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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3749_Библиотеки_им_академика_М_И_Перельмана
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L. Kabbani et al.
pre- deployment state and facilitate removal from the arterial wall. If these techniques are unsuccessful, we do not hesitate to leave the bare stent segments in situ
even in an infected setting (assuming all graft material has been excised).
It is important to note that complete removal of an endograft with suprarenal xation can tear the aorta, injure the adjacent renal or visceral artery origins, and prolong
suprarenal cross-clamp time, all contributing to adverse outcomes. Complete excision of the endograft can necessitate extension of the aortotomy above the level of
the renal orices. When this is required, we perform a beveled anastomosis to incorporate SMA and right renal arteries and then perform left renal artery reimplantation
or bypass (Fig.9.2). A retroperitoneal approach simplies this maneuver with greater
direct exposure to allow the construction of a proximal beveled anastomosis.
Fig. 9.2 Proximal prosthetic
graft (beveled) with reimplantation of the left renal artery
with distal endograft remaining in situ
9 Endovascular Aortic Stent Graft Explantation
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Distal
Given the extensive inammation in the pelvis, obtaining distal control can be challenging. As such, several techniques are available to obtain distal control. One
method is utilizing Pruitt occlusion balloons, placed and positioned directly into
each of the limbs of the aortoiliac endograft. This is especially useful when infection is not suspected and the distal segment of the endograft, already noted preoperatively to be adequately sealed, can be left in situ. Also, transfemoral balloon
occlusion of both iliac limbs is an alternative option. Occasionally, we transect the
iliac limbs of an endograft if there is extensive inammation in the pelvis. The transected iliac limbs of the stent graft are then incorporated (Fig.9.3) into the distal
Fig. 9.3 Proximal
prosthetic graft
anastomosed to distal
limbs of endograft (left in
situ) with incorporation of
iliac vessel wall
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L. Kabbani et al.
anastomosis. This technique is particularly useful in patients with ruptured aneurysms where time and blood loss are of the essence. It is preferred that with distal
suturing, the graft limb is also incorporated into the native iliac vessels. Alternately,
suturing the medial margins of iliac limbs together to create a new aortic bifurcation
or “new carrefour” can be performed. This allows a tube graft to be used for the
distal anastomosis. It is advantageous to ensure that the stitches are passed through
the graft fabric and the aortic wall to obtain better hemostasis and attachment. The
intent of this technique is to reduce the extent of dissection and decrease operative
time with the potential secondary effect of decreasing morbidity.
A less common situation occurs with a type Ib endoleak in which it is determined
that the proximal attachment site is intact and the problem leading to the sac expansion is related to distal seal, either unilaterally or bilaterally. Most type Ib endoleaks
can be managed via extension of the iliac limbs into the distal common iliac or
further down into the external iliac. The hypogastric artery in this situation can be
embolized or if preservation is desired, an iliac branch device can be deployed.
Rarely, in the emergent open repair setting of a rupture AAA with a prior endograft
(and once it is determined that the source of the rupture is a distal Type Ib), the
proximal endograft can be left in place with the new graft sutured to the prior endograft and extended into the native iliac vessel beyond the prior seals zones of the
endograft (Fig.9.4).
Complications
This is an extensive operation, one which has signicant physiologic insult to the
patient. Bleeding from the proximal anastomosis can result from inadequate incorporation of healthy native aortic tissue into the anastomosis. If graft infection is the
indication for explant, recurrent infection remains a risk, but should be minimized
by performing wide debridement and by utilizing an omental wrap.
Similarly, bleeding from distal anastomosis can occur secondary to failure to
incorporate healthy iliac vessel into the distal anastomosis. Iliac artery degeneration
progressing to iliac rupture after complete endograft removal from the iliac arteries
can occur. This may be related to disruption of iliac artery wall integrity while excising the iliac limbs.
EVAR explant has signicant morbidity and mortality with a complication rate
of 27–60% [4, 5]. Major complications include renal dysfunction, respiratory failure, and cardiac complications inclusive of myocardial infarction. Due to concern of
the potential for signicant blood loss, we recommend using cell saver in noninfected cases.
Outcomes for EVAR explantation are dependent upon the indication for excision
and repair with mortality rates of 40% reported in the setting of post—EVAR ruptured AAAs [4, 5]. However, when EVAR explants are performed electively, mortality rates should be less than 5%. Therefore, patients with EVAR failures not
9 Endovascular Aortic Stent Graft Explantation
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Fig. 9.4 Incorporated
proximal endograft
anastomosed into the distal
main body of the new
aorto-bi-iliac prosthetic
graft
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amenable to endovascular salvage need expeditious evaluation for EVAR explantation so that an emergent operation can be avoided. Referral to tertiary care centers
that perform high volumes of aortic repair is recommended. Postoperative imaging
surveillance is of paramount importance particularly for those patients who have
had partial graft explantation.
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L. Kabbani et al.
Take-Home Points
1. Explantation of aortic stent graft is required in the setting of prior EVAR compli-
cated by endoleak-induced sac expansion, aortic rupture, graft infection, and
recalcitrant graft thrombosis.
2. This is a complex procedure with worse outcomes compared to standard open
AAA repair. Suprarenal or supraceliac proximal control is frequently required,
and the retroperitoneal approach is favored when infrarenal clamping is not possible or anticipated. Transperitoneal exposure and infrarenal clamping is suitable
when stent graft migration occurs with a preserved infrarenal neck.
3. One of the unique technical challenges of explantation of the aortic endograft is
the need to manage and deal with the suprarenal xation apparatus. The operating surgeon must have in his arsenal several different and tailored methods to
completely or partially excise the suprarenal xation and to allow the secure
construction of a proximal anastomosis.
4. Graft infection will require complete graft excision (and replacement with an
infection resistant conduit), whereas partial graft excision can be judiciously
employed in instances of sac expansion and rupture secondary to endoleak.
References
1. Kansal V, Nagpal S, Jetty P.Editor's choice- late open surgical conversion after endovascular
abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2018;55(2):163–9.
2. McFarland G, et al. Infrarenal endovascular aneurysm repair with large device (34-to
36-mm) diameters is associated with higher risk of proximal xation failure. J Vasc Surg.
2019;69(2):385–93.
3. Dubois L, etal. A Canadian multicenter experience describing outcomes after endovascular
abdominal aortic aneurysm repair stent graft explantation. J Vasc Surg. 2021;74(3):720–728.e1.
4. Arnaoutakis DJ, etal. Strategies and outcomes for aortic endograft explantation. J Vasc Surg.
2019;69(1):80–5.
5. Lyden SP, etal. Technical considerations for late removal of aortic endografts. J Vasc Surg.
2002;36(4):674–8.
Chapter 10
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Open Repair ofSplanchnic Artery
Aneurysms
SachinderSinghHans
Surgical Anatomy
The abdominal aorta has three anterior branches: celiac trunk, superior mesenteric
artery (SMA), and inferior mesenteric artery (IMA) which supplies the GI tract.
Celiac Trunk
The celiac trunk is the rst major branch of the abdominal aorta and arises just
below the aortic hiatus and 1–3cm long and runs horizontally and forward slightly
to the right above the pancreas and splenic vein. It divides into left gastric, common
hepatic, and splenic arteries.
Superior Mesenteric Artery
The superior mesenteric artery (SMA) arises from the aorta 1–2cm below the celiac
trunk at the level of L1 vertebral body. It lies posterior to the body of the pancreas
and splenic vein. It passes forward and inferiorly anterior to the uncinate process of
the pancreas and the third portion of the duodenum to enter the root of the mesentery of the small intestine and supplies the midgut. The superior mesenteric vein
(SMV) lies to the right side of the SMA. In about 15% of individuals, hepatic artery
may arise from the SMA.
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© 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_10
117
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S. S. Hans
Inferior Mesenteric Artery
The inferior mesenteric artery (IMA) is smaller in size than the SMA and arises
from the anterolateral aspect of the aorta at the level of L3 vertebral body 3–4cm
above the aortic bifurcation.
Splanchnic Artery Aneurysms
Splanchnic artery aneurysms are uncommon. In contemporary vascular practice,
splanchnic artery aneurysms are diagnosed with increasing frequency due to widespread utilization of imaging modalities. Splanchnic artery aneurysms may be associated with aneurysms in the thoracic aorta, abdominal aorta, renal arteries, and
popliteal and femoral arteries.
Splanchnic artery aneurysms may be true aneurysms or false aneurysms (pseudoaneurysms). True aneurysms are usually caused by atherosclerosis (degenerative), bromuscular dysplasia, collagen vascular disease, and Ehlers–Danlos
syndrome. Pseudoaneurysms are often related to trauma, iatrogenic injury, local
inammatory process, or infection. Because of the rare occurrence of splanchnic
artery aneurysms, their natural history and risk of rupture are not well dened. The
widespread adoption of endovascular therapy has signicantly impacted the therapeutic management of splanchnic artery aneurysms and is now often the preferred
treatment modality. However, open repair of splanchnic artery aneurysms remains
an option when endovascular therapy is not appropriate. Aneurysms of the celiac
trunk and its branches are the most common among all splanchnic artery aneurysms.
Splenic Artery Aneurysms
Asymptomatic splenic artery aneurysms larger than 3.0cm should be considered for
repair. In women of childbearing age, even smaller aneurysms should be repaired.
All false aneurysms should be repaired. Smaller calcied aneurysms (less than
2cm) can be observed. Splenic artery aneurysms have a female preponderance of
four to one. Aneurysms in mid and distal portion of the splenic artery are often saccular. Most splenic artery aneurysms are asymptomatic. Hemodynamic instability
with hemorrhage shock may occur due to free rupture and is often associated with
pregnancy. Initial bleeding from rupture may be contained in the lesser sac.
Endovascular repair with coil embolization or stent graft is successful in vast majority of cases. If catheter-based approach is not feasible due to excessive tortuosity of
splenic artery, open treatment may either involve exclusion of the aneurysm with
proximal and distal ligation or ligation with interval reconstruction. Splenectomy is
reserved for distal and hilar lesions not suitable for ligation or reconstruction.
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Incision
1. Either a midline laparotomy or a bilateral subcostal incision is preferred. In
patients with suspected rupture, a midline incision is preferable.
2. Proximal splenic artery aneurysms are exposed by incising the gastrohepatic
ligament and entering the lesser sac (Fig.10.1). An aneurysm from the mid to
distal splenic artery is exposed through the gastrocolic omentum.
3. Posterior wall of the stomach is separated from the anterior surface of the
pancreas.
4. The entire length of the pancreas is exposed from its head to the body and tail
toward the hilum of the spleen.
5. An incision is made in the posterior peritoneum. The splenic artery aneurysm
can be exposed from the origin to the middle portion of the splenic artery
(Fig.10.2).
6. For aneurysms located in the distal splenic artery, gastrosplenic ligament is
divided and the posterior peritoneum over the distal splenic artery is divided
after its careful palpation. Proximal control of splenic artery is obtained by using
a right-angle clamp and passing a silastic vessel loop. Care is taken not to injure
the splenic vein, which courses next to the splenic artery. If the splenic artery
aneurysm extends to the hilum of the spleen, splenectomy with aneurysm resection is performed en bloc. Arterial reconstruction following proximal and distal
ligation of the splenic artery is not necessary because of the abundant
collaterals.
7. In patients with giant splenic artery aneurysms, the normal proximal and distal
splenic artery may be difcult to visualize because of the size of the aneurysm.
Fig. 10.1 Opening in the
gastrohepatic omentum for
exposure of proximal
splenic artery aneurysm,
celiac artery aneurysm, and
hepatic artery aneurysm
120
Fig. 10.2 Stomach
retracted superiorly.
Exposed proximal and mid
splenic artery aneurysm at
the superior border of the
pancreas
S. S. Hans
Once the proximal control is obtained, aneurysm sac is opened, and pancreatic
branches of splenic artery are ligated from within. In such patients with ligation
of the distal splenic artery, the spleen remains viable via its arterial supply from
the left gastric artery branches.
Complications
1. Post-splenectomy infection: Appropriate vaccination regimen should be under-
taken following splenectomy if performed in association with removal of splenic
artery aneurysm. If the spleen is viable following ligation of the splenic artery
but does not have a pulsatile ow, vaccination regimen should be considered.
2. Left upper quadrant abscess, pancreatic stula, and pancreatitis are other rare
complications of splenic artery aneurysm repair.
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121
Hepatic Artery Aneurysms
Hepatic artery aneurysms are the second most common splanchnic artery aneurysms. Most are extrahepatic and are more common in the common hepatic artery.
Most hepatic artery aneurysms are asymptomatic. Hepatic artery aneurysm has the
highest incidence of rupture among all splanchnic artery aneurysms. Hepatic artery
aneurysm may present as right upper quadrant or epigastric pain followed by upper
GI hemorrhage and jaundice. Repair of hepatic artery aneurysms should be considered for all symptomatic patients and for aneurysms greater than 2cm in diameter.
All intrahepatic pseudoaneurysms should be considered for repair.
The anatomical relationship of the hepatic artery aneurysm to the gastroduodenal
artery and associated liver disease is a major determinant for treatment options.
When anatomically feasible, catheter-based therapeutic approach should be considered as the rst line of management. As the gastroduodenal artery provides an excellent collateral ow to the liver, common hepatic artery aneurysm can be treated with
ligation. If the gastroduodenal artery is small, arterial reconstruction will be necessary. Hepatic artery ligation should not be considered in the presence of cirrhosis of
the liver. For intrahepatic pseudoaneurysm, a catheter-based approach is preferred.
Hepatic resection (segment) may be necessary in select group of patients.
Incision
Both midline laparotomy and bilateral subcostal incisions are appropriate for repair
of nonemergent hepatic artery aneurysm.
Exposure oftheHepatic Artery
The lesser sac is entered through an opening in the gastrohepatic omentum. Proximal
portion of the hepatic artery arising from the celiac artery trunk is exposed by elevating the stomach with further exposure of the lesser sac as the dissection is continued. The junction of the common hepatic artery and the proper hepatic artery is
marked by the origin of the gastroduodenal artery. Interposition grafting following
aneurysmorrhaphy should be performed in cases where gastroduodenal artery needs
to be sacriced.
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