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122
S. S. Hans
Interposition Graft
Proximal and distal control is obtained, and patient is given systemic bolus of heparin 100units/kg. The aneurysm is opened, and small feeding arteries are ligated and
“normal” hepatic artery proximal and distal to the aneurysm is identied. In patients
with more proximal common hepatic artery aneurysms near the origin of the celiac
axis, proximal anastomosis of the interposition graft may need to be performed to
the supraceliac aorta. Interposition graft using PTFE graft or reversed greater saphenous vein (GSV) is selected depending upon the clinical situation as vein graft is
preferred in the presence of associated inammation or infection such as pancreatitis (Fig.10.3).
Proximal anastomosis to the common hepatic artery is preferred as an end-to-end
anastomosis and to the supraceliac aorta as an end-to-side anastomosis (Fig.10.4).
The exposure of the supraceliac aorta is described in the chapter on ruptured abdominal aortic aneurysms (AAA). In patients with urgent or emergent symptoms, proximal anastomosis may be performed to the right common iliac artery and tunneled
through the right transverse mesocolon.
Distal hepatic anastomosis is performed in an end-to-end fashion using continuous 5-0 or 6-0 cardiovascular polypropylene sutures.
Fig. 10.3 Hepatic
interposition graft
following resection of
hepatic artery aneurysm
with proximal anastomosis
to the origin of the hepatic
artery
10 Open Repair ofSplanchnic Artery Aneurysms
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Fig. 10.4 Repair of
hepatic aneurysm with
proximal anastomosis to
the supraceliac artery and
distal anastomosis to the
hepatic artery proximal to
the gastroduodenal artery.
The left gastric and splenic
artery are lighted
123
Celiac Axis Aneurysm Repair
Aneurysm arising from the proper celiac axis is uncommon and is usually present
in association with other splanchnic or aortic aneurysms. Most celiac aneurysms are
diagnosed incidentally on imaging for diagnosis of other intra-abdominal pathology. Rupture is associated with signicant mortality and aneurysm greater than
2.0cm should be considered for repair.
Options for open repair include ligation alone and aneurysm resection with
bypass, and in selected cases of isolated saccular aneurysms, aneurysmorrhaphy
may be considered. When ligation alone is considered, adequate collateral circulation must be present, and this treatment modality should be avoided in the presence
of liver disease or in patients with prior splenectomy. In case of aneurysm resection
with a bypass grafting, an aortoceliac bypass is performed with a prosthetic conduit.
Exposure is either a midline abdominal or bilateral subcostal incision. The lesser
sac is entered through an opening in the gastrohepatic omentum. The celiac artery
trunk and its branches are exposed by elevating the stomach with further exposure
of the lesser sac as the dissection is continued. Careful dissection around the origin
of the celiac axis is performed. The main three branches of the celiac axis are
exposed, and when an aneurysm involves trifurcation of the celiac trunk, splenic,
and left gastric arteries, these can be sacriced and aortohepatic bypass should be
performed (Fig.10.5a, b).
124
S. S. Hans
Fig. 10.5 (a) Celiac artery
aneurysm, AP view. (b)
Celiac artery aneurysm,
lateral view
a
b
For proximal celiac axis aneurysms, bypass requires proximal anastomosis to the
supraceliac aorta, which is exposed by separating the bers of the right crus after
making an opening in the gastrohepatic omentum and retracting the esophagus with
a Penrose drain to the left and retraction of the left lobe of the liver, following division of the left triangular ligament. The supraceliac aorta is relatively free of atherosclerotic disease in most patients and is a satisfactory site of proximal inow in most
10 Open Repair ofSplanchnic Artery Aneurysms
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125
instances. Median arcuate ligament and the fascia over the supraceliac aorta are
divided. Gentle blunt nger dissection should be performed medially and laterally
to expose the supraceliac aorta.
Arterial reconstruction is then performed. Aortic control is obtained via application of an occlusion clamp to the supraceliac aorta after adequate heparinization is
performed. Though Satinsky clamp (partially occluding clamp) can be used, we
prefer complete clamping of the supraceliac aorta almost perpendicular to the aorta
by an angled DeBakey clamp proximally and distally by an angled vascular clamp
so that any bleeding from the lumbar branches will not interfere with a clean dry
eld after aortotomy incision is made. The blood pressure should be kept slightly
low (mean pressure, 70–80mmHg) before application of the clamp as the blood
pressure tends to increase following clamping of the aorta. This enables proximal
anastomosis to be completed safely in a “dry” eld.
Proximal anastomosis to the supraceliac aorta is performed using 3-0 or 4-0 cardiovascular polypropylene suture, and distal anastomosis is performed end to end
with 5-0 or 6-0 CV polypropylene suture to the celiac trunk above its division into
its three branches (Fig.10.6), and if adequate distal anastomotic site, splenic and
left gastric artery are ligated and divided and distal anastomosis is performed to the
hepatic artery. Care should be taken to avoid kinking of the conduit in patients in
whom interposition vein graft is used.
Open treatment of proximal celiac artery aneurysms may consist of ligation in
the presence of adequate collateral circulation. Ligation without arterial bypass
should be avoided in the presence of liver disease or in patients with prior splenectomy. Aneurysmectomy with aortoceliac bypass grafting using prosthetic graft is
performed when arterial reconstruction is required.
Fig. 10.6 Repair of celiac
artery aneurysm with graft
from the supraceliac aorta
to the celiac artery
proximal to its branches
126
S. S. Hans
Superior Mesenteric Artery
The superior mesenteric artery tends to occur in the proximal 4–5cm of the artery
(Fig.10.7a, b). Superior mesenteric aneurysms are more common among males.
Most SMA aneurysms are due to mycotic etiology (60–70%) with Staphylococcus
and Streptococcus species being the dominant microorganisms. Mycotic SMA
aneurysms occur more frequently in patients with a history of intravenous drug
abuse or bacterial endocarditis. They are more frequently symptomatic as compared
to other splanchnic artery aneurysms. Rupture rate of SMA aneurysm ranges from
35% to 50%. Repair in symptomatic/mycotic aneurysms or in aneurysms should be
undertaken regardless of their size.
Fig. 10.7 (a) Superior
mesenteric aneurysm
exposed at the root of the
mesentery. The superior
mesenteric vein to the right
of the artery. (b) Superior
mesenteric artery
aneurysm 3–4cm from its
origin, lateral view
a
10 Open Repair ofSplanchnic Artery Aneurysms
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Fig. 10.7 (continued)
b
Operative Management
127
Branch SMA aneurysms can be ligated. Superior mesenteric artery aneurysm should
be repaired via a midline laparotomy with direct exposure of the SMA by retracting
the transverse colon with its mesocolon upward and small bowel mesentery to the
right following mobilization of the ligament of Treitz. Dissection is done in the root
of the mesentery and branches of SMA are controlled. In most patients, interposition graft is from the proximal SMA with distal anastomosis to the SMA, followed
by resection of the SMA aneurysm performed in an end-to-end to fashion. Distal
SMA aneurysms are suited for aneurysmorrhaphy and with plication or patch angioplasty. In the presence of infection, autogenous vein bypass is required.
Large saccular aneurysms can be treated with aneurysmorrhaphy. The injury to
the superior mesenteric vein should be avoided as it lies to the right of the SMA.
If the SMA aneurysm involves its ostia (uncommon), antegrade superior mesenteric bypass from the supraceliac aorta to mid SMA is performed following resection of the aneurysm. In that situation, the proximal anastomosis is end to side and
the distal anastomosis can be performed end to end.
Exposure of the supraceliac aorta has been previously described. Exposure of the
SMA in the root of the mesentery is performed by lifting the transverse colon and
mesocolon superiorly and palpating the artery in the root of the mesentery. The
superior mesenteric artery is exposed by making a longitudinal incision in the root
of the mesentery, and a retro pancreatic tunnel (preferred) or prepancreatic tunnel is
made by blunt nger dissection for allowing the passage of a graft from the supraceliac aorta to the exposed portion of the SMA for distal anastomosis.
128
S. S. Hans
If a retrograde bypass is planned, the infrarenal aorta or left common iliac artery
is explored by retracting the duodenum to the right and incising or medially reecting the descending and sigmoid colon. Proximal site of anastomosis is selected
depending upon the plaque burden and the graft is directed in a gradual curved path
like a lazy “C.” Potential kinking of the graft and the presence of signicant atherosclerotic disease in the aortoiliac segment make this a poor second choice for
inow site.
A more useful alternative for transcural approach to the SMA is medial visceral
rotation by incising the peritoneal reection from the diaphragm to the pelvis to
mobilize the descending colon medially. Next, the splenorenal and phrenicocolic
ligaments are divided. The descending colon, stomach, body and tail of pancreas,
and spleen are rotated anteriorly and medially by replacing the hand underneath the
visceral bundle. This plane can be either anterior or behind the left kidney. The
operating table should be tilted toward the right to aid in mobilization of the viscera
medially.
Other Splanchnic Artery Aneurysms
Gastric artery and gastroepiploic artery aneurysms are rare. Most patients present
with intraperitoneal rupture with a high mortality rate. Therefore, repair should be
recommended in patients with gastroepiploic artery aneurysm and gastric artery
aneurysms. The operation consists of operative ligation with or without arterial
reconstruction.
Aneurysms involving jejunal, ilial, and colic arteries comprise a very small portion of all splanchnic artery aneurysms. Rupture of jejunal and ilial aneurysms is
less common than colic aneurysms. Rupture usually occurs into the peritoneal cavity. All mesenteric branch artery aneurysms should be repaired by ligation or resection with intraoperative assessment of the bowel viability. Occasionally, simultaneous
small bowel resection or colon resection may need to be performed.
Gastroduodenal artery and pancreaticoduodenal artery aneurysms are uncommon and account for a small portion of all splanchnic artery aneurysms. These aneurysms are more often pseudoaneurysms secondary to pancreatitis. When true
pancreaticoduodenal artery aneurysms are associated with occlusive disease of the
celiac axis, both aneurysm and lesion of the celiac axis need treatment. In that situation, the celiac axis should be revascularized to minimize the risk that the embolization of the pancreaticoduodenal artery aneurysm will interrupt the major collateral
arterial circulation to the celiac axis.
Chapter 11
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Renal Aneurysm Repair
AbdulKaderNatour andAlexanderD.Shepard
Renal artery aneurysms (RAAs) are rare entities that the average vascular surgeon
will encounter very infrequently. The overwhelming majority are asymptomatic and
discovered incidentally on imaging performed for other reasons. Ruptured RAAs
carry signicant morbidity and mortality, and patients at risk for rupture should be
repaired electively. The major risk factors for rupture are size and pregnancy. There
has been considerable debate recently over the size threshold for aneurysm repair.
Traditionally a 2cm diameter was considered the threshold for repair, but many now
advise watching until >3cm. Symptoms of hypertension can sometimes result from
aneurysms arising from bromuscular dysplasia (FMD) associated with a stenosis
or from micro-embolization of mural thrombus (less common).
Preoperative imaging is performed with a thin-cut, high-quality computed tomographic angiogram (CTA) of the abdomen. Careful review of this study with threedimensional (3-D) reconstruction is imperative to dene RAA and branch anatomy
preoperatively (Fig.11.1). Most of these aneurysms are saccular and arise at bifurcation/branch points and 15% are bilateral. Creation of a 3-D printed model can be
very helpful in planning repair.
A. K. Natour
Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
e-mail: anatour1@hfhs.org
A. D. Shepard (*)
Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
Wayne State University School of Medicine, Detroit, MI, USA
e-mail: ASHEPAR2@hfhs.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_11
129
130
A. K. Natour and A. D. Shepard
ab
Fig. 11.1 Three-dimensional reconstruction of a large right RA aneurysm. (a) Anterior view;
distal main RA to the lower pole of the kidney is obscured on this view. (b) Posterior view clearly
denes distal main RA arising from posterior surface of aneurysm and its relationship to a large
upper pole segmental artery
Operative Steps
These procedures are usually best performed through a modied transverse supraumbilical (“frown”) incision, though some surgeons prefer a standard midline celiotomy with a transperitoneal (TP) approach to the kidney. The patient is placed on
the table supine with the contralateral arm tucked at the side to create a space for
anchoring a mechanical retraction system (e.g., Thompson or Omni-Tract) to the
table. A rm foam pad is placed under the ipsilateral ank to slightly elevate the
involved kidney. An upper abdominal transverse incision from the contralateral
anterior axillary line to the ipsilateral posterior axillary line is made if treating unilateral disease or extending to both anks if treating bilateral disease (unusual). The
rectus abdominis muscles are transected and the oblique muscles divided in the
direction of their bers.
Right renal artery (RA) exposure: An incision is made in the lateral peritoneal
reection from the hepatic exure to the cecum, and with blunt dissection, the
hepatic exure mobilized toward the midline. The duodenum and pancreas overlying the right kidney are displaced medially to the left (Kocher maneuver) exposing
the aorta, inferior vena cava (IVC), and renal vessels (Fig.11.2). Dissection of the
right renal vein (RV) from the surrounding tissue is performed from its junction
with the IVC to the renal pelvis. Ligation and division of any small tributaries are
performed to allow complete mobilization and subsequent retraction of the right RV
to expose the underlying right renal artery (RA).
11 Renal Aneurysm Repair
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a
b
131
c
Fig. 11.2 Exposure of the right RA using limited right medial visceral rotation. (a) Dotted line is
incision in peritoneal reection used to mobilize hepatic exure and part of the ascending colon.
(b) Dotted line is incision to mobilize the duodenum off the right kidney (Kocher maneuver). (c)
Right RA aneurysm exposed by mobilizing and retracting right RV cephalad
Dissection of the renal artery is carried out in a proximal-to-distal fashion relative to the aneurysm. When exposing the proximal-most right RA under the IVC, it
is usually necessary to divide small branches of the IVC including lumbar veins.
Larger branches should be suture ligated to avoid inadvertent dislodgement with
problematic bleeding during subsequent medial IVC retraction. After gaining control of the proximal RA, branches distal to the aneurysm are identied and controlled with small-caliber elastic loops. Careful review of preoperative imaging will
ensure that no branches are inadvertently missed. This usually requires some dissection of the aneurysm itself, which should be minimized as large aneurysms are thin
walled and can be easily torn if care is not taken. Once both inow and outow
vessels have been controlled, the aneurysm itself is mobilized. Control of posterior
branches may have to await resection of the aneurysm itself.
Left renal artery (LRA) exposure: Exposure of the left RA follows a similar ret-
roperitoneal dissection as performed on the right but with a partial left medial visceral rotation. The peritoneal reection lateral to the left colon and spleen is incised
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