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256 Nazareno and Aziz
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Chapter 21 / Pancreatic Pseudocysts 257
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258 Nazareno and Aziz
Chapter 22 / Surgery of the Abdominal Aorta 259
VII
SURGERY ON AORTA AND ITS BRANCHES
260 Saltzberg, Maykel, and Akbari
Chapter 22 / Surgery of the Abdominal Aorta 261
22
Surgery of the Abdominal
Aorta and Branches
Stephanie Saltzberg, MD, Justin A. Maykel, MD,
and Cameron M. Akbari,
CONTENTS
INTRODUCTION
SURGICAL CONSIDERATIONS
OPERATIVE TECHNIQUE
ALTERNATIVE PROCEDURES
COMPLICATIONS OF AORTIC SURGERY
COST
SUMMARY
REFERENCES
MD
INTRODUCTION
Diseases of the aorta and its branches may be commonly thought of as either occlusive
or aneurysmal. Within the aorta itself, the most commonly affected area is the abdominal
aorta, and, more specifically, the disease is mostly confined to the level of aorta below
the renal arteries, or the so-called infrarenal segment. Whereas arteriosclerosis obliterans clearly is the etiologic agent in nearly all cases of occlusive disease, the pathogenesis
of atherosclerotic aortic aneurysms is less clear, despite their name. Indeed, emerging
evidence has promoted the participation of other factors in addition to atherosclerosis,
such as excessive collagenase and elastase activity, genetic susceptibility, and hemodynamic factors (1).
Arteriosclerotic occlusive disease of the aorta and iliac vessels known as, “aortoiliac
disease” is one of the most common conditions encountered by vascular surgeons.
Because atherosclerosis is a systemic process, the occlusive disease is seldom confined
to the aortoiliac vessels alone, and most patients will have occlusive disease involving
the infrainguinal or even visceral (mesenteric and renal) arteries as well. In fact, aortic
“spillover” atherosclerotic disease, in which atherosclerotic plaque extends from the
aorta into the orifice of the visceral vessels, is the most common cause of visceral arterial
From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery
Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ
261
262 Saltzberg, Maykel, and Akbari
Fig. 1. CT scan of an abdominal aortic aneurysm with intramural thrombus.
occlusive disease. It is, therefore, axiomatic that treatment of renal or mesenteric occlusive disease should consider this process (2).
The single most important consideration in the approach to abdominal aortic aneurysms (AAA) is their propensity for rupture and death (Fig. 1). In the United States, it
is the 13th leading cause of death, and implicated in more than 15,000 deaths annually.
Because of Laplace’s Law, in which wall tension is directly related to radius, the risk of
rupture increases with increasing size of the aneurysm, and, in fact, the greatest predictor
of rupture remains the absolute size of the aneurysm itself (1).
The normal diameter of the infrarenal aorta (by far, the most common site of abdominal aortic aneurysms) is about 2 cm, and because an aneurysm is defined as a localized
increase in diameter greater than 50% normal, almost all AAAs are 3.5 cm or larger.
Several natural history studies have shown that the risk of rupture dramatically increases
once the aneurysm approaches 5 cm, and the risk rises exponentially above this number.
For example, the rupture rate for a 5-cm AAA is about 5% annually, which rises to 7%
annually for a 6-cm AAA, and then to 20% annually for aneurysms greater than 7 cm in
diameter. Aneurysms smaller than 5 cm have about a 1% annual rupture rate, and most
of these small asymptomatic aneurysms are followed carefully to ensure that they do not
enlarge suddenly (1).
SURGICAL CONSIDERATIONS
Emerging technology has been responsible for multiple new treatments in patients
with aortic disease, including percutaneous transluminal angioplasty (PTA), either with
or without stenting, stent grafts in patients with aortic aneurysms, and improved tech-
Chapter 22 / Surgery of the Abdominal Aorta 263
niques with the “gold standard” of open surgical repair. Whatever modality is used, the
underlying question should address whether any treatment is needed. For example,
based on the natural history and rupture risk, most surgeons will consider treatment for
an aneurysm of the abdominal aorta greater than 5 cm, but this decision may be modified
in a high-risk patient. Similarly, an active middle-aged person with lifestyle-limiting
buttock, and thigh claudication secondary to aortoiliac occlusive disease should be
approached differently from an elderly patient who is bedridden.
Insofar as operative approaches are treating a localized manifestation of a systematic
process (i.e., atherosclerosis), consideration should be directed toward some assessment
of coronary reserve and cardiac risk. Multiple studies and scoring systems have focused
on this, and their discussion is beyond the scope of this chapter; however, suffice it to
say that more than 50% of patients undergoing vascular reconstruction will have some
element of cardiac disease. Specifically, this becomes more important in the patient
undergoing aortic surgery, in that clamping of the aorta presents a tremendous increase
in cardiac afterload and strain. Ultimately, preoperative evaluation (including bedside
assessment, physiologic functional testing, coronary angiography, or some combination
of these) should be tailored to the individual patient, and postoperative care should
include a heightened awareness that the most common cause of death in these patients
remains cardiac-related.
OPERATIVE TECHNIQUE
The abdominal aorta may be approached by either a transperitoneal (using either a
midline or transverse abdominal incision) or a retroperitoneal (flank) approach. The
traditional, and most common, technique is via a midline, transperitoneal approach.
Although there are some data to suggest a decreased incidence of postoperative pulmonary complications and ileus with the retroperitoneal approach, the final decision is
ultimately based on the patient’s anatomy, body habitus, and on the individual surgeon’s
personal preference and experience with the two approaches.
The transperitoneal technique is usually through a midline incision from the xiphoid
to the pubis (Fig. 2). Once the peritoneal cavity is entered, the abdominal organs are
manually and visually inspected for any untoward and unexpected pathology. Because
the abdominal aorta is located in the retroperitoneum, below the root of the small bowel
mesentery, it is usually approached by first lifting, and carefully retracting the small
bowel and fourth portion of the duodenum to the right of midline. The retroperitoneum
is then incised, allowing for exposure of the aorta. The left renal vein is an important
landmark, usually crossing anterior to the aorta, and signifies the cephalad extent of the
dissection for most infrarenal pathology.
The dissection proceeds more distally on top of the aorta to the level of the iliac
arteries. These are carefully dissected free for subsequent control and clamping. For
more distal exposure of the iliac arteries, attention should be directed to finding the
ureters as they cross anterior to the vessels.
If the suprarenal aorta need be exposed, as for renal artery reconstruction or mesenteric artery bypass, the dissection is directed more cephalad above the left renal vein. The
aorta can be clamped at this location either suprarenally (i.e., above the renal arteries, but
below the superior mesenteric artery), or it may be clamped in a supraceliac position. The
latter implies cross-clamping of the aorta at the level of the diaphragm and assumes a
264 Saltzberg, Maykel, and Akbari
Fig. 2. Abdominal aortic aneurysm via transperitoneal approach. Dotted line shows the extent of
the aneurysm.
greater physiologic insult owing to the warm ischemia time experienced by the visceral
organs (3).
Once the aorta is dissected free, the patient is anticoagulated with a bolus of heparin
and the aorta is clamped. The iliac vessels are usually clamped as well, to prevent troublesome back-bleeding from the open aorta. For infrarenal aortic aneurysms, the aneurysm
sac is opened longitudinally, the aorta is completely divided proximal to the aneurysm,
and similarly divided at the level of the iliac vessels (Fig. 3). Lumbar arteries typically
arise from the infrarenal aorta, and their orifices are oversewn from within the aneurysm
sac. The graft is then sewn in place proximally and distally, and subsequently the opened
aneurysm sac is closed over the graft (Figs. 4–6). If the aneurysm extends to above the
renal vessels, the renal arteries are “reimplanted” and sewn into the side of the graft.
If the operation is being performed for occlusive disease, the proximal infrarenal
aortic anastomosis may be performed either “end to end,” that is sewn to the divided
aorta. Alternatively, it may be performed “end to side,” in which the aorta is not divided,
but instead a small elliptical piece of aorta is removed, and the end of the graft sewn to
Chapter 22 / Surgery of the Abdominal Aorta 265
Fig. 3. Opening of aneurysm sac with proximal control of the aorta and distal control of the iliac
arteries. Dotted line shows the excised wall of the aneurysm.
the side of the aorta. As the occlusive process typically involves the iliac arteries, and
because of concern over progression of disease in the iliac segment, the usual outflow
site for these grafts is at the femoral level.
ALTERNATIVE PROCEDURES
Endovascular stent grafts are an alternative to the conventional open surgical repair
of abdominal aortic aneurysms in carefully selected patients. Improvements in technology have increased the ability to perform these procedures. With current technology,
50% of patients with AAA are candidates for an endovascular repair rather than conventional surgery. These compact systems are comprised of prosthetic grafts coupled to
stents that are deployed via a transfemoral approach. The reported theoretical advantages
of the endovascular approach to AAA include decreased cardiac and pulmonary complications, fewer blood transfusions, minimal surgical dissection, and increased availability
to those with comorbidities that would exclude them from conventional repair (4).
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