Retroperitoneal approach to aaa repair
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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

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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:231elective15 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-implantation5Renal re-implantation /graft62 horseshoe kidneys1 accessory renal3 left renal grafts.AxBfem &aortic graft excision2Duodenal closure2

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 patients1 Ischemic colitis and MSOF1 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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