble
Inferior Vena Cava
Physical Examination
A 58-year-old male with congestive cardiomyopathy and diabetes mellitus was found to have
a 6.5-cm-wide abdominal aortic aneurysm by
clinical examination. In addition, the patient
had patchy mottling of the right big and second
toes and the left fth toe. The right femoral
pulse was slightly diminished, but the left femoral pulse was absent. Right popliteal, posterior tibial, and dorsalis pedis pulse were absent
as well. The chest X-ray showed cardiomegaly,
and an EKG showed left ventricular hypertrophy with ST segment changes. Ultrasound
examination of the abdomen conrmed the
presence of an AAA with transverse diameter
of 6.5cm. Retrograde aortogram revealed that
the aneurysm extended to involve the proximal
portion of the right common iliac artery. There
was mild stenosis of the distal right common
iliac artery. In addition, the left common iliac
artery was occluded, with reconstitution of the
external and internal iliac arteries at their origin (Fig. 5.1). The arteries below the groin,
though smaller in size, did not show any occlusive disease. Because of the presence of a large
abdominal aortic aneurysm and signicant
iliac artery occlusive disease, the patient underwent an open aortic reconstruction on
November 11, 1982.
5
Fig. 5.1 Abdominal aortogram showing AAA and left
iliac artery occlusion
Procedure
Preoperatively, a Swan-Ganz catheter was
inserted. The AAA was found between two
channels of a duplicated inferior vena cava.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_5
23
24
Left IVC
Right IVC
Fig. 5.2 Operative picture showing left-sided IVC
5 Open Repair ofAbdominal Aortic Aneurysm inaPatient withDouble Inferior Vena Cava
A.A.A
The left- sided vena cava joined the right-sided
vena cava at the neck of the aneurysm so as to
form one common venous channel. Both renal
veins joined at the same level. The left lateral
wall of the aneurysm projected behind and
beyond the left-sided vena cava. The neck of the
aneurysm was mobilized very carefully
(Fig.5.2). The upper portion of the left vena cava
was mobilized, and tape was passed around it.
The aneurysm was resected between the two
caval veins, and aortic bifurcation graft
(18 × 9 mm Verisoft, Meadox) prosthesis was
inserted (Figs.5.3 and 5.4). On the right side, the
right limb of the graft was anastomosed to the
common iliac artery bifurcation and on the left
to the common femoral artery in an end-to- side
fashion. The postoperative course was uneventful, and the patient was discharged on the eighth
postoperative day in a satisfactory condition.
Discussion
The incidence of a double inferior vena cava
varies between 0.5 and 0.3 percent in the general population [1, 2]. The development of the
IVC is a complicated process involving three
Fig. 5.3 Diagrammatic representation of intraoperative
ndings
Fig. 5.4 Postoperative inferior vena cava showing double
IVC
pairs of venous channels: posterior cardinal,
subcardinal, and supracardinal. Chuang et al.
[3] presented a simplied classication of
Invited Commentary fromGraham W.Long, MD
25
anomalies of postrenal segment of IVC into
four types:
• Type A: Persistent right posterior cardinal
vein (retrocaval ureter)
• Type B: Persistent right subcardinal vein (normal IVC)
• Type C: Persistent left subcardinal vein (left
IVC)
• Type BC: Persistent right and left supracardinal and subcardinal veins (double IVC)
Normally, the left renal vein is formed by the
persistence of the ventral limb and regression of
the dorsal limb of the renal venous collar.
Persistence of the dorsal limb results in formation of a retroaortic left renal vein, while persistence of both dorsal and ventral limbs results in
formation of a circumaortic venous ring. Absence
of hepatic segment of the IVC with azygos or
hemiazygos continuation is commonly associated with congenital heart disease, asplenia, and
polysplenia [3]. Detailed knowledge of various
venous anomalies in association with AAA is
important for the vascular surgeon, since such
anomalies may be found unexpectedly at the time
of exploration. Lindblad [1] found a double IVC
and AAA at the time of aortoiliac reconstruction
for occlusive disease. Dupont reported an isolated left-sided vena cava in a patient with AAA
[2]. He obtained proximal control of the aneurysm above the level of the right renal vein.
Duplicated vena cava is ten times more common
than an isolated left-sided vena cava [2]. Above
the level of the renal vein, the IVC is single and is
on the right side even if it is duplicated below that
level, as was present in our case. The preoperative detection of congenital anomalies of the IVC
by CTA decreased the incidence of venous injuries [3–5]. In most patients with double IVC,
mobilization of left-sided IVC is sufcient to
perform open AAA repair. Division of left-sided
vena cava during AAA repair with and without
reconstruction has been described but is rarely
necessary [3, 4].
Exposure of the neck of the aneurysm must be
done very carefully in patients with duplicated
vena cava, as the left-sided channel crosses
toward the right anteriorly near the upper part of
the aneurysm. A small tear in the tributary of a
double vena cava can lead to serious intraoperative hemorrhage. Inadvertent ligation of one of
the paired venous channels can lead to thrombosis with subsequent edema of the extremity and
other sequelae of venous hypertension. The leftsided vena cava was mobilized as the aneurysm
extended behind and beyond this channel for a
distance of 3.0cm. Mobilization of the iliac arteries was straightforward. Postoperative venography via bilateral femoral venous approach
revealed detailed anatomic distribution of duplicated vena cava (Fig.5.4).
Invited Commentary fromGraham
W.Long, MD
The author describes elective open repair of an
AAA from 1982in which an unexpected nding
of a duplicated IVC was encountered. He
describes the preoperative evaluation and the
measures taken for uneventful conduct of the
operation.
The patient in this case underwent appropriate
preoperative evaluation with a combination of
ultrasound and aortography. Nonetheless, a
potential issue with this approach is the inability
to visualize incidental pathology, such as tumor
or inammatory masses and venous anomalies.
This case illustrated a duplicated IVC, but more
common variations include a retroaortic renal
vein or circumaortic venous ring. In the current
era of endovascular aneurysm repair, nearly every
AAA undergoes preoperative CTA, which makes
the above considerations moot.
Being familiar with anatomic variations of the
IVC is important to the vascular surgeon for two
reasons. First, recognizing a left-sided IVC prevents ligation and subsequent left leg venous
thrombotic complications. Second, the left-sided
IVC crosses the aorta obliquely and is joined by
the left renal vein at the level of the aortic neck.
This obscures access to the neck and requires
careful mobilization of these venous structures to
allow for proximal clamp placement. This often
includes ligation of the draining lumbar vein off
this IVC-renal venous complex to prevent avulsion and hemorrhage.
26
5 Open Repair ofAbdominal Aortic Aneurysm inaPatient withDouble Inferior Vena Cava
Aortic surgeons must be prepared for anatomic variants which affect the conduct of the
operation. Dr. Hans presents a solid example of
this with a duplicated IVC.
References
1. Lindblad L. Duplicated inferior vena cava in a
patient with an abdominal aortic aneurysm. Ann Chir
Gynecol. 1978;67:30–2.
2. Chuang VP, Mena CE, Hoskins PA. Congenital
anomalies of the inferior vena cava. Review of
embryogenesis and presentation of a simplied classication. Br J Radiol. 1974;47:206–13.
3. Dimic A, Markovic M, Cvetkovic S, Cinara I, Koncar
I, Davidovic L.Abdominal aortic surgery in the presence of inferior vena cava anomalies: a case series.
Ann Vasc Surg. 2017;39:137–42.
4. Radermecker MA, Van Damme H, Kerzmann A,
Creemers E, Limet R. Association of abdominal
aortic aneurysm, horseshoe kidneys, and left-sided
inferior vena cava: report of two cases. J Vasc Surg.
2008;47(3):645–8.
5. Truty MJ, Bower TC. Congenital anomalies of the
inferior vena cava and left renal vein: implications
during open abdominal aortic aneurysm reconstruction. Ann Vasc Surg. 2007;21(2):186–97.
Mycotic Aneurysm
oftheAbdominal Aorta
6
Physical Examination
A 53-year-old male was admitted to South
Macomb Hospital on October 8, 1981, with chills
and high fever of 2week’s duration (102–103°F).
This fever was accompanied with pain in the
lower back and left lower quadrant of the abdomen aggravated by walking. He had a history of
60 pack years of nicotine abuse. At the time of
admission, he had a fever of 102.6°F with a heart
rate of 120 beats per minute and blood pressure
130/80mm Hg. Examination of the chest revealed
diffuse rhonchi with rales. A pulsatile non-tender
mass was palpable in the abdomen lateral to the
umbilicus. Laboratory data revealed a hemoglobin of 12.9 gm/dl, hematocrit 36%, and a WBC
count 17,300/cm with shift to the left.
Sedimentation rate was 54 mm/hg. The chest
X-ray was normal. Ultrasound and CT scan of the
abdomen revealed a 5.0cm transverse diameter
infrarenal aortic aneurysm. Two blood cultures
were positive for E. coli, and the patient was
started on antibiotics (Kefzol and Tobramycin). A
retrograde aortogram revealed a saccular aneurysm of the infrarenal abdominal aorta (Fig.6.1).
Procedure
Patient underwent open repair of the aneurysm
on December 16, 1981. Infrarenal abdominal
aortic aneurysm was associated with an
enlarged preaortic lymph node with induration
and edema of the left lateral wall of the aneurysm. Cultures of the preaortic lymph nodes
were positive for E. coli. After proximal and
distal control was obtained, the aneurysm was
opened. There was evidence of dissection with
a smaller true lumen and a larger false lumen
(Fig. 6.2). The proximal extent of dissection
was 2.0cm below the origin of the renal arteries, and distally the dissection stopped at aortic
bifurcation. The aneurysm was resected completely and replaced by a 16.0×8.0mm Verisoft
(Meadox) Dacron graft. Culture of aneurysm
wall was positive for E. coli. Histopathological
examination of the aneurysm revealed an atherosclerotic aneurysm with acute and chronic
inammatory changes in its wall.
Patient was discharged on January 4, 1982, on
oral Keex, followed by 6weeks of intravenous
antibiotics (Kefzol and Tobramycin).
The patient was readmitted on February 26,
1982, with aspirin overdose secondary to severe
back pain that was an associated low-grade fever
(99–100 °F). Follow-up aortogram revealed a
normally functioning graft (Fig.6.3) without any
anastomotic disruption. X-ray of the lumbosacral spine revealed osteomyelitis of the 2nd, 3rd,
and 4th lumbar vertebrae with positive bone scan
(Fig. 6.4). Simultaneous left femoral arterial
blood and a left femoral venous culture did not
grow any microorganisms, but the patient continued to receive intravenous antibiotics. A
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_6
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