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Retroperitoneal Approach to AAA Repair. George E. Hajjar MD. FRCSC Division of Vascular and Endovascular Surgery University of Ottawa Canada. Ottawa Canada The Nations Capital. Pop 990,000. Retroperitoneal AAA Repair. Advantages: Lesser post-op pain, easier respiratory functions.

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retroperitoneal approach to aaa repair

Retroperitoneal Approach to AAA Repair

George E. Hajjar MD. FRCSC

Division of Vascular and Endovascular Surgery

University of Ottawa

Canada

Vascular and Endovascular Surg U of O

Canada

ottawa canada the nations capital pop 990 000
Ottawa Canada The Nations Capital. Pop 990,000

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair
Retroperitoneal AAA Repair
  • Advantages:
  • Lesser post-op pain, easier respiratory functions.
  • Less third spacing and fluid shift.
  • Less hypothermia
  • Less bowel oedema, and transient ischemia
  • Less post op ileus and need for NG suction
  • Better exposure of suprarenal aorta
  • The Aorta is a retroperitoneal structure

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair1
Retroperitoneal AAA Repair
  • Advantages (Contd):
  • Avoids going through intra-abdominal adhesions and scarring
  • Prevents development of intra-abdominal adhesions and scarring
  • Decreases the chances of duodenal injury, and intramural haematoma
  • Decreases the incidence of Aorto-duodenal fistula development
  • Possibly decreases length stay.

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair2
Retroperitoneal AAA Repair
  • Not widely used:
  • Unfamiliarity with the approach
  • Reserved for selective difficult cases
  • Fear of incisional complications : muscle eventration although it does occur it is well tolerated in this patient population. No incisional hernias or eviscerations.
  • Fear of difficulty exposing associated iliac disease: Right iliac aneurysm or femoral exposure if needed.

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair3
Retroperitoneal AAA Repair
  • Procedure of choice In
  • Hostile abdomen
  • Juxta-renal or supra-renal aneurysms
  • Horseshoe Kidney
  • Redo Aortic Surgery
  • Inflammatory aneurysms
  • Avoided:
  • If concurrent right renal repair is needed
  • Left sided vena cava, other venous anomalies
  • Ruptured aneurysm with large left sided haematoma

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair horseshoe kidney
Retroperitoneal AAA RepairHorseshoe kidney
  • Requires Re-implanting renal branches to the isthmus

Vascular and Endovascular Surg U of O

Canada

ruptured aaa
Ruptured AAA
  • Avoid left sided ruptures. Unless low down and neck is accessible

Vascular and Endovascular Surg U of O

Canada

redo aortic surgery
Redo Aortic Surgery
  • Remote ABF. Proximal aortic aneurismal degeneration

Vascular and Endovascular Surg U of O

Canada

right iliac aneurysms
Right iliac aneurysms
  • Mobilization of the retroperitoneum low down in the left pelvis
  • Relaxing the upper incisional retractors
  • Ligating and transecting the IMA , allows further aneurysm mobilization .

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair4
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair5
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair6
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair7
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

draining lumbar vein
Draining Lumbar vein

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair venous anomalies
Retroperitoneal AAA Repair venous anomalies

Vascular and Endovascular Surg U of O

Canada

suprarenal exposure
Suprarenal exposure

Vascular and Endovascular Surg U of O

Canada

iliac exposure
Iliac Exposure

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair8
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair9
Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience
Retroperitoneal AAA Repair: our experience
  • Demographics:251 consecutive Patients (2004-2012)M : 195 F: 56Age: 87-52 Av:71.5 Mean: 71
  • Co morbidity:CAD: 112COPD: (1 or 2 puffers) 40 Diabetes: 44Obesity: (BMI>30) 46Hx of smoking: 230HTN: 165

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience1
Retroperitoneal AAA Repair: our experience
  • Aneurysm Characteristics:
  • Primary: 246 patients
  • Redo : 5 patients1 pat. 1 yr post REVAR2 pats. Secondary ADF, in a Type IV AAA post remote aortic Sx.1 pat. IAAs post ruptured AAA repair 4 years earlier1 pat. Had an AAA 10 years post ABF end to side graft

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience2
Retroperitoneal AAA Repair: our experience
  • Aneurysm Characteristics:231 elective15 acute /symptomatic5 ruptured (3 acute, 2 chronic)
  • Other findings:2 horseshoe kidneys6 inflammatory89 IAA. 54 bilat. 15 R. 20 L.46 patients had previous abdominal surgery.

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience3
Retroperitoneal AAA Repair: our experience
  • Proximal control:212 infrarenal33 Suprarenal6 Supraceliac, type IV AAA repair.
  • Type of Repair:136 Tube graft89 AIs. 54 Bilat, 15 R, 20 L24 ABFs.2 pericardial patch aortic closures

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience4
Retroperitoneal AAA Repair: our experience
  • Additional procedures:IMA re-implantation 5Renal re-implantation /graft 6 2 horseshoe kidneys 1 accessory renal 3 left renal grafts.AxBfem &aortic graft excision 2Duodenal closure 2

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair our experience5
Retroperitoneal AAA Repair: our experience
  • Mortality:
  • No intra-op mortality
  • 30 day Mortality : 2 patients 1 cardiogenic shock 1 respiratory failure
  • In hospital death : 2 patients 1 Ischemic colitis and MSOF 1 progressive renal failure, resp failure
  • Total in hospital mortality:4 (1.6%)

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair length of stay
Retroperitoneal AAA Repair: Length of stay

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair complications
Retroperitoneal AAA Repair: Complications
  • Cardiac:Arrhythmias 12, (1 Pneumo: pacemaker)CHF10, (1 needed mitral repair)MI: 8 ( 2 required intervention)
  • Renal:20 transient rise in Creatinine6 ARF: 2 hemofiltration only, 3 transient dialysis, 1 permanent
  • Respiratory:Exacerbation of COPD:5 ( 1 needed home O2)1 PEDVT
  • Post-op bleed:6 total. 4 no source was found. 2 splenectomy

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair complications1
Retroperitoneal AAA Repair: Complications
  • GI:Ischemic colitis: 8 transient, 4 C.diff, 2 colectomiesUGI bleeding. 6 gastro duodenal erosions ( 1 required cauterization)4 post-op ileus.
  • Peripheral ischemia: 4 patients:Ext iliac occlusion (1), bilat SFA thrombosis post RAAA(1)popliteal artery occlusion (thrombectomy and fasciotomy)SFA atheroembolic diseaseAcute occlusion of one ABF limb, required urgent revision

Vascular and Endovascular Surg U of O

Canada

retroperitoneal aaa repair incisional complications
Retroperitoneal AAA Repair: Incisional complications
  • 13 patients.
  • Wound infection:62 proven cultures with purulent drainage4 erythema. No culture Rx with Abx.
  • Wound haematoma: 4
  • Serosanguinous drainage: 3
  • Late incisional complications:1 Intercostal neuralgia(tip of 11th rib was excised for higher exposure)2 excision of Prolene knot6 specific complaints about asymmetric bulge needed reassurance

Vascular and Endovascular Surg U of O

Canada

conclusion
Conclusion
  • Retroperitoneal approach for AAA repair is easily feasible.
  • Can be used in a variety of conditions including right iliac aneurismal disease, aortoiliac disease.
  • Approach of choice for hostile abdomens, redo aortic surgery, inflammatory aneurysm, horseshoe kidney, suprarenal aneurysms
  • Does not provide access to right renal artery if needed
  • Avoided in large left retroperitoneal haematomas and ruptured AAA

Vascular and Endovascular Surg U of O

Canada

ottawa the parliament buildings
Ottawa: The Parliament buildings

Vascular and Endovascular Surg U of O

Canada

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