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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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130 Section 8: Aortoiliac Disease
Correct Answer C Open repair of ruptured AAA
References
1. Warshaw, A. L., & O’Hara, P. J. (1978). Susceptibility of the pancreas to ischemic injury in shock.
Ann Surg, 188(2), 197–201. PMID: 686887
2. Hans, S. S. (1989). Pancreatitis and duodenal obstruction after aortic surgery. Am Surg, 55(3),
177–179. PMI D:2919843
36. RATIONALE
Dilutional coagulopathy is due to dilution along with consumption of platelets during massive
transfusion and resuscitation with a large volume of crystalloids. Crystalloids do not contain
adequate coagulation factors. Adequate fibrinogen levels are essential in managing dilutional
coagulopathy. After excessive hemodilution, fibrin clots are more prone to fibrinolysis because
major antifibrinolytic proteins are decreased. Fresh-frozen plasma, platelet concentrates, and
cryoprecipitate are considered to be the mainstay of hemostatic therapies. In disseminated
intravascular coagulopathy, clotting factors are decreased with elevation of PTT and PT and
increased in fibrin split products. In primary fibrinolysis there is a decrease in serum fibrinogen, and fibrin degradation products are increased with elevated D-dimer. Fibrin split degradation products are normal in dilutional coagulopathy, but Hct and platelets are slightly low with
slight elevation of PTT and PT.
Correct Answer C Dilutional coagulopathy
Reference
Weiss, G., Lison, S., Spannagl, M., & Hei ndl, B. (2010). Expressiveness of global coagulation parameters
in dilutional coagulopathy. Br J Anaesth, 105(4), 429–436. PMID: 20693180
37. RATIONALE
A horseshoe kidney occurs in approximately 0.25%–0.5% of patients requiring AAA repair. The
preferred surgical options for unruptured AAA with a horseshoe kidney in an elective setting
are endovascular aneurysm repair or open repair using a left f lank retroperitoneal approach.
In a hemodynamically stable patient with leaking AAA and horseshoe kidney, endovascular
repair is a satisfactory option, but in patients who are hemodynamically unstable and horseshoe kidney was only detected at the time of laparotomy, the isthmus of the horseshoe kidney, if
it is thin, can be divided, as it has almost no renal parenchyma. If the isthmus is thick, it should
be mobilized with a prosthetic graft brought underneath the isthmus. A medial visceral rotation may be necessary to gain adequate exposure. According to the renal artery anatomy, types
of arterial patterns varying from (a) a single renal artery on each side, (b) two renal arteries
on each side and one to the isthmus, (c) multiple renal arteries are described in patients with
horseshoe kidney. During open repair, preservation of renal arteries of 2 mm or greater in diameter should be considered, as their ligation may lead to ischemia of the renal parenchyma. Renal
injury has been reported in 17% of patients undergoing AAA repair in the presence of a horseshoe kidney. Ligation of aberrant renal arteries of <2 mm can be performed without significant
risk of renal complications. Reimplantation of accessory renal arteries (>2 mm) into the prosthetic graft can be performed using a Carrel patch technique.
Correct Answer D Should be decided by the anatomy of the aneurysm and arterial supply to
the horseshoe kidney
Section 8: Aortoiliac Disease 131
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Reference
Sachsamanis, G., Charisis, N., Maltezos, K., et al. (2019). Management and therapeutic options for
abdominal aortic aneurysm coexistent with horseshoe kidney. J Vasc Surg, 69(4), 1257–1267.
PMID: 30591298
38. RATIONALE
Results from the Eurostar Registry consisting of 4901 patients from 113 centers reported a rupture
rate of 4.7% for the first year and 0.6% for the second year following endovascular aneurysm repair.
The common features of rupture of AAA in a patient with prior endograft are:
A. Poor compliance and follow-up
B. Stent graft migration
C. Endoleak
In 34 patients in the Eurostar Registry, 39% had no complications prior to the diagnosis of
rupture: EVAR was complicated by endoleaks in 20%–25% of patients. Approximately 10% of
patients will develop type I endoleak, which is often associated with hostile neck anatomy (short
angulated aortic neck with calcified wall, circumferential thrombus at the neck), which prevents a good seal at the proximal neck. Graft migration may occur due to progressive proximal
aneurysmal dilatation of the aorta. The decision to perform endovascular or open repair for
ruptured AAA in a patient with prior endograft depends on the anatomical findings on CTA of
the abdomen and pelvis, and the patient’s hemodynamic status and experience of the surgeon.
Correct Answer D Choice of endovascular versus open repair depends on the findings of the
CTA of the abdomen and pelvis and clinical condition of the patient
Reference
Fransen, G. A., Vallabhaneni, S. R., Sr., van Marrewijk, C. J., et al. (2003). Rupture of infra-renal aortic
aneurysm after endovascu lar repair: a series f rom EUROSTAR regist ry. Eur J Vasc Endovasc Surg,
26(5), 487–493. PMID: 14532875
39. RATIONALE
Coverage of one and occasionally both renal arteries may be required to facilitate EVAR in patients
who are prohibitive risks for open repair. From a vascular quality initiative dataset (2013–2018)
analysis, in 2278 patients with ruptured AA A, 2230 had no renal coverage, 30 had single renal
artery coverage, and 18 had coverage of both renal arteries. On multivariant regression analysis,
bilateral renal artery coverage was associated with increased odds of in-hospital mortality (OR
5.7%), permanent dialysis/30-day mortality (OR 9.5%), and permanent dialysis (OR 47.5%). Single
renal artery coverage increased the odds of permanent dialysis/30-day mortality (OR 2.8%). From
these observations it was concluded that bilateral renal coverage during repair of ruptured AAA
significantly increases in-hospital mortality and lowers the long-term survival. Single renal artery
coverage increases the risk of permanent dialysis/30-day mortality primarily as a result of permanent dialysis. It does not significantly affect the in-hospital mortality or 1-year survival and should
be considered a viable option in select patients with ruptured A AA with prior EVAR.
Correct Answer C Single renal artery coverage increases the odds of permanent dialysis/
30-day mortality primarily due to the need for permanent dialysis
132 Section 8: Aortoiliac Disease
Reference
Tanious, A., Boitano, L. T., Wang, L. J., et al. (2020). Renal artery coverage during endovascular aneu-
rysm repair for ruptured abdominal aortic aneurysm. Ann Vasc Surg, 62, 63–69. PMID: 31201979
40. RATIONALE
The incidence of late open conversion after EVAR should be <5%. The main indications for graft
explantation include persistent type IA endoleak despite unsuccessful secondary interventions to
correct the endoleak, graft infection, or refractory graft occlusion. The incidence of explant of an
endograft is not related to the type of endograft used. Endograft failure <1 year is most commonly
due to failure of the proximal seal at the initial procedure and underscores the need to understand
the device limitations if used outside the instructions for use (IFU). Late failures are most commonly due to aneurysmal degeneration of the seal zones and device material failure and may
occur even after a decade of successful EVAR repair. Emergent repair is most frequently required
for infection or rupture. The operative approach is determined by surgeon preference and clinical
factors such as suprarenal fixation. Both retroperitoneal and transabdominal approaches can be
used, with suprarenal clamping required in most patients. Aortoiliac repair is the most common type of reconstruction after explant of the endograft. Mortality for emergent explant can be
as high as 40%. In the elective setting, mortality should be <5%. In patients undergoing explant
for graft infection, complete graft removal and replacement with an infection-resistant conduit
should be performed. However, partial graft excision can be judiciously employed in patients with
instances of sac expansion and rupture secondary to endoleak.
Correct Answer B 1%–5%
Reference
Turney, E. J., Steenberge, S. P., Lyden, S. P., et al. (2014). Late graft explants in endovascular aneurysm
repair. J Vasc Surg, 59(4), 886–893. PMID: 24377945
41. RATIONALE
It is important to note that complete removal of an endograft with suprarenal fixation can tear
the aorta, injure the adjacent renal or visceral artery origins, and prolong suprarenal crossclamping time. Complete excision of the endograft may necessitate extension of the aortotomy
above the level of the renal orifices. When this is required, a beveled anastomosis to incorporate
the superior mesenteric artery and right renal artery and left renal artery reimplantation or
bypass as necessary should be considered. A retroperitoneal approach simplifies this maneuver. For distal iliac control, a Pruitt occlusion balloon catheter or number 10 arterial dilator is
Section 8: Aortoiliac Disease 133
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placed and positioned directly into each limb of the aortoiliac endograft to stop retrograde flow.
Occasionally, iliac limbs of the stent graft are transected if there is extensive inflammation in
the pelvis and are incorporated into the distal anastomosis. Rarely in emergent open repair in
the setting of a ruptured aneurysm with the source of rupture due to a type IB endoleak, the
proximal endograft can be left in place with the new graft sutured to the prior endograft and
extended to the native iliac vessels beyond the prior seal zones. However, most patients with
rupture secondary to type IB endoleak can be managed by coil embolization of the ipsilateral
hypogastric artery and extension of the iliac limb into the external iliac artery.
Correct Answer D Release of barbs with wire cutter and iced saline in a syringe to collapse
the suprarenal segment
Reference
Dubois, L., Harlock, J., Gill, H. L., et al. (2021). A Canadian multicenter experience describing out-
comes af ter endovascu lar abdominal aort ic aneurysm repai r stent graf t explanat ion. J Vasc Surg,
74(3), 720–728.e721. PMID: 33600929
42. RATIONALE
Showing large type I endoleak with extravasat ion of the contrast due to rupture of A AA.
The Eurostar Registry reported from 1996 to 2000 that 2464 patients were registered with a
mean follow-up of 12.19 months, with confirmed rupture in 14 patients. The cumulative risk
of rupture was approximately 1% per year.1 Significant risk factors for rupture were type IA
endoleak, type III endoleak, graft migration, and postoperative kinking of the graft. Forty-one
134 Section 8: Aortoiliac Disease
patients underwent late conversion to open repair. The cumulative risk of late conversion was
approximately 2.1% per year. In this study, first- and second-generation devices were used for
EVAR. According to FDA panel reporting on 10,228 U.S. patients who underwent EVAR from
1999 to 2008, only 42% of patients met the most stringent criteria for endovascular repair.2
Aneurysm sac expansion >5 mm/yr is an independent predictor of later mortality even after
adjusting for the presence of endoleak and occurrence of sac intervention.3 Even in the absence
of identifiable endoleak, sac expansion warrants close observation.
3
Correct Answer B Overall incidence of late conversion is 1.9% and delayed risk of rupture is
1% per year
References
1. Harris, P. L., Vallabhaneni, S. R., Desgranges, P., et al. (2000). Incidence and risk factors of late
rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the
EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm
repair. J Vasc Surg, 32(4), 739–749. PMID: 11013038
2. Circulatory System Devices Panel Meeting. (2021). FDA executive summary. Retrieved from
https://www.fda.gov/media/153647/download
3. Deery, S. E., Ergul, E. A., Schermerhorn, M. L., et al. (2018). Aneurysm sac expansion is independently associated with late mortality in patients treated with endovascular aneurysm repair.
J Vasc Surg, 67(1), 157–164. PMID: 28865980
43. RATIONALE
Computed tomography angiography of a patient with secondary aortoenteric fistula. There is gas accumulation within
the aneurysm sac in proximity to the bif urcated graft (white arrow pointing to air wit hin the aneurysm sac).
Section 8: Aortoiliac Disease 135
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In a hemodynamically stable patient, once the diagnosis is either confirmed or
highly suspected, the operating surgeon must decide between two radically different
approaches:
A. Staged or sequential extra-anatomic bypass followed by aortic graft excision (infected)
B. Aortic graft excision with in-line aortic graft replacement with one of the following
conduits:
I. Femoral vein (venous autograft)
II. Cryopreserved arterial allograft
III. A new prosthetic graft with antimicrobial impregnation (rifampin)
Extensive debridement of the aortic wall and inflammatory tissue with omental coverage
is essential. Staged extra-anatomic bypass and graft excision is reserved for patients
with multiple comorbidities. If cryopreserved allograft is not available, a rifampinimpregnated Dacron graft is a good alternative. The cryopreserved allograft is placed in
such a way that lumbar arteries are anterior. In good- to moderate-risk patients, when
planning arterial allograft or rifampin-impregnated Dacron graft, availability of 3 mm
of the aortic neck below the renal arteries is sufficient to achieve a satisfactory proximal
anastomosis.
Correct Answer B Cryopreserved arterial allograft
Reference
Fatima, J., Duncan, A. A., de Grandis, E., et al. (2013). Treatment strategies and outcomes in patients
with infected aortic endografts. J Vasc Surg, 58(2), 371–379. PMID: 23756338
44. RATIONALE
Following a long midline incision, the supraceliac aorta is controlled by mobilization of the
left lobe of the liver to the right by division of the triangular ligament and gastroesophageal junction to the left and separating the right crus of the diaphragm. Distal control is
obtained at the level of the iliac vessels or distal graft anastomosis. Any omentum encountered is preserved for use as a pedicle flap. Proximal control is moved from the supraceliac
to the infrarenal location expeditiously to reduce the visceral/renal ischemic time. Before
placement of the proximal clamp, the patient is given an appropriate dose of heparin and
intravenous mannitol. The duodenal defect is debrided and closed primarily transversely.
Distal anastomosis to the common iliac artery bifurcation is preferable. If a groin anastomosis becomes necessary, attempts should be made to preserve retrograde flow to at least
one hypogastric artery. Emergent endovascular stent graft placement in a patient with
bleeding secondary to aortoenteric fistula as a “bridge” to definitive surgical repair may be
considered in high-risk patients.
Correct Answer B Supraceliac via midline laparotomy
Reference
Kakkos, S. K., Bicknell, C. D., Tsolakis, I. A., & Bergqvist, D. (2016). Editor’s choice — management of
secondary aorto-enteric and other abdominal arterio-enteric fistulas: a review and pooled data
analysis. Eur J Vasc Endovasc Surg, 52(6), 770–786. PMID: 27838156
136 Section 8: Aortoiliac Disease
45. RATIONALE
There is no definite consensus for the appropriate length of treatment with antibiotics to be
used for endograft infections with or without aortoenteric fistula. Most vascular and infectious
disease specialists recommend 6 weeks of treatment with intravenous antibiotics and then
transition to lifetime oral suppressive antibiotics. The rate of reinfection after treatment for aortoenteric fistula after open aortic surgery is significant at 24% and 41% at 1 and 2 years, respectively. These results are not based on type of reconstruction and were similar for extra-anatomic
and in situ repair.
Correct Answer D 6 months/possibly lifelong
Reference
Batt, M., Jean-Baptiste, E., O’Connor, S., et al. (2011). Early and late results of contemporary man-
agement of 37 secondary aortoenteric fistulae. Eur J Vasc Endovasc Surg, 41(6), 748–757. PMID:
21414 817
46. RATIONALE
Postoperative aortogram showing patent left aortorenal bypass graft following repair of A AA with tear in the aorta near
the origin of left renal artery.
Operative repair of juxtarenal AAA can be technically challenging. In the absence of the
need to visualize the right distal common iliac artery, a left flank retroperitoneal approach
is being increasingly used for open repair of proximal complex AAAs, repeat aortic surgery,
AAA in the presence of horseshoe kidney, hostile abdomen, or inflammatory AAA. In the
presence of aortic laceration at the origin of the left renal artery, a satisfactory option is
to ligate the renal artery near its origin and reconstruct a prosthetic bypass using a 6-mm
PTFE prosthesis with origin of the graft from the main body of the prosthetic graft or the left
limb of the prosthetic graft (proximally) using end-to-side anastomosis and an end-to-end
anastomosis to the spatulated left renal artery distally. Renal artery reconstruction at the
Section 8: Aortoiliac Disease 137
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time of open repair of paravisceral aneurysm increases the risk of acute kidney injury
and mortality.
Correct Answer D Bypass graft to the left renal artery with origin from the main body or the
left limb of the prosthetic graft (end-to-side) to the left renal artery with end-to-end anastomosis
distally
Reference
Wooster, M., Back, M., Patel, S., Tanious, A., Armstrong, P., & Shames, M. (2017). Outcomes of concomi-
tant renal reconstruction during open paravisceral aortic aneurysm repair. J Vasc Surg, 66(4),
1149–1156. PMID: 28648481
47. RATIONALE
Silastic loop around each renal artery supplying pelvic kidney near the iliac graft limb to iliac artery anastomosis.
Careful evaluation of the preoperative imaging is important to identify and then plan for reconstruction of the renal arteries supplying the pelvic kidney. The pelvic kidney may be rotated
with its pelvis lying inferiorly, and some patients with pelvic kidney and horseshoe kidney may
have multiple renal arteries as opposed to a single renal artery on each side. Various methods
such as temporary shunt, in situ renal perfusion, and use of an axillofemoral graft as alternative
to maintaining blood supply to the pelvic kidney during aortic clamping have been proposed.
The use of cold renal perfusion reduces renal metabolic demands. A solution containing 250 mL
of 1% Ringer’s lactate plus methyl prednisolone, mannitol, and heparin is infused in the renal
138 Section 8: Aortoiliac Disease
artery using irrigating balloon catheters or a balloon-tipped Pruitt perfusion catheter. A
custom-made fenestrated graft has been described to be used in the highest-risk patients. Renal
arteries and ureters should be carefully identified during open repair. Systemic heparization
before aortic cross-clamping, use of ice cold saline renal perfusion, and reestablishment of
arterial flow are important steps to preserve renal function in the pelvic kidney. During distal
anastomosis of iliac limbs of the prosthetic graft, each renal artery to the pelvic kidney is incorporated in the distal anastomosis.
Correct Answer D Reimplantation of renal arteries supplying the pelvic kidney incorporating
in the aortobiiliac graft reconstruction
Reference
Majumder, B., Perera, A. H., Browning, N., et al. (2017). Fenestrated endograft as a new perspec-
tive for the treatment of infrarenal abdominal aortic aneurysm with a congenital pelvic
kidney – a case report and review of literature. Ann Vasc Surg, 45, 266.e261–266.e264. PMID:
28712962
48. RATIONALE
Section 8: Aortoiliac Disease 139
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Inferior mesenteric artery reimplantation.
Patients undergoing open AAA repair with prior colon resection, severe superior mesenteric
artery stenosis, or large inferior mesenteric artery with prominent mesenteric collateral such
as arc of Riolan are at a greater risk of developing colon ischemia with the possibility of colon
infarction. Standard EVAR with coverage of the IMA will result in ischemic colitis, as the IMA
is large and its coverage may result in sigmoid colon ischemia. A fenestrated graft (homemade)
can be challenging to design. If the patient has SMA stenosis and a normal-size IMA, SMA stenting should be considered prior to EVAR, provided the superior mesenteric artery stent does not
project proximally into the aorta for >1 cm, as it may get dislodged during deployment of the
main body of the stent graft. Open repair with reimplantation of the inferior mesenteric artery
as a Carrel patch is probably the safest option in this clinical scenario.
Correct Answer B Open repair with inferior mesenteric artery reimplantation
Reference
Hans, S. S. (2020). Abdominal aortic aneurysm repair in a patient with celiac artery occlusion and a
large inferior mesenteric a rtery. In S. S. Hans (Ed.), Challenging arterial reconstructions: 100 clini-
cal cases (pp. 15–17). Cham, Switzerland: Springer Nature Switzerland AG.
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