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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
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110 Section 8: Aortoiliac Disease
In a patient with a large-diameter juxtarenal abdominal aortic aneurysm (AAA) with COPD, the left
retroperitoneal approach is preferable. In most patients undergoing repair of AAA using the left retroperitoneal approach, the patient is positioned in a modified right lateral decubitus position with
the shoulders positioned at 70 degrees to the table and the hips rotated as far posteriorly as possible.
For infrarenal AA A repair, the left flank incision is carried back into the 11th intercostal space. For
repair of a juxtarenal AAA, exposure of the pararenal aorta is carried with an incision extending to
the 10th intercostal space. The peritoneum often overlying the transversalis fascia is stripped away
from the abdominal wall, and the musculature is followed to the peritoneal sac and its contents
are retracted anteriorly. This plane is developed superficial to the lumbodorsal fascia (the posterior
extension of the transversalis fascia) behind the left kidney so that left kidney and ureter are also
reflected anteriorly. The lumbar branch of the left renal vein crossing over the aorta proximally is a
reliable landmark, with the left renal artery identifiable just above and proximally. In patients with
a retroaortic left renal vein, it is necessary to leave the kidney “down” in its normal anatomical position and expose the aorta anterior to the kidney to avoid ligating the left renal vein.
Correct Answer C Left retroperitoneal approach with left kidney remaining in its anatomical
position
Reference
Shepard, A. D. (2017). Open nonruptured infrarenal aortic aneurysm repair. In S. S. Hans, A. D.
Shepard, & H. R. Weaver (Eds.), Endovascular and open vascular reconstructions: a practical
approach (pp. 197–204). Boca Raton, FL: CRC Press.
3. RATIONALE
From the Danish Vascular Registry and the Danish Ventral Hernia Database (2007–2012),
2597 patients (838 aortic occlusive disease and 1759 AAA repair) underwent open aortic
reconstruction, and the cumulative risk of hernia was 10.4% after 6 years of follow-up. The
study found that high body mass index and AAA repair were independent risk factors for a
subsequent incisional hernia surgery in patients undergoing aortic reconstructive surgery.
Retroperitoneal incision for aortic aneurysm repair may result in injury to the 11th intercostal nerve, which may result in paresthesia in about 30% patients and a “bulge” in the lateral
abdominal wall with muscle atrophy in 7%–15%. A genetic predisposition to weakened
connective tissue causing the aorta to expand and a subsequent hernia to develop is hypothesized as a common pathophysiological entity in the two diseases. Patients undergoing
AAA repair have a 1.6-fold higher risk of subsequent hernia repair than patients undergoing
reconstruction for aortoiliac occlusive disease.
Correct Answer C 10%–15%
Reference
Henriksen, N. A., Helgstrand, F., Vogt, K. C., et al. (2013). Risk factors for incisional hernia repair
after aortic reconstructive surgery in a nationwide study. J Vasc Surg, 57(6), 1524–1530,
e1521–1523. PMID: 23548175
4. RATIONALE
Clinically significant colon ischemia occurs in 1%–2% of patients following open repair of AAA
with a 50%–75% mortality. Mortality can be as high as 90% if the bowel resection is required for
infarction. Colon ischemia is far more common than small bowel ischemia. Early postoperative diarrhea, melena, hematochezia, and persistent metabolic acidosis mandate definitive
Section 8: Aortoiliac Disease 111
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diagnostic aids such as fiberoptic sigmoidoscopy. Ligation of a large inferior mesenteric artery
is necessary in the presence of a meandering mesenteric artery (arc of Riolan), superior mesenteric artery, and celiac artery occlusive disease. Atheroembolism or retractor blade injury to
SMA and prior colon resection are contributing factors for interstitial ischemia. Patients with
associated significant SMA stenosis in the presence of large mesenteric collaterals or a largesized inferior mesenteric artery may need reimplantation of the inferior mesenteric artery into
the prosthetic graft using a Carrel patch technique or preoperative stenting of the superior
mesenteric artery. Once the diagnosis of colon ischemia is confirmed by fiberoptic sigmoidoscopy or colonoscopy, the patient should be adequately resuscitated and started on intravenous
antibiotics targeted towards intestinal microorganisms. If ischemia is localized to mucosa and
muscularis mucosa, the patient can be managed conservatively, whereas full-thickness infarction will require emergent laparotomy and bowel resection. In patients with ischemia limited to
mucosa and muscularis mucosa, late stricture may develop.
Correct Answer B 1%–2% of patients
Reference
Chaikof, E. L., Dalman, R. L., Eskandari, M. K., et al. (2018). The Society for Vascular Surgery prac-
tice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg, 67(1),
2–77.e72. PMID: 29268916
5. RATIONALE
Graft infections occur in less than 1% of patients undergoing elective repair for unruptured
AAA. An aortic prosthetic graft is at risk of infection at the time of implantation or later by
a hematogenous spread. Aortic graft infections are difficult to diagnose, as the patient may
present with nonspecific symptoms such as generalized weakness, malaise, anorexia, and
unexplained weight loss. Occasionally, the patient may present with overt sepsis. Common
pathogens include Staphylococcus aureus and Staphylococcus epidermidis. The laboratory
and diagnostic studies are often nondiagnostic. Leukocytosis with a shift to the left, elevated
C-reactive protein, and sedimentation rates are often present.
112 Section 8: Aortoiliac Disease
Correct Answer A <1% of patients
Reference
Hallett, J. W., Jr., Marshall, D. M., Petterson, T. M., et al. (1997). Graft-related complications after
abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.
J Vasc Surg, 25(2), 277–284; discussion 285–276. PMID: 9052562
6. RATIONALE
Due to the increased use of endovascular repair for infrarenal AAA, most patients requiring
open AAA in contemporary vascular practice have juxtarenal or pararenal AAAs. To obtain
satisfactory proximal exposure, the left renal vein may need to be ligated and divided medial to
the adrenal and gonadal veins if transperitoneal repair is selected. Depending on the quality of
the aorta just below the renal arteries, suprarenal, infrarenal, or inter-renal control is obtained.
Division of the left renal vein followed by the reanastomosis does not offer any advantage in
terms of renal function status on a long-term basis as compared to its ligation. Ligation of the
left renal vein is associated with an increased incidence of AKI and renal function deterioration in the early postoperative phase. However, long-term renal function does not seem to be
affected. Supraceliac control or proximal aortic balloon occlusion is rarely necessary during
repair of even a large juxtarenal AAA.
Correct Answer A Ligation of the left renal vein medial to the gonadal and adrenal vein
Reference
Pandirajan, K., Katsogridakis, E., Sidloff, D., et al. (2020). Effects of left renal vein ligation during open
abdominal aortic aneurysm repair on renal function. Eur J Vasc Endovasc Surg, 60(6), 829–835.
PMID: 32912760
7. RATIONALE
Section 8: Aortoiliac Disease 113
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Choosing an appropriate site for proximal control is one of the most important determinations
of operative success with proximal AAA repair. The more proximal the aortic clamp, the greater
strain on the myocardium and the greater renal/visceral ischemic burden. It is also important to
avoid clamping the diseased aorta with an increased risk of renal/visceral and lower extremity
atheroembolism. When the origin of the SMA is too close to the renal arteries, supraceliac clamping
is preferable because aorta at that site is reliably the least diseased. A left flank approach through
the 9th or 10th intercostal space (ICS) is preferable for repair of a suprarenal abdominal aortic
aneurysm. Positioning of the patient begins in a modified left thoracotomy position. The incision
begins just below the umbilicus at the lateral border of the left rectus sheath and carried obliquely
into the chest via the 9th or 10th ICS. The diaphragm is divided circumferentially beginning at the
costal margin approximately 2 cm from its lateral attachments to avoid injury to the branches of
the phrenic nerve. A mechanical retractor system, the Integra Omni-Tract (Integra Life Science Co.,
Plainsboro, NJ), is key to good exposure. A retroperitoneal plane posterior to the left kidney is developed, and the left kidney with peritoneal sac and its contents are retracted to the patient’s right. The
lumbar branch of the renal vein (LRV) is carefully sought as it crosses over the aorta and is divided,
providing a guide to the location of the left renal artery. The left diaphragmatic crus are divided
along the long axis of the aorta, and this is facilitated by insertion of the left index finger under the
crus on top of the aorta. This step helps in exposure of the SMA and celiac artery. Investing fascia
over the aorta is divided, and the surgeon’s index finger is passed just anterior to and posterior to
the aorta to allow passage of the vascular clamp. Extraluminal control is less cumbersome than
intraluminal control with balloon occlusion catheters. Control of the right common iliac artery can
be safely obtained using intraluminal control during a retroperitoneal approach.
Correct Answer D Left flank retroperitoneal approach through the left 10th intercostal space
Reference
Shepard, A. D. (2018). Proximal abdominal aortic aneurysm repair. In S. S. Hans, A. D. Shepard,
H. R. Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstruction: a
practical approach (pp. 213–219). Boca Raton, FL: CRC Press.
8. RATIONALE
114 Section 8: Aortoiliac Disease
Most aortic surgeons prefer exposure of the proximal abdominal aorta using a left retroperitoneal flank approach. Exposure of the more proximal abdominal aorta can also be obtained
through a midline incision using medial visceral rotation (MVR). With MVR, peritoneal reflection lateral to the left colon and spleen is incised from the sigmoid colon cephalad to the aortic
hiatus. A retrorenal vein is developed, and the spleen, pancreas, and left kidney are retracted
medially to provide exposure of the entire abdominal aorta from the aortic hiatus to its bifurcation. The major disadvantage of this approach is the lack of access to the distal descending
thoracic aorta, a high incidence of splenic injury (20%), and pancreatitis. In most instances, a
supraceliac clamp placement is appropriate, and intraluminal control is more cumbersome in a
patient during laparotomy.
Correct Answer A Clamp placement at the supraceliac level
Reference
Shepard, A. D. (2018). Proximal abdominal aortic aneurysm repair. In S. S. Hans, A. D. Shepard,
H. R. Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstruction: a
practical approach (pp. 213–219). Boca Raton, FL: CRC Press.
9. RATIONALE
Section 8: Aortoiliac Disease 115
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Acute kidney injury (AKI) is one of the most commonly reported complications of paravisceral
AAA repairs. Minimizing visceral clamp time is critical. Before clamping, hemodynamics
should be optimized. Mannitol (25 g) is administered 15–20 minutes before aortic crossclamping. Inflation of a small (4 or 5 Fr) balloon-tipped occlusion catheter within the orifice
of the right renal artery can block the passage of debris into the renal artery. When prolonged
(>30 minutes) renal ischemia times are anticipated or in patients with preexisting CKD, cold
renal perfusion to reduce metabolic demands consisting of 250 cc of 1°C Ringer’s lactate solution (plus methylprednisolone, mannitol, and heparin) is infused into each kidney followed
by 50 mL every 10–15 minutes for the duration of clamping. Infusion is performed through a
balloon-tipped Pruitt perfusion catheter (9 Fr) for larger renal arteries (LeMaitre Vascular, Inc.,
Burlington, MA) and 4 or 5 Fr catheters for smaller renal arteries. A similar technique can be
used for perfusion of the superior mesenteric artery.
Correct Answer C Perfusion of the renal arteries with a solution of cold Ringer’s lactate,
heparin, mannitol, and methylprednisolone during aortic occlusion
Reference
Kabbani, L. S., West, C. A., Viau, D., et al. (2014). Survival after repair of pararenal and paravisceral
abdominal aortic aneurysms. J Vasc Surg, 59(6), 1488–1494. PMID: 24709440
10. RATIONALE
Paravisceral aortic reconstruction usually requires a beveled end-to-end anastomosis which
incorporates the origin of renal and visceral arteries. How that is performed depends on the
relationship of the renal arteries to the aorta. If both renal arteries originate anteriorly with
most of the aneurysmal wall extending posteriorly, a posterior bevel is possible. With this
reconstruction the aorta is trimmed to leave the two renal arteries, the SMA and, if necessary, the celiac artery, on the anterior tongue of the aorta while the graft is cut to leave the
corresponding posterior bevel. In practice, this type of reconstruction is usually not feasible.
More commonly the proximal reconstruction is a laterally based beveled anastomosis that is
used when the renal arteries are separated by a significant amount of aneurysmal wall. This
technique incorporates the right renal artery, SMA, and celiac artery into the graft or, more
frequently, bypassed with a small-caliber sidearm graft previously sewn onto the aortic graft
(6 mm PTFE). When using a renal graft, it is imperative to carefully rotate (trim the aortic
graft) so that the sidearm is appropriately positioned, usually at the 2 o’clock position (SMA
at 12 o’clock), as this will prevent subsequent sidearm kinking of the graft. The graft-to-aorta
anastomosis is performed with the inclusion technique, taking the first suture bites at the
level of the dependent right renal artery and then carrying the suture line up the posterior
wall of the aorta and taking double-thickness bites until the transected edge of the aorta
is encountered. Single-thickness aortic wall stitches bring the suture line up to the level of
the SMA or celiac artery and then down the transected anterior wall. Following appropriate flushing maneuvers, the perfusion catheters are removed and the suture line is secured,
allowing sequential flow to the right renal artery to the celiac and the SMA. If the aneurysm
extends well above the origin of the celiac artery mandating an end-to-end anastomosis
between the graft and the aorta with reimplantation of the celiac artery, the SMA and left
renal artery are done as a separate inclusion patch.
Correct Answer D All of the above are acceptable techniques depending on the local
anatomy
116 Section 8: Aortoiliac Disease
Reference
Shepard, A. D. (2018). Proximal abdominal aortic aneurysm repair. In S. S. Hans, A. D. Shepard,
H. R. Weaver, P. G. Bove, & G. W. Long (Eds.), Endovascular and open vascular reconstruction: a
practical approach (pp. 213–219). Boca Raton, FL: CRC Press.
11. RATIONALE
The natural history of thoracoabdominal aortic aneurysm is that of progressive enlargement.
The mean rate of growth for TAAA is 0.2 cm/year and is accelerated in patients with dissections and connective tissue disorders. The 5-year survival of patients with TAAA is 13%, and
aneurysm rupture is the cause of death in nearly 75% of untreated patients. Factors associated
with rupture include aneurysm diameter, rapid expansion, COPD, steroid use, female gender,
advanced age, and renal insufficiency. Contemporary series indicate that the rupture risk
increases substantially as the aneurysm diameter reaches greater than 6 cm or with a growth
rate of 10 mm per year. For patients with TAAA secondary to chronic dissection or those with
Marfan syndrome, a 5-cm threshold is used.
Correct Answer C 6.0 cm
Reference
Conrad, M. F., & Cambria, R. P. (2008). Contemporary management of descending thoracic and thora-
coabdominal aortic aneurysms: endovascular versus open. Circulation, 117(6), 841–852. PMID:
18268161
12. RATIONALE
Section 8: Aortoiliac Disease 117
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Many adjuncts have been recommended to minimize spinal cord ischemia (SCI) after TAAA
repair, and only cerebrospinal fluid (CSF) drainage is evidence-based. Intercostal reconstruction had been routinely practiced despite evidence that it is based on retrospective studies.
Distal aortic perfusion via left arterial-femoral bypass used in conjunction with motor-evoked
potential (MEP) monitoring to dynamically assess SCI during the operation has replaced
epidural cooling as the principal cord-protective strategy in patients with type I–III TAAA.
Preservation of continuous perfusion of the pelvis (hypogastric artery) is logical and prudent.
The addition of MEP monitoring enables the surgeon to depend on objective criteria for direct
selective intercostal reconstruction and replaces the subjective application of intercostal
reimplantation.
Correct Answer C Distal aortic perfusion with intraoperative motor evoked potential
monitoring
Reference
Conrad, M. F., & Cambria, R. P. (2008). Contemporary management of descending thoracic and thora-
coabdominal aortic aneurysms: endovascular versus open. Circulation, 117(6), 841–852. PMID:
18268161
13. RATIONALE
Distal perfusion through atrial femoral bypass and maintenance of distal perfusion pressure at
60–70 mmHg via a centripetal, motorized pump is simple and requires a low dose of systemic
heparin. Atrial femoral bypass is initiated by cannulation of the left inferior pulmonary vein,
and the arterial return is via the left common femoral artery. Liberal use of atrial femoral bypass
for patients with type I–III TAAA is based on the concept of the spinal cord collateral network,
emphasizing the importance of pelvic/hypogastric vessels and a selective approach toward
intercostal reconstruction. Continuous perfusion of mesenteric circulation during reconstruction of the visceral aortic segment is desirable. This can be accomplished with either a Y
connection from the atrial femoral bypass circuit or with in-live mesenteric shunting from the
proximal graft after completion of proximal anastomosis.
Correct Answer D 60–70 mmHg
Reference
Conrad, M. F., & Cambria, R. P. (2008). Contemporary management of descending thoracic and thora-
coabdominal aortic aneurysms: endovascular versus open. Circulation, 117(6), 841–852. PMID:
18268161
14. RATIONALE
As the number of comorbid conditions increases, so does the overall operative risks of repair
of TAAA. Many series have reported that the presence of coronary artery disease, COPD, and
renal insufficiency increases mortality. Preoperative renal insufficiency is the most powerful
predictor of postoperative renal failure. Minimizing renal ischemic times, use of cold perfusate,
avoiding intraoperative hypotension, and treating stenotic lesions with either bypass or open
stent placement reduce renal injury. Postoperative renal dysfunction negatively affects shortand long-term survival.
Correct Answer A 30 cc
118 Section 8: Aortoiliac Disease
Reference
Conrad, M. F., & Cambria, R. P. (2008). Contemporary management of descending thoracic and thora-
coabdominal aortic aneurysms: endovascular versus open. Circulation, 117(6), 841–852. PMID:
18268161
15. RATIONALE
SCI is the most devastating nonfatal complication associated with TAAA reconstruction. The pathogenesis of SCI after aortic replacement is multifactorial, but ultimately results from an ischemic
insult caused by temporary or permanent interruption of the spinal cord blood supply. SCI manifests along a clinical spectrum from complete flaccid paraplegia to varying degrees of paraparesis.
The degree of SCI directly predicts long-term survival after TAAA repair. Patients with incomplete
deficits often recover reasonable function and have a long-term survival like those without SCI.
Patients with an SCI deficit score of 1 rarely live beyond the first year. The incidence of dialysisdependent renal failure following open repair of thoracoabdominal aortic aneurysm is 2%–3%.
Correct Answer D Type I–III thoracoabdominal aortic aneurysm and urgency of operation
Reference
Conrad, M. F., & Cambria, R. P. (2008). Contemporary management of descending thoracic and thoracoab-
dominal aortic aneur ysms: endovascular versus open. Circulation, 117(6), 841–852. PMID: 18268161
16. RATIONALE
(a) Inf lammatory AAA with adherent third and fourth portion of the duodenum. (b) Opened AAA with duodenum
remaining attached to duodenum wall.
Section 8: Aortoiliac Disease 119
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Mesenteric ischemia during and after open TAAA repair has a reported incidence of about 2.5%
with a 62% mortality. Mortality is substantially higher if the ischemia is not discovered and
corrected intraoperatively or immediately postoperatively. The exact manifestation of ischemia
depends on the involved vascular distribution. Celiac malperfusion may vary from clinically
nonsignificant to fulminant hepatic failure, pancreatitis, or duodenal necrosis, depending on
the patient’s anatomy, collateral supply, and preexisting visceral disease. Superior mesenteric
artery malperfusion most commonly manifests as bowel ischemia. Visceral reconstruction is
preferably performed by an inclusion patch (type II and III) or within the distal (type I) or proximal (type IV) anastomoses. Any intrinsic visceral disease may compromise aortic reconstruction at the time of operation. This may include transaortic orificial eversion endarterectomy
and/or stenting. A rapidly escalating vasopressor or inotrope requirement, worsening metabolic
acidosis, and rising serum lactate despite adequate volume resuscitation raise the suspicion of
mesenteric ischemia both intraoperatively and postoperatively. If clinical diagnosis is strongly
suspected in the immediate postoperative period, prompt re-exploration should be carried out.
Correct Answer C 2%–3%
Reference
Achouh, P. E., Madsen, K., Miller, C. C., et al. (2006). Gastrointestinal complications after descending
thoracic and thoracoabdominal aortic repairs: a 14-year experience. J Vasc Surg, 44(3), 442–446.
PMID: 16950413
17. RATIONALE
Inf lammatory abdominal aortic aneurysms (AAAs) are uncommon and occur with a frequency
from 3% to 10% of surgically repaired AAAs. Inf lammatory AAAs occur at a younger age with
familial tendency and occur more commonly in men with a histor y of nicotine abuse in the vast
majority of patients. Most patients present with abdominal or back pain, weight loss, and increased
sedimentation rate. Inflammatory aortic aneurysms are usually isolated to the infrarenal segment
of the abdominal aorta within a characteristic inf lammatory cuff of periaortitis and perianeur ysmal
fibrosis encasing the aneurysm wall, which enhances with contrast. At surgical exploration, a pearly
white, glistening aortic wall with dense adhesions to the duodenum (mainly third portion) can be
seen. Ureters are often adherent in the retroperitoneal space to the inflammatory abdominal aortic
aneurysm and may result in hydronephrosis. The dense inflammatory reaction extends from just
below the origin of the renal arteries to just above the common iliac artery bifurcation.
Correct Answer B Duodenum and ureter
Reference
Pennell, R. C., Hollier, L. H., Lie, J. T., et al. (1985). Inf lammator y abdominal aortic aneurysms: a t hirty-
year review. J Vasc Surg, 2(6), 859–869. PMID: 4057444
18. RATIONALE
The primary key to the operation is wide exposure. Preincisional placement of ureteral stents
has been recommended. Early division of the left renal vein (not mandatory) prevents undesired
bleeding during renal vein dissection and provides better proximal exposure in patients undergoing abdominal aortic aneurysm repair using the transperitoneal approach. The ligament of
Treitz should be carefully mobilized, but the third portion and proximal fourth portion of the
duodenum should be left attached to the aneurysmal wall and after proximal and distal clamping, opening the anterior wall of the aneurysm with the attached duodenal wall like a trap door,
which is retracted toward the right, will help to prevent an injury to the duodenal wall.
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