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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Rupture ofAbdominal Aortic
Aneurysm inaPatient
withaHorseshoe Kidney
17
Physical Examination
A 61-year-old male presented to the emergency
room on March 7, 2007, with abdominal pain and
syncope. Emergency contrast-enhanced CT scan
of the abdomen and pelvis revealed a leaking
abdominal aortic aneurysm (AAA) with a horseshoe kidney (Fig.17.1). Associated medical conditions included hypertension, diabetes mellitus,
obesity, and nicotine abuse. There were associated bilateral common iliac aneurysms and calcied plaque with diffuse narrowing of both
external iliac arteries.
Procedure
Patient underwent emergency repair of ruptured
abdominal aortic aneurysm with right aortofemoral and left external iliac graft through the
transperitoneal approach. The main body of the
graft was brought under the isthmus of the
horseshoe kidney. His postoperative course was
complicated by multi-organ failure (respiratory
failure, mild renal failure, and dilution coagulopathy). Subsequently, patient developed
lower gastrointestinal bleeding secondary to
left colon and rectal infarction and underwent
total abdominal colectomy with ileostomy. He
was also found to have extensive diverticulosis
of the left colon. In the postoperative period,
patient was found to have signicant weakness
of the lower extremities. He was discharged following aneurysmal repair 6 weeks later and
underwent extensive physical and occupational
therapy. Patient presented 10 years later with
symptomatic 6cm anastomotic aneurysm in the
right groin which was repaired with interposition of 10mm knitted Dacron graft. Patient was
last seen in July 2019in satisfactory condition.
He was found to have a small-size renal carcinoma on the right portion of the horseshoe kidney, but because of signicant comorbidities,
patient refused any further intervention for the
suspected renal cancer.
Discussion
Horseshoe kidney occurs in approximately 0.25–
0.5% of patients requiring abdominal aortic
aneurysm repair [1, 2]. The preferred surgical
options for AAA with a horseshoe kidney in an
elective setting are endovascular aneurysm repair
(EVAR) or repair using a left retroperitoneal
ank approach, depending upon the morphology
of the aneurysm and location of the dominant
renal arteries [1, 2]. In a hemodynamically stable
patient with a leaking AAA and a horseshoe kidney, EVAR can be attempted, but in most patients,
the transperitoneal approach becomes necessary
[1, 2]. The isthmus of the horseshoe kidney can
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_17
61
62
17 Rupture ofAbdominal Aortic Aneurysm inaPatient withaHorseshoe Kidney
Fig. 17.1 Leaking AAA with horseshoe kidney
be divided if it is thin and has minimal renal
parenchyma. If the isthmus is thick, dissection
underneath the mobilized isthmus (as in this
patient) or medial visceral rotation may be necessary to gain adequate exposure [1, 2].
Postoperative complications following a
repair of ruptured aneurysm in a patient with a
horseshoe kidney are common. Incidence of
renal insufciency is reported to be 17% [1].
Adequate knowledge of the vascular anatomy
to the horseshoe kidney is essential to determine the approach of choice in a patient with
horseshoe kidney associated with abdominal
aortic aneurysm [1, 2].
References
1. Stroosma OB, Kootstra G, Schurink H.Management
of aortic aneurysm in the presence of a horseshoe kidney. Br J Surg. 2001;88:500–9.
2. Illig KA, Green RM. Diagnosis and management of
the “difcult” abdominal aortic aneurysm: pararenal
aneurysms, inammatory aneurysms and horseshoe
kidney. Semin Vasc Surg. 2001;14:312–7.
Rupture ofPararenal Aortic
Aneurysm
18
History andPhysical Examination
A 59-year-old male presented to the emergency
room on April 1, 2007, with acute onset of
abdominal pain radiating to the back. CT scan
of the abdomen and pelvis revealed 8.5 cm
abdominal aortic aneurysm with retroperitoneal
hematoma. Medical comorbidities included
hypertension and nicotine and alcohol abuse.
Abdominal aorta was dilated to 3.2cm at the
level of superior mesenteric artery. His renal
function was normal. Patient was taken to the
operating room for emergent repair of a leaking
abdominal aortic aneurysm (pararenal) with a
retroperitoneal hematoma.
Procedure
Midline incision was made and a Bookwalter
retractor (Symmetry Surgical, Nashville, TN)
was applied. The ligament of Treitz was mobilized and left renal vein was ligated close to the
inferior vena cava. Both renal arteries and proximal portion of superior mesenteric artery was
exposed after the crus of the diaphragm was
divided on both sides. Patient was started on
mannitol infusion. Proximal vascular clamp was
applied above both renal arteries and just below
the superior mesenteric artery. A 22 × 11 mm
knitted Dacron graft was selected, and proximal
anastomosis was done in two layers: horizontal
mattress sutures of four “O” cardiovascular
polypropylene suture (Ethicon, Somerville, NJ)
and second layer of continuous sutures. Sutures
were applied in such a manner that the inferior
wall of the renal artery was included in the
suture line so that the proximal anastomosis was
at the level of the renal arteries. Distal reconstruction was performed to the right common
femoral artery on the right side on an end-toside fashion and to the left external iliac artery
with an end-to-side fashion as well. In the postoperative period, patient developed delirium tremens due to alcohol withdrawal which
responded to administration of thiamine, multivitamins, and nutritional support. Patient was
discharged on the tenth postoperative day.
Patient underwent a follow-up CTA of the abdomen in 2013 which showed that the suprarenal
segment of the aorta measured 4.4cm. CTA performed in 2014 showed that the AAA measured
4.7cm (Figs.18.1 and 18.2) and at the level of
renal arteries. In January 2019, patient underwent repair of femoral anastomotic aneurysm
with reimplantation of deep femoral artery as a
cuff with 8mm interposition graft to the previously placed femoral artery of the graft and
proximal femoral artery (Figs. 18.3 and 18.4).
Recent arteriography showed suprarenal AAA
and satisfactory repair of femoral anastomotic
aneurysm with patent interposition graft and
patent reimplanted deep femoral artery into the
graft (Figs.18.5 and 18.6).
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_18
63
64
Fig. 18.1 Postoperative CTA (2014) 7years following open repair
18 Rupture ofPararenal Aortic Aneurysm
Fig. 18.2 CTA showing small proximal para- anastomotic
aneurysm with small amount of thrombus
Discussion
Open repair of pararenal aortic aneurysms can be
carried out with acceptable morbidity and mortality. However, endovascular repair has continued to emerge as an alternative in high-risk
Fig. 18.3 CTA showing right femoral anastomotic aneu-
rysm repair
patients. Recently, Truijers reported endovascular repair in a high-risk patient with Nellix graft
with two chimney grafts extending to both renal
arteries with satisfactory outcome in a patient
with leaking pararenal aneurysm [1]. However,
these options are more applicable in elective
situations.
Dijkstra et al. reported two patients who
underwent endovascular aneurysm sealing for
juxtarenal aneurysm using the Nellix device and
chimney-covered stents. However, at 6months,
Discussion
65
Fig. 18.4 Showing operative pictures of repair of right femoral anastomotic aneurysm with interposition 8mm Dacron
graft and reimplantation of deep femoral artery
66
Fig. 18.5 Aortogram showing descending thoracic and
proximal abdominal aortogram (2019) with patent aortofemoral iliac graft
18 Rupture ofPararenal Aortic Aneurysm
one of the patients developed a right retroperitoneal hematoma with small extravasation near
the lower pole of right kidney for which he
underwent coil embolization. However, patient
subsequently died from multi-organ failure [2].
In patients with a contained retroperitoneal
hematoma who are hemodynamically stable and
have suprarenal aneurysm in addition to an
infrarenal aneurysm, a left ank retroperitoneal
approach is useful. Author has performed this
approach on three occasions with satisfactory
results in two patients.
In some patients, a transperitoneal midline
approach with mobilization of suprarenal segment by dividing crus of the diaphragm on
either side, ligation of the left renal vein close
to the inferior vena cava will allow placement
of proximal clamp just below the superior mesenteric artery. Supraceliac control of the aorta
is also a suitable option in such instances.
Suprarenal segment of aorta may not need to be
repaired at the time of repair of leaking infrarenal AAA. Patient should be followed with
Fig. 18.6 Reimplanted deep femoral artery into femoral interposition Dacron graft
References
67
imaging studies such as CTA of the abdomen
and pelvis. Recently, Wang et al. compared
operative technique of the plication of the aneurysm cuff with the graft sown up to the renal
arteries (as was in this case) with a beveled
anastomosis with renal artery bypass in patients
undergoing open repair of juxtarenal aortic
aneurysms. There were112 patients in the plication group and 87in the renal artery bypass
group. They observed that the more complex
technique involving left renal artery bypass was
not protective against long-term anastomotic
degeneration, decline in renal function, and
mortality [3]. Future interventions for suprarenal aortic aneurysm will depend upon its size
and general medical condition of the patient.
Open or branched endograft repair may need to
be undertaken [4].
Invited Commentary fromAudra
A.Duncan MD, FACS, FRCSC
The author describes a 59-year-old patient with a
ruptured 8.5 cm pararenal aortic aneurysm
repaired with open reconstruction. This case
illustrates several key points in management of
complex aortic aneurysm. First, the option to
repair with an open technique rather than an
endovascular repair is often dependent on the surgeon preference and device availability. With the
large size of the paravisceral aorta, it is likely that
a fenestrated device would extend into the thoracic aorta if appropriately sized, and that coverage would increase the patient’s risk of spinal
cord ischemia. Other options, such as chimney
grafts, are an option in ruptured patients but have
a high risk of endoleak which is potentially dangerous in patients with preexisting rupture and
hematoma. The use of open repair, especially in a
young patient, seems to be a sound decision.
Intraoperative decision making is often
guided by the preoperative CT scan, and this
patient was fortunately stable enough to have a
CT before surgery. Decision about the level of
clamp is often made before laparotomy if imaging is available. In this case, either a supraceliac
clamp or a supraSMA clamp would also have
been reasonable, whereas a suprarenal clamp
was placed in this patient. Due to infrequent
involvement of the supraceliac aorta in the atherosclerotic disease process, clamping at this
site is preferable. The disadvantage of supraceliac clamping is a higher cardiac event rate [5].
This patient may also have done well with a
supraSMA clamp, since the aorta appears normal in size above the SMA.This dissection can
be done by dividing the crus on either side of the
aorta, mobilizing the renal vein, and extending
the renal vein proximally. The clamp is then
placed on the aorta proximal to the SMA with
the renal vein on the superior side of the clamp,
so the clamp acts as a retractor for the vein and
the exposure is excellent. Although ligation of
the left renal vein can be done, this maneuver
does increase the risk of renal failure [5]. Other
options are mobilization of the vein by ligation
of tributaries (adrenal, lumborenal, gonadal) or
by clamping, transection, and re-anastomosing
the renal vein after aortic graft reconstruction.
The author chose to extend the graft to the
femoral artery and reconstruct the distal anastomoses in an end-to-side manner. If possible,
extension of graft into the femoral arteries should
be avoided in order to reduce the risk of prosthetic graft infection that is associated with groin
incisions. In addition, most aortic reconstructions are performed in an end-to-end manner, in
order to eliminate as much aneurysmal tissue as
possible. If an end-to-side anastomosis is constructed, the native iliac must be ligated, and the
remaining artery “pouch” is at risk of dilation
and potential rupture in the long term. Overall,
this patient is young with a large aneurysm, as
well as an anastomotic aneurysm. He will require
close follow- up, including assessment for thoracic aortic aneurysm and assessment of the etiology of the pseudoaneurysm (i.e., was the
pseudoaneurysm caused by infection?). At his
young age, open repair remains the most durable
option for his aortic reconstruction.
References
1. Truijers M, Vansterkenburg S, Lardenoije JW, Reijnen
MPJ.Endovascular repair of ruptured pararenal aortic
aneurysms using the Nellix endovascular aneurysm
68
18 Rupture ofPararenal Aortic Aneurysm
sealing system and chimney grafts. J Endovasc Ther.
2015;22(3):391–4.
2. Dijkastra M, Lardenoye JW, Van Oostayen JA,
Zeebregts CJ, Reijne M. Endovascular aneurysms
sealing for juxtarenal aneurysms using the Nellix
device and chimney covered stents. J Endovasc Ther.
2014;21:541–7.
3. Wang LJ, Tsougranis GH, Tanious A, Chang D, etal.
The removal of all proximal aortic tissue does not
affect anastomotic degeneration after open juxtarenal
aortic aneurysm repair. J Vasc Surg. 2020;71:390–9.
4. Hans SS. Open rupture AAA repair. In: Hans SS,
Shepard S, Weaver M, editors. Endovascular and open
vascular reconstruction: a practical approach. Boca
Raton: CRC Press, Taylor and Francis Group, LLC;
2018. p.205–11.
5. West CA, Noel AA, Bower TC, Cherry KJ Jr, Gloviczki
P, Sullivan TM, et al. Factors affecting outcomes of
open surgical repair of pararenal aortic aneurysms: a
10-year experience. J Vasc Surg. 2006;43:921–7.
Rupture ofAbdominal Aortic
Aneurysm withTear ofInferior
Vena Cava inaPatient withPrior
Endograft
19
Physical Examination
This 63-year-old man was seen at the emergency
room on May 17, 2001, with severe abdominal
pain of sudden onset, associated with postprandial nausea and vomiting. He was diaphoretic,
with a blood pressure of 120/80 mm Hg and a
heart rate of 120 beats per minute. Medical
comorbidities included hypertension, severe coronary artery disease, and depression. In January
2000, the patient was admitted to an outside hospital with signicant coronary artery disease and
abdominal aortic aneurysm. At that time, the
patient underwent extensive cardiac evaluation,
including coronary arteriography and electrophysiological studies.
History
Coronary arteriography and primary stenting of
the right coronary artery was performed vial left
brachial cutdown by the cardiologist in June
2000. Left anterior descending or circumex coronary artery did not show any stenosis. The estimated left ventricular ejection fraction was 20%
with an increased left ventricular end-diastolic
pressure of 18mm Hg.
On January 30, 2000, the patient underwent
spiral CT scanning of the abdomen followed by
abdominal aortography. The CT scan results
(6mm collimation) revealed a 7.0cm infrarenal
abdominal aortic aneurysm. The transverse diameter of the neck of the abdominal aortic aneurysm
just below the renal arteries measured 28.0mm,
and the length of the aortic neck was about
15.0 mm, with 60 degrees neck angulation
(Fig. 19.1). The review of the records from the
outside hospital revealed that the repair of the
abdominal aortic aneurysm was performed with
AneuRx stent graft (Medtronic, Sunnyvale, CA)
on February 4, 2001, under spinal anesthesia.
Review of the operative records showed that femoral artery cutdowns were performed. Left brachial artery cutdown was also performed for
Fig. 19.1 Abdominal aortogram showing signicant
angulation of the aortic neck
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_19
69
19 Rupture ofAbdominal Aortic Aneurysm withTear ofInferior Vena Cava inaPatient withPrior Endograft
70
capturing the gate for placement of the left iliac
extension limb.
A 28.0mm × 16.0mm (16.5cm long) primary
component of the AneuRx stent graft was
deployed from the right femoral artery, and a
16mm iliac limb (11.5cm long) was deployed via
the left femoral artery approach. In addition, an
aortic extension cuff (28.0mm to 3.75cm long)
also was deployed. According to the operative
report, there was no evidence of endoleak, with
complete exclusion of the aneurysm at the time of
completion arteriography during the operation.
Hemoglobin at the time of hospital presentation was 12.5 g with a hematocrit of 35.0.
Contrast enhanced CT scan of the abdomen
Fig. 19.3 Right iliac limb in close proximity to inferior
vena cava
and pelvis revealed a 7.0 × 7.0cm AAA, with
collection of contrast media outside of the
aneurysm and increase in soft tissue density
around the aneurysm with fat stranding
(Fig.19.2). There was a collection of contrast
material between the stent graft and the mural
thrombus of the AAA, indicative of a large
endoleak. The right iliac limb was near the
IVC as visualized with CT scan results
(Fig.19.3).
toma primarily extending toward the right side.
For proximal control, the left renal vein was
ligated. Suprarenal control of abdominal aorta
was obtained, and both renal arteries were controlled with silastic vessel loops. Vascular clamps
were applied to the external iliac and hypogastric
arteries on each side. The site of rupture of AAA
was anteromedial. The aneurysm was opened at
the site of rupture. The main component of the
graft and the aortic extender cuff migrated out of
the proximal neck. There was no tissue incorpo-
Procedure
ration of the graft. The main body of the graft was
easily removed. However, the iliac limbs were
Patient was taken to the operating room on emergency basis on May 17, 2001. He was found to
have rupture of AAA with retroperitoneal hema-
well incorporated and were somewhat difcult to
remove.
The left iliac limb was completely separated
from the main body of the graft. The right iliac
limb of the graft 2–3cm from its distal end developed marked angulation and resulted in the penetration of the IVC just above the common iliac
vein junction. A 3.0cm laceration of the left lateral wall of the inferior vena cava was repaired
with 5-0 polypropylene (Ethicon, Somerville,
NJ) was performed after application of an Allis
clamp. Estimated blood loss was about 2500cc.
Eight units of packed cells, two units of fresh frozen plasma, and ten liters of crystalloids were
administered. A 20.0 mm × 10.0 mm Gelsoft
knitted Dacron graft (Sulzer Medica, Scotland,
United Kingdom) was used for aortobiiliac
Fig. 19.2 Showing large endoleak and extravasation of
the cabin layer of the duodenal wall of AAA
reconstruction. The patient was on ventilatory
support for 3days after surgery. Left lower lobe