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Chapter 10 Pararenal Aortic Aneurysms 161
Fig. 3 Reformatted 3-D tomographic arteriogram of the juxtarenal aortic aneurysm in
Figure 2 (See Color Plates)
Fig. 2 Computed tomogram of a juxtarenal aortic aneurysm
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162 J.C. Stanley
pararenal AAAs, aortic branch disease may not be adequately defined by MRA
studies because of turbulent flow and phase-dropout phenomenon.
Renal artery stenotic disease, severe enough to warrant endovascular or open
operative therapy, complicates the treatment of patients with pararenal AAAs.
In some series, renal artery interventions have been undertaken in more than
40% of cases.
5
Aortic spillover arteriosclerosis accounts for 80% of the renal
stenoses, and critical narrowings exceeding 70–80% are bilateral in a third of
the patients. The surgical therapy in many of these cases is controversial, in
part due to the lack of clinical data to conclusively support renal artery recon-
structive procedures in instances of ischemic nephropathy, as well as a paucity
of clinical data that the renal artery is at high risk when clamping the perirenal
aorta during the aneurysmectomy. Nevertheless, treatment of coexisting renal
artery stenotic disease is justified when anatomic or functional studies support
a diagnosis of renovascular hypertension. The technique of reconstructing the
renal artery in these cases varies, with some favoring an aortorenal bypass
6
and
others an aortorenal endarterectomy.
4,
7–
10
Surgical risks attending operations for pararenal AAA are greater than for
treatment of infrarenal AAAs. Three obvious factors contribute to these risks.
First, a relatively extensive aortic dissection is required for repair of pararenal
AAAs, which translates into increased surgical manipulation of the renal
and superior mesenteric arteries as well as greater lengths of operative time.
Fig. 4 Aortogram of a suprarenal aortic aneurysm with renal artery involvement (arrow).
Reprinted with permission from Henke and Stanley.
26(p. 231)
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Chapter 10 Pararenal Aortic Aneurysms 163
Second, intraoperative renal ischemia due to having to clamp the aorta above
the renal arteries is an inescapable part of these cases. Third, cardiac strain is
greater due to the increased afterload necessitated by the more proximal aortic
clamping in these cases.
Whereas most clinicians are selective with cardiac evaluations for infrarenal
AAA repair, the magnitude of treating pararenal AAAs supports a more liberal
screening of occult coronary artery disease. It is the author's advice that
noninvasive pharmacological or exercise cardiac testing be undertaken in all
patients with pararenal AAAs, and cardiac catheterization pursued if signifi-
cant myocardial ischemia is suspected. Although by no means direct proof of
the validity of such testing, preoperative cardiac studies have become common
in most practices, resulting in an acceptable cardiac morbidity in those patients
undergoing open surgical treatment of their pararenal AAAs.
2–
5,
9,
11
Operative Technique
Certain technical aspects of open surgical treatment of pararenal AAAs are
well recognized by vascular surgeons, and are of importance to others who
are advising these patients about their therapeutic options. Three basic means
of exposing pararenal AAAs for optimal surgical therapy exist: (1) transab-
dominal, (2) retroperitoneal, and (3) thoracoabdominal. The patient's anatomic
disease, prior abdominal surgery, body habitus, and the surgeon's personal
preference are determining factors as to which approach is to be used. Each has
distinct advantages and each carries different risks to the overall procedure.
A direct abdominal approach with a vertical midline or supraumbilical
transverse incision is used in treating most pararenal AAAs.
4
Direct expo-
sure of the pararenal aorta at the base of the mesentery and mesocolon is
usually pursued, although indirect aorta exposure following medial visceral
rotation may be undertaken as an alternative approach, especially in the case
of unusually large pararenal AAAs. While medial visceral rotation yields
excellent exposure of the aneurysm neck and renal vessels, pancreatitis is a
potential complication.
4,
12
In some patients, such as those with a very acute
costophrenic angle, an abdominal approach alone limits the surgical exposure
and increases the operative risks. In that setting, a thoracoabdominal incision
allows greater visualization of the aorta and its branches.
A retroperitoneal approach through a flank or thoracic incision is preferred
by some.
3,
5,
13,
14
This approach is associated with less postoperative fluid
requirements and a shorter hospital stay, but no difference in morbidity or mor-
tality has been documented.
3
If a right renal artery or iliac artery reconstruc-
tion is required, it may be technically very difficult using this approach, and in
such circumstances, a second abdominal incision may be required.
A major factor contributing to operative morbidity relates to the proximal
aortic clamp placement at the suprarenal levels, be it between the renal and
superior mesenteric arteries as well as above the superior mesenteric artery or
celiac artery. The patient's anatomy and disease are often the primary determi-
nants of where clamp placement is to occur.
Supraceliac aortic clamping is clearly easier in terms of dissection, and the
aorta at that level is usually less atherosclerotic. This site provides positioning
of the clamp away from the renal artery orifices and anastomotic area. Although
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164 J.C. Stanley
some have reported no difference in patient morbidity and mortality between
any of the potential clamp sites,
4
others have presented evidence that supraceliac
control decreases mortality and postoperative renal failure.
1,
2,
15,
16
The potentially
severe coagulopathy accompanying supraceliac clamping in the experimental
setting
17
has not been evident in recent clinical series.
1,
2,
15
Perhaps most impor-
tant to choosing the level of aortic clamping is the significant mortality observed
when clamping the proximal aorta between the renal and superior mesenteric
arteries or between the superior mesenteric and celiac arteries.
1,
2,
15
Placement of
a clamp below the superior mesenteric artery should only be done if a reasonable
distance exists between the former vessel and the renal arteries.
If the segment of aorta being clamped is not free of extensive atherosclerosis
or luminal thrombus, unclamping and repositioning the clamp to a more proxi-
mal site may be associated with atheroembolization, visceral infarction, and
death.
2,
3,
9,
11
In regard to the latter, once the pararenal aorta has been exposed,
isolation and transient occlusion of the renal and mesenteric arteries with
microvascular clamps before proximal aortic clamping is a very important
means of preventing embolization of dislodged aortic debris that might cause
irreversible injury to the kidneys and intestines.
The dominant cause of morbidity and a substantial cause of mortality
following open pararenal AAA repair is renal failure.
9
Minimizing kidney
ischemia during performance of the proximal aortic anastomosis to less than
30 min may decrease the incidence of postoperative renal insufficiency.
2,
8,
12
It has been noted that the duration of supravisceral clamp time is directly
related to morbidity and mortality.
3,
18,
19
The proximal aortic anastomosis may
often be completed in a more expeditious manner if the infrarenal aorta is
transected and transposed to a position above the left renal vein where sutur-
ing can be completed in an unencumbered manner. Following completion of
this anastomosis, the aorta and graft can be repositioned behind the left renal
vein. Transecting the left renal vein to gain easier exposure of the pararenal
aorta is not recommended and has been associated with greater postoperative
renal insufficiency.
20
Replacing the clamp to the graft below the renal arteries
and restoring flow to the kidneys after proximal aortic anastomosis comple-
tion will decrease renal ischemia, but caution must be taken to flush any aortic
debris loosened by the proximal clamp, before restoring renal blood flow. If
flushing is not done, loose material may embolize to the kidneys.
Another technique to minimize renal ischemic injury is with kidney hypo-
thermia.
5
The author favors infusion of chilled (4°C) Ringer's lactate, to which
is added 1000 U heparin, 12.5 g Mannitol, and 44.6 mEq of sodium bicar-
bonate/liter. Approximately 150 ml of this solution is infused through each
renal artery orifice, with repeated administration if the occlusion time exceeds
30 min. This practice may be most efficacious for patients with preoperative
renal insufficiency.
1–
3,
9
Ice-slurry packing of the kidneys may also lower the
core kidney temperature, but such is more cumbersome and less often under-
taken in most practices.
In most patients with juxtarenal aortic aneurysms, the proximal graft-to-
aorta anastomosis occurs at the level of the renal artery orifices (Fig. 5 ). In
some patients, the graft must be carried posteriorly above the renal arteries. In
other instances, the anastomosis incorporates the proximal aorta and one renal
artery with reimplantation of the other renal artery.
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Chapter 10 Pararenal Aortic Aneurysms 165
In most suprarenal aortic aneurysms, the graft anastomosis will be above
the renal vessels with bilateral reimplantation of the renal arteries or
some other means of maintaining normal renal blood flow. Nonanatomic renal
revascularization with grafts to the kidney originating from the supraceliac
aorta, or in some instances as hepatorenal or splenorenal bypasses, are of value
in these circumstances (Fig. 6 ).
Fig. 5 Common open surgical reconstructive options used in treating juxtarenal aortic aneurysms: ( a ) juxtarenal
graft placement, abutting the renal arteries and ( b ) tapered graft extending posteriorly above the renal arteries.
Reprinted with permission from Henke and Stanley.
26(p. 231)
Fig. 6 Common open surgical reconstructive options used in treating suprarenal aortic aneurysms: ( a ) suprarenal
graft placement with bilateral renal artery implantation and ( b ) suprarenal graft placement with right hepatorenal
bypass and left splenorenal bypass. Reprinted with permission from Henke and Stanley.
26(p. 232)
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166 J.C. Stanley
Surgical Outcomes
Open operative treatment of pararenal AAAs in contemporary series has been
accompanied by modest morbidity and mortality rates (Table 1 ). Mortality
figures from experienced institutions averages around 5%,
3,
5,
8,
9,
18–
21
being
slightly greater than that from contemporary series on infrarenal AAAs. Some
have reported mortality rates nearly fourfold higher with suprarenal versus
juxtarenal aneurysm repair.
18
Blood loss and fluid requirements are typically
twice that of infrarenal AAA repairs but such is not an independent predictor
of patient outcome.
Unfortunately, the morbidity associated with the open surgical treatment of
pararenal AAAs remains high. The major complication of the operative treatment
of pararenal AAAs and often times the cause of death, as previously mentioned,
is renal failure. The incidence of postoperative renal failure ranges from 10% to
30%, and is highest among patients with preoperative renal insufficiency and
in those requiring concomitant renal artery reconstruction.
2,
4,
5,
8,
18,
20–
22
However,
the need for chronic hemodialysis in survivors is low. Intestinal ischemia and
infarction is also a recognized cause of death in these patients.
9
Renal failure has
accounted for more than half the mortality in several series.
1–
3,
5,
8
Treatment of coexisting renal artery disease causing renovascular hyperten-
sion results in improved blood pressure control in 50–70% of these patients,
although only 20% are cured of their hypertension. Outcomes regarding reversal
of ischemic nephropathy and prevention of renal artery disease progression are
ill-defined in contemporary literature, with no evidence-based data supporting
the routine reconstruction of the renal arteries in this subgroup of patients.
Overall survival at 5 years following the open surgical therapy of pararenal
AAAs has been cited as low as 40% and as high as 75% with most late deaths
due to cardiac causes,
8,
19,
23
not unlike that observed after infrarenal AAA
repairs. It is relevant to any discussion of pararenal AAAs to recognize that
serious comorbidities in certain patients may preclude safe endovascular or
open operative repair of their aneurysms, and in these individuals, nonoperative
therapy may be quite appropriate.
24,
25
Nevertheless, given the lethal nature of
aneurysmal expansion with rupture, operative treatment of pararenal AAAs is
warranted in all patients who are otherwise acceptable surgical candidates.
Table 1 Operative outcomes of treating pararenal abdominal aortic aneurysm.
a
Institution
Number
of patients
Operative mortality
(%)
New onset postoperative
dialysis (%)
University of California, San Francisco, California
9
257 5.8 7.0
Mayo Clinic, Rochester, Minnesota
20
247 2.8 3.7
H San Raffaele Institute, Milan, Italy
21
107 4.2 3.4
Methodist Hospital, Houston, Texas
8
101 7.9 7.9
University of Michigan, Ann Arbor, Michigan
b
84 3.5 2.4
Washington University, St. Louis, Missouri
5
65 1.5 3.1
Henry Ford Hospital, Detroit, Michigan
3
53 3.8 5.7
a
Reported series composed of differing numbers of juxtarenal and suprarenal aneurysms, as well as differing numbers of patients
subjected to concomitant renal revascularization procedures. This invalidates direct comparisons of one series to another
b
Three year experience (1996–1999) originally presented in 2000
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Chapter 10 Pararenal Aortic Aneurysms 167
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Abstract The advent of endovascular abdominal aortic aneurysm repair (EVAR)
has led to a decrease in postoperative morbidity, shorter hospital stays, and
quicker recovery time following abdominal aortic aneurysms repair. Nevertheless,
EVAR continues to be burdened with similar ischemic complications as seen
with open aortic surgery, and occurs in 3–10% of patients. Signs and symptoms
of pelvic ischemia (PI) include buttock and thigh claudication (BC and TC),
impotence, perineal necrosis, rectal necrosis, colonic necrosis, and distal
spinal cord or lumbar plexus ischemic neuropathy. Some of the mechanisms
that may contribute to PI include interruption of hypogastric arterial circulation
and atheroembolization. Several case reports and small retrospective studies
have found that preservation of direct internal iliac artery (IIA) perfusion is
important in preventing PI complications. The incidence of colonic ischemia
after EVAR is 1.5%, though multiple large series have reported no cases of
ischemic colitis. Preserving direct blood flow to the IIAs is likely the key in
preventing this complication, particularly in the presence of a patent inferior
mesenteric artery.
Keywords
Pelvic ischemia during EVAR , Collateral pelvic circulation , Pelvic
ischemia , AAA repair , IIA occlusion during EVAR , Claudication and AAA
repair , Bowel ischemia
Introduction
Signs and symptoms of pelvic ischemia (PI) include buttock and thigh claudication
(BC and TC), impotence, perineal necrosis, rectal necrosis, colonic necrosis, and
distal spinal cord or lumbar plexus ischemic neuropathy. Endovascular abdomi-
nal aortic aneurysm repair (EVAR) has proven to be safe and effective in
preventing aneurysm expansion and rupture.
1– 4
Successful endovascular
treatment of abdominal aortic aneurysms (AAAs) requires undilated arterial
segments, relatively free of disease proximal and distal to the aneurysm.
5
Chapter 11
Pelvic Ischemia During Endovascular
Abdominal Aortic Aneurysm Repair
Juan Fontcuberta , Manuel Doblas , Antonio Orgaz , Angel Flores ,
Jose Gil , Ignacio Leal, and Enrique Criado
G. Upchurch and E. Criado (eds.) Aortic Aneurysms, Contemporary Cardiology
DOI: 10.1007/978-1-60327-204-9_11, © Humana Press, a part of
Springer Science + Business Media, LLC 2009
169
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170 J. Fontcuberta et al.
These undiseased arterial sites are necessary for the fixation of the endovascular
prosthesis to the arterial wall. Tight apposition and fixation is necessary to
achieve exclusion of the aneurysm from the arterial circulation.
6,
7
Extension of the aneurysm to the bifurcation of the common iliac artery
(CIA) necessitates deployment of the distal aspect of the endovascular graft
in the external iliac artery (EIA). This in turn results in interruption of arterial
flow to the ipsilateral internal iliac artery (IIA).
8
In addition, when the IIA
exhibits significant aneurysmal dilatation, its perfusion must be interrupted
to prevent rupture.
9,
10
The effects of IIA occlusion vary greatly in their sever-
ity and are dependent on the circumstances under which occlusion occurs.
11
These effects range from asymptomatic occlusion to the development of
significant pelvic and spinal cord ischemia.
12–
15
Complications resulting from unilateral IIA occlusion associated with
EVAR have been observed in 12–45% of cases.
16–
19
Unilateral IIA occlu-
sion may be a relatively innocuous event; however, the occlusion of both
IIAs appears to be associated with a greater likelihood of development of an
ischemic complication.
16,
18,
19
The advent of EVAR has led to a decrease postoperative morbidity, shorter
hospital stay, and quicker recovery time following AAA repair. Nevertheless,
EVAR continues to be burdened with similar ischemic complications as seen
with open aortic surgery. Ischemic complications after EVAR occur in 3–10%
of patients. The mechanisms that may contribute to PI include interruption of
hypogastric arterial circulation and atheroembolization.
Pelvic Collateral Circulation
Collateral pathways connect the midgut, hindgut, and pelvis via the superior
mesenteric artery (SMA), inferior mesenteric artery (IMA), IIA, and profunda
femoris arteries. Midgut to hindgut collaterals include the meandering artery,
or the arch of Riolan, and the marginal artery of Drummond, both of which
originate from the left branch of the middle colic artery and connect to the left
colic artery or IMA.
20
The sigmoid colon can receive collateral perfusion from the IIA via hemor-
rhoidal arteries. In the event of chronic occlusive disease of the IMA, the left
IIA may provide most of the blood supply to the sigmoid colon. The IIA can
also provide collateral circulation to the distal spinal cord and the lumbosac-
ral nerve roots via iliolumbar and lateral sacral arteries. These collaterals are
especially important when the artery of Adamkiewicz is occluded or originates
very proximally.
The femoral arteries also can play a significant role in buttock and peri-
neal perfusion via medial and lateral circumflex femoral arteries. The medial
circumflex femoral artery terminates in the obturator artery, a branch of
the IIA. The lateral circumflex femoral artery directly supplies the gluteal
muscles. The superior and inferior gluteal arteries supplying blood to the
buttocks are the main branches of the IIA.
Iliopoulos et al.
11
conducted a study measuring intraluminal IIA pressures
and its variations after intermittent clamping of the pelvic branches from ten
patients. The findings from the study suggested that ascending branches from
the ipsilateral external iliac-deep femoral system provide a more significant
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