Abstract
Patients who have unfavourable anatomy for endovascular repair of an abdominal aortic aneurysm require open repair. This is particularly the case for juxtarenal aortic aneurysms, or those patients with small or occluded iliac access vessels.
An experience of ‘fast-track’ abdominal aortic aneurysm repair that was previously reported is updated in the present case. A retroperitoneal approach to the aorta is taken, using a small incision, and is followed by a patient care pathway protocol that demonstrated excellent results and a shortened length of stay. The present update on 56 patients is approximately double the previously reported experience.
Keywords: Abdominal aortic aneurysm, Juxtarenal, Open repair
Endovascular repair (ER) of abdominal aortic aneurysms (AAAs) continues to gain market share within the treatment paradigm of AAA disease. Nevertheless, there are a significant number of patients in whom the anatomy of the aneurysm does not permit durable ER. These patients are best managed with open surgical repair (OR) of the aneurysm. In a previous publication (1), the primary author presented his experience with 30 patients who underwent an operation using a limited incision (10 cm to 15 cm in length) for a retroperitoneal approach to the aorta. Standard prosthetic graft endoaneurysmorraphy was performed, and a patient care pathway protocol was used to shorten the length of the hospital stay and improve clinical outcome. Good results were demonstrated in the original report. We report an expansion of our experience to 56 patients, nearly doubling the initial report, along with additional techniques we have developed for management of the challenging juxtarenal aortic aneurysm.
METHODS
The technique for retroperitoneal repair of AAAs has previously been described in detail and will be briefly summarized here (1). The patient is placed with the pelvis flat on the operating table, and the left upper body is angled 45°. This allows for a limited skin incision (10 cm to 15 cm in length) from the lateral border of the left rectus abdominis muscle to the tip of the 11th rib.
After division of the abdominal wall musculature, the peritoneum and its contents are bluntly mobilized medially while leaving the left kidney in its anatomical location. A self-retaining Bookwalter retractor (Codman Inc, USA) was used to expose the aorta from the level of the left renal vein to the iliac bifurcation, including the right common iliac artery. Low-profile Cosgrove clamps (Edwards Lifesciences LLC, USA) were used to allow for atraumatic occlusion of the aorta and iliac arteries, while providing excellent unobtrusive exposure for the surgeon.
AAAs with short necks (less than 0.5 cm) or no necks (juxtarenal) have required mobilization of the left renal vein without dividing it, and placement of the proximal aortic clamp above the lower of the two renal arteries (Figure 1). This allows for normal perfusion of the proximal renal artery and creation of the anastomosis in the healthiest section of the aorta, at or just below the renal artery orifice. Back bleeding from the renal artery below the aortic clamp is usually minimal because the renal artery is an end vessel. Rarely will a clamp on the lower renal artery be necessary to prevent back bleeding. On completion of the proximal anastomosis, the clamp is moved onto the graft, allowing perfusion of both renal arteries.
Figure 1).
Aortic clamp placed below one renal artery and above the other
A standard postoperative protocol is followed; it begins with a minimum of 4 h recovery in the postanesthesia care unit before determining whether monitoring in the intensive care unit (ICU) is necessary. Most patients who require ICU observation stay overnight and transfer to the surgical floor on postoperative day 1. Intravenous metacloperamide 10 mg is administered every 8 h in the immediate postoperative period for bowel stimulation. Clear liquids are started on the first postoperative day and advanced, as tolerated, to soft foods by postoperative day 3.
A bisacodyl suppository is administered on postoperative day 2 or 3, if required, for stimulation of a bowel movement. Epidural anesthesia is used in the immediate postoperative period, with transition to oral analgesics and removal of the epidural and urinary catheters on postoperative day 2 or 3. Most patients are discharged on postoperative day 3 or 4.
RESULTS
The initial experience with 30 consecutive patients (Table 1) has now been nearly doubled to total 56 (Table 2). The group is comprised of 20% women (n=11) and 80% men (n=45) with infrarenal AAA measuring greater than 5.0 cm (range 5.0 cm to 8.5 cm; median 5.7 cm) that were repaired electively (n=49) or urgently (n=7). All AAA patients since January 2001 were evaluated for either OR or ER. Patients who were not candidates for ER because of unfavourable AAA anatomy underwent OR; patients who were good candidates for both were given an informed choice. Patients determined to be poor operative candidates at high risk of perioperative morbidity and mortality underwent ER. The most common reason for failure of ER candidacy is lack of an adequate ‘neck’ for proximal landing of the stent graft. The breakdown of patients, according to American Society of Anesthesiology (ASA) classifications, was: ASA II, 4% (n=2); ASA III, 75% (n=42); and ASA IV, 21% (n=12).
TABLE 1.
Clinical profile of the first 30 patients undergoing ‘fast-track’ abdominal aortic aneurysm (AAA) resection
| No. | Age, years | Sex | AAA size, cm | ASA class | Blood loss, mL | Graft diameter (mm) and type | ICU LOS | Hospital LOS | Complications | Comments |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 70 | F | 5.0 | IV | 350 | 18, tube | 1 | 5 | Renal failure, dialysis | Solitary kidney with pre-existing renal insufficiency |
| 2. | 63 | M | 5.3 | III | 400 | 18, tube | 1 | 3 | None | |
| 3. | 54 | M | 5.5 | III | 500 | 20 × 10, bifurcated | 1 | 3 | None | |
| 4. | 67 | M | 6.6 | III | 500 | 20 × 10, bifurcated | 1 | 4 | None | |
| 5. | 63 | M | 6.0 | III | 700 | 20 × 10, bifurcated | 1 | 4 | None | |
| 6. | 74 | M | 5.5 | III | 500 | 22, tube | 1 | 3 | None | |
| 7. | 74 | M | 8.5 | III | 500 | 18, tube | 1 | 3 | None | Obese (125 kg), urgent AAA repair |
| 8. | 60 | M | 5.8 | III | 700 | 18 × 9, bifurcated | 0 | 3 | None | Inflammatory AAA |
| 9. | 60 | M | 6.2 | III | 500 | 18, tube | 0 | 4 | Ureter injury | Inflammatory AAA |
| 10. | 70 | M | 7.8 | IV | 500 | 18 × 9, bifurcated | 0 | 7 | Transient renal insufficiency | Symptomatic AAA, urgent repair |
| 11. | 73 | M | 5.2 | III | 500 | 18, tube | 0 | 3 | None | |
| 12. | 77 | M | 6.2 | III | 450 | 16 × 8, bifurcated | 1 | 3 | None | |
| 13. | 67 | M | 5.5 | III | 400 | 18, tube | 0 | 3 | None | Left adrenalectomy for adenoma |
| 14. | 60 | M | 6.0 | III | 500 | 20 × 10, bifurcated | 0 | 3 | None | Obese (120 kg) |
| 15. | 68 | M | 5.8 | III | 400 | 18 × 9, bifurcated | 1 | 3 | None | |
| 16. | 50 | M | 5.5 | II | 400 | 18 × 9, bifurcated | 0 | 3 | None | |
| 17. | 62 | M | 5.5 | III | 350 | 18, tube | 1 | 4 | None | Symptomatic AAA, urgent repair |
| 18. | 61 | M | 6.5 | III | 5400 | 20 × 10, bifurcated | 1 | 1 | Expired, splenic injury | Not EVAR candidate |
| 19. | 70 | M | 5.5 | IV | 400 | 20, tube | 1 | 4 | None | Juxtarenal AAA |
| 20. | 63 | M | 7.0 | III | 800 | 22, tube | 1 | 3 | None | Juxtarenal AAA |
| 21. | 73 | M | 5.5 | III | 1100 | 18 × 9, bifurcated | 1 | 3 | None | Occluded iliac artery |
| 22. | 72 | M | 6.9 | III | 500 | 20, tube | 1 | 3 | None | |
| 23. | 81 | F | 5.0 | III | 500 | 18, tube | 1 | 4 | None | Symptomatic AAA |
| 24. | 65 | M | 6.1 | III | 1300 | 20, tube | 1 | 4 | None | Previous renal transplant |
| 25. | 71 | M | 7.5 | III | 500 | 18, tube | 1 | 3 | None | Juxtarenal AAA |
| 26. | 88 | F | 6.5 | III | 1300 | 20, tube | 1 | 4 | None | Inadequate neck for EVAR |
| 27. | 65 | M | 7.5 | III | 700 | 22, tube | 0 | 3 | None | Juxtarenal AAA |
| 28. | 67 | F | 5.5 | III | 350 | 16, tube | 1 | 3 | None | Inadequate neck for EVAR |
| 29. | 67 | F | 5.5 | III | 1200 | 16 × 8, bifurcated | 1 | 3 | None | Small iliac artery |
| 30. | 69 | M | 6.5 | III | 500 | 18, tube | 1 | 4 | None | Inadequate neck for EVAR |
Data from reference 1. ASA American Society of Anesthesiology; EVAR Endovascular aneurysm repair; F Female; ICU Intensive care unit; LOS Length of stay, days; M Male; No. Patient identification number
TABLE 2.
Clinical profile of patients who underwent ‘fast-track’ abdominal aortic aneurysm (AAA) resection after the initial report
| No. | Age, years | Sex | AAA size, cm | ASA class | Blood loss, mL | Graft diameter (mm) and type | ICU LOS | Hospital LOS | Complications | Comments |
|---|---|---|---|---|---|---|---|---|---|---|
| 31. | 71 | M | 5.5 | IV | 500 | 18 × 9, bifurcated | 1 | 4 | None | Juxtarenal AAA |
| 32. | 70 | M | 6.0 | III | 1200 | 18 × 9, bifurcated | 1 | 6 | None | Juxtarenal AAA |
| 33. | 55 | F | 5.3 | IV | 500 | 16, tube | 2 | 3 | None | Inadequate neck for EVAR |
| 34. | 76 | M | 6.0 | IV | 200 | 16 × 8, bifurcated | 1 | 4 | None | Inadequate neck for EVAR |
| 35. | 62 | F | 5.5 | III | 500 | 18, tube | 1 | 3 | Incisional hernia | Juxtarenal AAA |
| 36. | 82 | M | 6.0 | III | 1200 | 18 × 9, bifurcated | 1 | 4 | None | Juxtarenal AAA |
| 37. | 78 | M | 7.0 | III | 1500 | 20 × 10, bifurcated | 1 | 5 | None | Juxtarenal AAA |
| 38. | 61 | M | 6.0 | III | 700 | 16, tube | 1 | 3 | None | Inadequate neck for EVAR |
| 39. | 75 | M | 6.4 | III | 500 | 18, tube | 3 | 9 | Cardiac dysrhythmia | Symptomatic juxtarenal AAA, urgent repair |
| 40. | 79 | M | 6.5 | IV | 2000 | 24, tube | 1 | 4 | Ischemic colitis | Juxtarenal AAA |
| 41. | 73 | M | 5.0 | III | 3000 | 16, tube | 1 | 5 | None | Juxtarenal AAA |
| 42. | 67 | F | 6.0 | IV | 700 | 24, tube | 1 | 4 | None | Symptomatic juxtarenal AAA, urgent repair |
| 43. | 70 | M | 5.5 | III | 1000 | 18, tube | 1 | 4 | None | Inadequate neck for EVAR |
| 44. | 78 | F | 6.0 | IV | 1000 | 16 × 8, bifurcated | 1 | 4 | None | Inadequate neck for EVAR |
| 45. | 63 | M | 7.0 | III | 800 | 22, tube | 1 | 3 | None | Juxtarenal AAA |
| 46. | 79 | M | 6.0 | III | 200 | 16 × 8, bifurcated | 1 | 4 | None | Juxtarenal AAA |
| 47. | 77 | M | 6.0 | III | 1200 | 16 × 8, bifurcated | 1 | 3 | None | Juxtarenal AAA |
| 48. | 64 | F | 5.5 | III | 200 | 14, tube | 2 | 4 | None | Juxtarenal AAA |
| 49. | 83 | M | 5.5 | IV | 700 | 16 × 8, bifurcated | 1 | 4 | None | EVAR attempt unsuccessful due to iliac occlusive disease |
| 50. | 63 | M | 6.5 | III | 850 | 16 × 8, bifurcated | 2 | 4 | None | Symptomatic juxtarenal AAA, urgent repair |
| 51. | 64 | M | 5.1 | III | 700 | 18 × 9, bifurcated | 1 | 4 | None | Rapidly expanding, inadequate neck for EVAR |
| 52. | 63 | M | 5.8 | III | 200 | 16 × 8, bifurcated | 1 | 3 | None | EVAR candidate, patient choice |
| 53. | 69 | M | 6.0 | III | 450 | 16 × 8, bifurcated | 3 | 5 | Atrial fibrillation | Juxtarenal AAA |
| 54. | 80 | M | 5.6 | IV | 700 | 18, tube | 7 | 14 | Pneumonia, renal failure, dialysis | Juxtarenal AAA |
| 55. | 67 | M | 5.3 | IV | 600 | 20, tube | 1 | 3 | None | Symptomatic juxtarenal AAA, urgent repair |
| 56. | 76 | F | 6.0 | II | 700 | 16, tube | 1 | 4 | None | Inadequate neck for EVAR |
ASA American Society of Anesthesiology; EVAR Endovascular aneurysm repair; F Female; ICU Intensive care unit; LOS Length of stay, days; M Male; No. Patient identification number
Most patients (n=48) stayed at least overnight in the ICU, although this is not the rule, and patients have been transferred directly to the surgical ward after a period of observation of at least 4 h in the postanesthesia care unit. The average length of stay for patients transferred to the ICU postoperatively was one day, with transfer to the surgical ward on postoperative day 1.
Removing the outliers at both ends (patients 18 and 54; Tables 1 and 2), the average length of stay in the hospital for the series of patients was 3.8 days, with a range of three to nine days.
Complications occurred in 16% of patients (n=9); these included cardiac dysrhythmias (n=2), transient renal insufficiency (n=1), renal failure requiring hemodialysis (n=2), ureter injury recognized intraoperatively and repaired (n=1), self-limited ischemic colitis (n=1), incisional hernia (n=1) and splenic injury (n=1). The mortality rate in the present series was 1.8% (n=1). This patient sustained a splenic injury from operative retraction in the region of the left upper quadrant with delayed diagnosis and hemorrhagic shock.
DISCUSSION
There has been a flurry of clinical research reported since the emergence of ER of AAAs in 1991 (2–15). It has been demonstrated that the short-term morbidity and mortality of ER is significantly better than OR (4,7,10,15). The Endovascular Aneurysm Repair (EVAR) Trial 1 (7) demonstrated a persistent 3% reduction in aneurysm-related deaths after four years in patients with ER versus OR, but with a significantly higher incidence of postoperative complications. This included the need for secondary intervention in those who underwent ER (41%) versus OR (9%) (7,10). The long-term durability of AAA OR has been well established, with several reports demonstrating late graft-related complications of 2.5% to 6.8% over a follow-up period of as many as 36 years (10). The need for secondary intervention is not benign; it increases the morbidity and mortality risk for the patient. It also increases the hospital costs for treatment of the AAA above the already high costs of ER compared with OR (8,11,14).
The trend in the long-term durability of AAA ER using current technology indicates a significant number of postoperative complications. Therefore, it also indicates a requirement for regular surveillance and a significantly higher rate of secondary interventions over the AAA OR (10). This has led many vascular surgeons to reserve its use only for those patients who are poor operative candidates. However, this patient population is shrinking due to improvements in anesthesia and intraoperative monitoring, preoperative cardiac and pulmonary evaluation and optimization, and postoperative care, especially in the field of critical care medicine. The desire for the proven long-term durability of AAA OR and a morbidity rate comparable with AAA ER has led to newer, less invasive techniques in OR, such as use of the mini-laparotomy and laparoscopic assistance (16–21). Case comparisons between OR and ER at the same institution, by the same surgeons, during the same time period have demonstrated similar objective results and a significant OR cost advantage (2,7,21).
We have previously reported our initial experience using a limited-incision retroperitoneal approach to AAA OR, and the use of low-profile clamps and retractors to improve visualization while limiting interference for the surgeon (1,2). In addition, we have developed a ‘fast-track’ postoperative care protocol in an effort to maximize return of bowel function and mobility (1). This includes physical therapy initiation on postoperative day 1, with discharge typically on postoperative day 3, either to home or to an inpatient rehabilitation facility if determined necessary. We have nearly doubled this initial report to now include 56 consecutive retroperitoneal AAA repairs using our ‘fast-track’ protocol.
Consistent with our initial findings, patient morbidity and mortality in our updated results were similar to the morbidity and mortality of the mini-laparotomy approach.
However, the advantage of the retroperitoneal approach is the avoidance of bowel manipulation and ileus development. This allows us to start oral intake almost immediately, including oral medications for blood pressure control and cardioprotection. In contrast to the mini-laparotomy series (19), we use epidural analgesia, which we believe allows quicker postoperative mobility due to improved pain control. At the appropriate dose, epidural pain control is excellent and allows continued use of the lower extremities, enabling the patient to get out of bed on postoperative day 1. The epidural and Foley catheters are typically removed on postoperative day 2, with analgesia provided orally with intravenous supplementation.
Our updated results continue to support our original claim that our ‘fast-track’ retroperitoneal AAA repair and patient-care pathway is similar to minimally invasive AAA repair (eg, mini-laparotomy or laparoscopic-assisted repair) in regard to objective measurements, such as operative times, transfusion requirements, hospital stay, and overall morbidity and mortality (Table 3). The advantages of our technique are the limited bowel manipulation from avoiding a transperitoneal approach, and the technique’s ability to be performed without advanced laparoscopic skills, necessary equipment and the associated significant learning curve required to perform the operation safely and successfully.
TABLE 3.
Updated comparison of ‘fast-track’ and mini-laparotomy techniques of abdominal aortic aneurysm repair
| Turnipseed, 2001 (19) | Cerveira et al, 1999 (17) | Current series | |
|---|---|---|---|
| Number of patients | 40 | 11 | 56 |
| Intraoperative outcomes | |||
| Average OR time, min | 185 | 131 | 175 |
| Average blood transfusions, units | 1.1±1.5 | 1.1±1.4 | 0.8±1.4 |
| Postoperative outcomes | |||
| Average ICU stay, days | 1.0 | 1.9 | 1.1 |
| Time to diet, days | 3.0 | 3.7 | 3.2 |
| Average hospital stay, days | 4.9 | 5.2 | 3.9 |
| Morbidity rate, % | 13 | 18 | 13 |
| 30-day mortality rate, % | 0 | 0 | 1.8 |
ICU Intensive care unit; OR Open surgical repair
Using retroperitoneal OR, we have been able to approach difficult juxtarenal AAA with a unique approach that enables perfusion to at least one renal artery, avoiding significant postoperative renal dysfunction. We place a clamp above the lower of the two renal arteries while the proximal aortic anastomosis is performed. This allows clamping and creation of an anastomosis at the healthiest section of the aorta, at or just below the renal orifice, avoiding the risk of renal ischemia and the potential for significant renal injury. It also ensures that the anastomosis is performed on a healthy portion of aorta, avoiding any fragile, diseased portion of the aorta. On completion of the proximal anastomosis, the clamp is moved onto the graft, allowing for perfusion of both renal arteries to resume. Using this technique, we had no incidents of prolonged renal insufficiency or renal failure.
CONCLUSION
Our technique for AAA repair uses a limited retroperitoneal incision and a ‘fast-track’ protocol for postoperative care that focuses on pain management using epidural analgesia, early ambulation with immediate physical therapy consultation, and early diet resumption. Our updated experience continues to support our claim that AAA OR has similar results to AAA ER and other minimally invasive AAA OR techniques, such as mini-laparotomy and laparoscopy-assisted repair, with several advantages. These advantages are the proven long-term durability of OR; the fact that close lifelong surveillance is not required as with ER, a significant cost savings to the health care system, and a cost and time savings for patients; advanced endovascular skills and the associated equipment are not necessary; advanced laparoscopic skills are not needed, as with laparoscopic-assisted approaches; and the reintervention rate and related morbidity is significantly lower than with ER using current available technology.
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