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9 Secondary Aortoduodenal Fistula Following Abdominal Aortic Aneurysm Repair
References
1. Hans SS, Acho RJ. Patients with unexplained
weight loss, anorexia, and back pain. JAMA Surg.
2019;154:185–6.
2. Nypaver T. Primary and secondary aorto-enteric
stula. 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.257–62.
3. Kakkos SK, Bicknell CD, Tsolakis IA, Bergqvis
TD. Helenic co-operative group of aortic surgery.
Editor’s choice – management of secondary aortoenteric stula and other abdominal aorto-enteric stula: a review and pooled data analysis. Eur J Vasc
Endovasc Surg. 2016;52:770–86.
Open Repair ofanInammatory
Abdominal Aortic Aneurysm
10
History andPhysical Examination
This 80-year-old male underwent contrastenhanced CT scan of the abdomen and pelvis
and was found to have 6.5 × 6.1cm abdominal
aortic aneurysm (AAA), 3.6 × 3.4cm right common iliac artery aneurysm, and 2.5cm left hypogastric artery aneurysm. CT scan also showed
thickened wall of the AAA with reactive changes.
Associated medical condition included hypertension, hyperlipidemia, and gout. Past surgical
history included lumbar laminectomy in 1995
and repeat laminectomy in 1996.
Procedure
On May 5, 2011, patient underwent open repair of
AAA and right common iliac artery aneurysm
and left hypogastric artery aneurysm. Epidural
catheter was placed by the anesthesia team. He
was found to have inammatory aortic aneurysm;
therefore 3rd and 4th fourth portion of duodenum
was not separated from the right lateral wall of
AAA.Following mobilization of the ligament of
Treitz and passage of silastic vessel loop around
the left renal vein, aortic neck was exposed.
Proximal anastomosis to the aortic neck after
removing the anterior wall of the AAA was performed using an 18 × 9 mm Dacron graft with
3′0″ CV polypropylene sutures. Distally the dissection was done to mobilize origins of both left
external iliac artery and hypogastric artery. During
mobilization of the common iliac artery, there was
excessive bleeding resulting from a tear at the
junction of external iliac and common iliac vein.
Because of excessive inammatory reaction
(Figs.10.1 and 10.2), it was decided to close the
common iliac artery and anastomose the left limb
Fig. 10.1 Diagram representing operative ndings
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_10
39
40
Fig. 10.2 Incision in the anterior wall of inammatory
AAA
10 Open Repair ofanInammatory Abdominal Aortic Aneurysm
of the aortic bifurcation graft to the left common
femoral artery in an end-to-side fashion. On the
right side, there was no normal cuff of the common iliac bifurcation due to large size of common
iliac aneurysm, and both the origin of right external iliac and hypogastric artery origin were separated by at least a centimeter and a half. Right
hypogastric artery was ligated, and end-to- end
anastomosis to the origin of the right external iliac
artery was performed. Patient received six units of
packed red cells and two units of fresh frozen
plasma in the operating room. Patient was found
to have paraplegia in the recovery room following
extubation. He was started on intravenous steroids. Spinal drain for CSF drainage was not performed because of low platelet count. Patient
developed sacral decubitus ulcer and was given
extensive physical and occupational therapy following extensive debridement of the gluteal area.
Patient had some improvement in motor function
but was essentially conned to the wheelchair.
MRI of the spinal cord showed ischemic changes
in the conus medullaris region with associated
edema. He was transferred to the rehabilitation
institute for further management and died 3years
later from complications of paraplegia.
Discussion
Paraplegia following infrarenal aortic reconstruction is multifactorial with occlusion of the greater
radicular artery (located at the level of T9–T12in
75%, T5–T8in 15%, and L1–L2in 10%) as the
predominant factor. Athero-embolization, suprarenal clamping, shock, and interruption of pelvic
arterial circulation are other important factors,
and in this patient interruption of pelvic arterial
circulation seems to be the most predominant
factor. This patient had thrombosed left hypogastric aneurysm, and ligation of the right hypogastric artery effectively led to loss of arterial supply
to the conus medullaris region of the spinal cord.
In this patient a separate bypass to the right hypogastric artery from the right iliac limb of the aortic bifurcation graft might have prevented this
complication.
Gloviczki et al. described six types of isch-
emic injury to the spinal cord [1]:
• Type I– complete infarction of the distal spinal cord manifesting as complete motor and
sensory loss distal to the lesion
• Type II– infarction of the anterior two third of
the spinal cord (anterior or spinal artery syndrome) manifesting as accid paraplegia with
loss of pain and sensation of temperature with
preservation of sense of vibration and
proprioception
• Type III– infarction of the lumbosacral roots
with or without patchy infarcts in the cord
manifesting as preservation of motor function
but with asymmetric decits
• Type IV – unilateral lumbar sacral plexus
infarction manifesting as unilateral lumbar
plexopathy
• Type V – segmental infarction of the spinal
cord manifesting as spastic paraplegia
• Type VI– infarction of the posterior one third
of the cord (posterior spinal artery syndrome)
References
41
manifesting as loss of sense of vibration and
proprioception, with preservation of motor
function
In some instances, post-interventional paraplegia may be delayed. Urgent neurological and
physiatry consultation should be performed.
Patients often require extensive physical or occupational therapy including bladder and bowel
care, and measures to prevent decubitus ulcers
and contractures in the lower extremities should
be undertaken immediately.
Data from EUROpean collaborators on Stentgraft Techniques for abdominal aortic Aneurysm
Repair (EUROSTAR) database demonstrated
that 5–10% of AAAs have an inammatory component. Ureteral obstruction causing hydronephrosis as a rst clinical appearance has been
described in up to 54% of patients with inammatory AAA. Patients with inammatory AAA
are often symptomatic with chronic abdominal
pain and weight loss and have associated elevation of sedimentation rate, C-reactive proteins,
and WBC count. Wieker et al. reported 33.9%
incidence of perioperative complications following open repair of inammatory AAA [2]. After
repair, perianeurysmal inammation decreases in
most patients on follow-up CT scans. These
patients require long time surveillance for hydroureteronephrosis and development of aortoenteric stula. Spinal cord ischemia following
endovascular aneurysm repair for AAA has also
been described [3].
References
1. Gloviczki P, Cross A, Stenson AW, Carr M, Bower
TC, Pariolero PC, Hellet JW, Toomey BJ, Cherry
KJ. Ischemic injury to spinal cord or lumbar sacral
plexuses after aorto iliac reconstruction. Am J Surg.
1991;162:131–6.
2. Wieker CM, Vonstien P, Massoni CB, Rangier F,
Bockler D, Geisbusch P.Long-term results after open
repair of inammatory infrarenal aortic aneurysms. J
Vasc Surg. 2019;69:440–7.
3. Berg P, Koffman D, VanMarrewijk CJ, Buth J.Spinal
cord ischemia after stent graft treatment for infrarenal abdominal aortic aneurysms. Analysis of
the Eurostar database. Eur J Vasc Endovasc Surg.
2001;22(4):342–7.
Right Subhepatic Approach
forInammatory Aortic Aneurysm
inaPatient withScoliosis
Extraperitoneal ank approach is being increasingly used for juxtarenal and thoracoabdominal
aneurysm repair. Patients with severe scoliosis
may present special problems with exposure that
could be compounded by choice of a wrong
incision.
History andPhysical Examination
An 85-year-old female with a permanent ventricular demand pacemaker inserted in 1983 was
admitted with poor appetite and weight loss for
6 months. A large pulsatile mass in the right
upper quadrant was detected with lumbar scoliosis to the right. A 24 hour dynamic echocardiogram showed pacemaker rhythm rate of 72 per
minute, with occasional premature ventricular
contractions, and ST segment depression. Chest
radiography showed changes suggestive of mild
congestive heart failure. Abdominal ultrasonography revealed abdominal aortic aneurysm to be
9 cm in transverse diameter. Congestive heart
failure was treated with digoxin (Lanoxin), amrinone, and furosemide (Lasix). Two-dimensional
echocardiography showed left ventricular dilation with ejection fraction of 30%. Abdominal
aortography performed via the right femoral
artery approach revealed a large infrarenal
abdominal aortic aneurysm with severe angulation of the aortic neck due to scoliosis (Fig.11.1).
11
Fig. 11.1 Aortogram showing right lateral angulation of
aortic neck with large AAA with large amount of
thrombus
Procedure
Midline abdominal incision was used for aneurysm repair. Removal of a large left ovarian
serous cyst facilitated exposure. The neck of the
aneurysm, located below the liver, was
approached between the gallbladder and the rst
and second portion of the duodenum by lysing
adhesions. The dense adhesions in the lower
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_11
43
44
Fig. 11.2 Showing exposure of aortic neck in the right
side of descending duodenum after limited kocherization
11 Right Subhepatic Approach forInammatory Aortic Aneurysm inaPatient withScoliosis
descending, transverse, and ascending portions
of the duodenum were diagnostic of inammatory aortic aneurysm. The liver was retracted
upward to expose the inferior vena cava and left
renal vein. The portal vein, inferior portion of the
bile duct, and a small portion of the head of the
pancreas were exposed and retracted to the left to
gain proximal control of the aorta (Fig. 11.2).
Proximal control of the aorta was obtained on the
right side of the descending duodenum just below
the origin of the renal arteries. Aneurysm was
resected partially, and anterior and left lateral
wall was kept adherent to the duodenum, and no
attempt was made to separate the duodenum from
the aneurysmal wall. A 19 × 9.5 mm woven
Dacron graft was brought obliquely underneath
the duodenal and aortic aneurysmal wall and
anastomosed to the right common iliac artery
bifurcation. After resection of the left iliac aneurysm, the graft was brought under the sigmoid
mesocolon and anastomosed to the left common
iliac bifurcation (Fig.11.3).
Fig. 11.3 Aortoiliac graft reconstruction
Amrinone was continued after the operation,
which resulted in gradual improvement of congestive heart failure. The following day, she
developed paroxysmal atrial brillation that was
controlled with intravenous verapamil and procainamide. On the third postoperative day, she
experienced two separate episodes of ventricular
tachycardia, which responded to cardiac debrillation, and her pacemaker rate was increased. She
continued to make gradual improvement, her
pacemaker rate was lowered to 75 from 100
beats/minute, and she was discharged on the 14th
postoperative day.
Discussion
Aortic aneurysm in patients with mild scoliosis
can usually be approached transperitoneally on
the left side of the ascending duodenum. The
degree of scoliosis with convexity to the right in
this patient caused aortic angulation and distortion of the usual anatomical relationships [1].
Inammatory AAAs have a dening triad of
thickened aneurysmal wall, extensive perianeurysmal brosis, and dense adhesions to surrounding structures like the small bowel and ureter.
Risk of rupture of inammatory aortic aneurysm
References
45
is generally thought to be lower than that of noninammatory aneurysms. The incidence of
obstructive uropathy is about 20%. Open surgical
treatment of inammatory AAA results in regression of the inammatory process in most patients.
Open repair is associated with signicant early
morbidity, increased transfusion requirements,
and increased length of stay with similar mortality as compared to noninammatory aneurysms.
Patients with inammatory AAA require longterm follow-up for surveillance for hydro-ureter
nephrosis and secondary aortoenteric stula.
Nitecki et al. reported that inammatory AAAs
have a strong familial connection and the current
smoking may play an important role in the
inammatory process [2]. They reported similar survival as compared to noninammatory
aneurysms. Retroperitoneal inammatory process resolved completely in 53% of patients,
but in 47% of patients, there was persistent
inammatory reaction following the repair of
open AAA.This resulted in obstruction of the
ureters (32%) and solitary or bilateral renal
artery with resultant renal atrophy. Right to left
medial visceral rotation is well described for
zone 1 retroperitoneal hematoma involving proximal inferior vena cava, portal vein, or major
arterial branches in the right upper quadrant by
incising the peritoneum lateral to ascending
colon and reecting it medially followed by
kocherization of the duodenum [3]. This technique is rarely necessary during open AAA
repair; however, patient described in this report
had severe scoliosis in the lumbar spine, resulting
in abnormal anatomy in the juxta and infrarenal
aorta necessitating modifying the exposure.
References
1. Hans SS. Right subhepatic approach for inammatory aortic aneurysm in a patient with scoliosis. J Vasc
Surg. 1992;16(1):129–30.
2. Nitecki SS, Hallett AW, Stenson AW, Ilstrup DM,
Bower TC, Cherry KJ, Gloviczki P, Pairolero
PC.Inammatory abdominal aortic aneurysm: a case/
control study. J Vasc Surg. 1996;23:860–9.
3. Ballard J. Surgical exposure in aortic surgery.
Springer; 2000. pp.79–100.
Large Symptomatic Abdominal Aortic Aneurysm
12
Physical Examination
A 52-year-old male was sent by his primary care
physician for CT scan of the abdomen as patient
complained of back pain and was found to have a
large palpable pulsatile mass in the abdomen.
Contrast enhanced CT scan showed 9.5cm transverse diameter infrarenal AAA with 90° aortic
neck angulation with fat stranding (Figs. 12.1,
12.2, and 12.3).
Procedure
Patient was taken to the operating room for emergent open repair of asymptomatic aneurysm as
patient was not suitable for endovascular aneurysm repair. Patient was explored through a midline abdominal incision, and after mobilization of
the neck of the aorta, infrarenal aortic clamping
was performed. There was aneurysmal dilation of
the left common iliac artery. Patient had a contained rupture of the posterior wall of the abdominal aortic aneurysm which was sealed by the
anterior spinal ligament. Following partial excision of the aneurysm, reconstruction was performed using an 18 × 9mm knitted Dacron graft.
Following the completion of the reconstruction
and prior to closure of the retroperitoneum, left
femoral pulse was found to be weak. Left femoral
artery exploration was performed, and a number
4 Fogarty catheter was passed proximally retrieving a small amount of plaque embolus. Following
this, patient had excellent pedal pulses. Patient’s
postoperative course was uneventful.
Discussion
Chronic contained rupture of abdominal aortic
Fig. 12.1 CT scan showing severe angulation of aortic
neck of AAA
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_12
aneurysm was rst described by Szilagyi etal.
[1]. Jones etal. described seven cases of chronic
47
48
Fig. 12.2 Large AAA
12 Large Symptomatic Abdominal Aortic Aneurysm
neuropathy and inguinal hernia pain have been
documented in such instances. If untreated,
aneurysm sac ruptures into the retroperitoneum
with massive blood loss [2, 3]. If aortic neck
angulation is less than 60° and patient otherwise
meets the criteria for endovascular repair, it (and
not the collar) should be preferred in managing a
patient with symptomatic AAA. Patient with
symptomatic AAA over 6cm in transverse diameter needs urgent repair because there is high
incidence of rupture if left untreated.
Fig. 12.3 Axial view showing large AAA with indistinct
post wall, indicative of contained rupture
contained rupture of abdominal aortic aneurysm
presenting as back pain or ank pain. Anterior
spinal ligament seals the perforation with resulting absence of retroperitoneal hematoma and
without any changes in hemoglobin or hematocrit [2]. Misdiagnosis of sealed rupture is not
infrequent [2, 3]. Besides back pain, femoral
References
1. Szilagyi RE, Elliot JB, Smith RP.Ruptured abdominal aortic aneurysms simulating sepsis. Arch Surg.
1965;91:263–75.
2. Jones CS, Reilly MK, Dalsing MC, Glover JL.Chronic
contained rupture of abdominal aortic aneurysm. Arch
Surg. 1986;121:542–6.
3. Sterpetti AI, Blair EA, Schulz RD, Feldhaus RJ,
Cisternio S, Chassan P. Sealed rupture of abdominal
aortic aneurysms. J Vasc Surg. 1990;11(3):430–5.
Abdominal Aortic Aneurysm
inaPatient withChronic
Lymphocytic Leukemia
13
History andPhysical Examination
A 70-year-old female was diagnosed with chronic
lymphocytic leukemia (CLL) 5 years earlier.
Patient underwent follow-up CT scan of the abdomen for further evaluation of CLL and was found
to have 5.8cm infrarenal abdominal aortic aneurysm with an accessory left renal artery near the
neck of the aneurysm. There was evidence of right
external iliac artery occlusion and a high- grade
stenosis of right common femoral artery. In addi-
tion, patient had 70% stenosis of the left external
iliac artery and 70% stenosis of the common femoral artery (Figs.13.1, 13.2, and 13.3). She complained of right hip and calf claudication. Other
associated medical comorbidities included hypertension, hyperlipidemia, type II diabetes mellitus,
and degenerative arthritis of the hip and spine.
She was a former smoker with a history of smoking 67 pack years. She quit smoking in 2014.
Laboratory data showed hemoglobin 9.7g, hematocrit 26, WBC count 42,500, and platelet count
Fig. 13.1 Infrarenal AAA with accessory left renal artery
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_13
49