This document describes the surgical technique for repairing type IV thoracoabdominal aortic aneurysms and suprarenal abdominal aortic aneurysms. The technique involves a retroperitoneal approach with suprarenal or supravisceral aortic clamping. Renal and intestinal arteries are continuously perfused using a passive shunt from the right axillary artery to protect these organs from ischemia during the procedure. The proximal anastomosis is beveled with the tip at the level of the celiac trunk. Patch insertion of visceral artery origins allows implantation into the graft. Renal protection techniques aim to limit ischemia time to less than 45-50 minutes to prevent renal failure, and may include cold perfusion, prostagland

1. SURGICAL TECHNIQUE FOR
SUPRARENAL AND
THORACOABDOMINAL TYPE
IV AORTIC ANEURYSMS
R. Halpern, S. Baila, H Moldovan,
Isabela Oprea, Florentina Matache,
Mihaela Craciun, S. Bubenek

2. Clinical presentation
 First Pt. 65 yo:
 Abdominal and lumbar pain and
 Syncope 1 day before hospitalization
 Second Pt. 59 yo:
 pulsatile abdominal mass - 10 months before
hospitalization and
 lumbar pain - 1 month before hospitalization
 Third Pt. 58 yo:
 abdominal pain - onset 2 weeks before hospitalization

3. Pt 1 contrast CT

5. Pt 3 contrast CT

6. Lab tests
 All patients had normal PREOPERATIVE
BP, HT, Hb, L, ureea, creatinin and
glucose levels

7. Patient position
 Operative position
 right lateral decubitus
 hips rotated 20-30 °
 table angulated in the middle
 left arm elevated
 Peridural and general anesthesia
with nonselective intubation
 Urinary catheter, invasive left
radial artery monitoring, large bore
venous lines and cell saver set up
From: http://www.or-live.com/memorialhermann/1234/event
Dr. Hazim J. Safi, Memorial Hermann Hospital, Huston,
Texas

8. Axillary Artery Canulation and
Materials
 Systemic heparinisation
70-100 UI heparin / Body
weight
 Canulation of right axillary
artery and set up the
shunt
 Synthetic graft on axillary
artery in termino-lateral
fashion
 Arterial canula inserted
into graft
 4 retrograde canulas
Medtronic
 Connecting tubes

9. Operative Approach
 Thoracic approach 8th intercostal space -
control of the distal thoracic aorta for
rapid clamping of aorta in case bursting
bleeding at the time of retroperitoneal
approach of abdominal aorta
 Phrenotomy
 Retroperitoneal approach - continuing the
oblique incision to below the umbilicus
 Approach to the infra diaphragmatic aorta
by rotation to right of the spleen, left
kidney and abdominal viscera
 Splitting of the left crus of the diaphragm
 Clamping of the aorta below diaphragm Sursa: http://www.or-live.com/memorialhermann/1234/event
 Aneurysm incision to the visceral level of Dr. Hazim J. Safi, Memorial Hermann Hospital, Huston,
aorta Texas

10. Continuous axilo-visceral shunt
 Clamping of axillary
artery distal the canula
 Identification and
canulation of renal
arteries, superior
mesenteric and celiac
trunk ostia
 Starting continuous
perfusion of visceral
arteries from right axillary
artery using the shunt

11. Proximal anastomosis
 Preparing the anastomotic site at suprarenal aorta
 Bevel the proximal end of the graft
 Anastomosis between the graft and visceral portion of the aorta with 3.0 polipropilene
suture (Clamping time 45-60 min)
 At the end of anastomosis taking off the canulas
 Distal anastomosis between graft and
 Aorta
 Femural arteries

12. Intraoperative view Pt. 1

13. Intraoperative view Pt 3

14. Postoperative course
 Uneventful
 Discharged after 7-10 day post op.
 With normal creatinin, TGO, TGP levels
 It was a spike in Creatinin, TGO and TGP levels on 2, 3
postop day up to 1.3 creatinin, 400 U/l TGO and 130 U/l
TGP
 Presence of intestinal motility during 2-3 day after surgery
 No respiratory or bleeding complications

15. Discussions

16. Types of Aortic Aneurysms
 Juxtarenal aortic aneurysms (3-20% of AAA)
 Thoracoabdominal type IV aneurysms
(Crawford classification) (4% of TAA)
 Infrarenal aortic aneurysm with hostile
infrarenal aortic neck (friability, calcification)
(unknown %)

17. The standard treatment of these types of aortic aneurysms
is
open surgical repair
until fenestrated endografts will be improved.
Hybrid procedures could be also an option
 This type of surgery is technically more demanding and
characterized by problems related to:
 suprarenal aortic control
 renal, hepatic and intestinal ischemia
 larger surgical dissection associated with bleeding problems
which may be followed by an increased operative mortality and
morbidity rate.

18. Abdominal Aortic
Aneurysm
Classification ProximalType II≥15 mm
neck
A:

 Distal extension down to
aortic bifurcation
 need for bifurcated
endografts
Type I Type II B: Type III
 Proximal neck ≥15 mm  Proximal neck ≥15 mm  Proximal neck <15 mm
 Distal cuff ≥10 mm  Aneurysmal involvement of  Distal expansion
 adapted for tubular endograft the proximal iliacal arteries  demands open surgery
 need for bifurcated
endograft
Type II C:
 Proximal neck ≥15 mm
Schumacher H, Eckstein HH,
 Distal extension down to iliac Kallinowski, F, Allenberg JR
bifurcation (1996) Morphometry and
classification in abdominal
 inappropriate for aortic aneurysms. J Endovasc
endografting Surg 4:39–44
 demands open surgery

19. Juxtarenal Aortic Aneurysm
Abdominal Aortic Aneurysm that
do not have an infrarenal aortic neck
and
where the aortic diameter is normal at the
level of celiac axis.

20. Juxtarenal Aortic
Aneurysm
Classification
 Type A aneurysm of interrenal aorta extending on suprarenal
aorta; the dilatation develops at the posterior aortic wall
 Type B infrarenal aortic aneurysm with normal interrenal aorta
and aneurysm of one or two renal artery origin.
 Type C juxtarenal aorta with normal interregnal aorta and
absence of aneurysm at renal arteries.
Ayari R, Paraskevas N, Rosset E, Ede B, Branchereau A. Juxtarenal aneurysm.
Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new
classification. Eur J Vasc Endovasc Surg. 2001 Aug;22(2):169-74.

21. Thoracoabdominal Aortic Aneurysms

22. Key points
 Retroperitoneal approach
 Suprarenal or supravisceral aortic clamping
 Renal and intestinal continuous perfusion (protection)
with a passive shunt from right axillary artery
 Beveled proximal anastomosis
 the tip on the level of celiac trunk
 the heel - infrarenal
 Patch insertion of visceral arteries origins into graft -
“Carrel patch” for visceral arteries implantation (in type
IV thoracoabdominal aneurysms)

23. Retroperitoneal approach
 1952 - Dubost - was the first to replace an aneurysm of
the abdominal aorta used a retroperitoneal approach
Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta. Reestablishment of the
continuity by a preserved human arterial graft, with result after five months. Arch Surg 1952; 64:405-408.
 1963 - Rob - first to give a detailed description of the
antero-lateral retroperitoneal
 advantages easier postoperative course
 disadvantages such as limited exposure.
Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963; 53:87-89.
 1980 – Williams - described the extended retroperitoneal
approach
 allows a better exposure not only of the infrarenal but also the
pararenal and even suprarenal aorta.
Williams GM, Ricotta J, Zinner M, et al. The extended retroperitoneal approach for treatment of
extensive atherosclerosis of the aorta and renal vessels. Surgery 1980; 88:846-855.

24. Retroperitoneal approach
 May provide less physiologic insult and a smoother
postoperative course.
 less ventilatory support and tolerated enteral feedings
quickly
Chang BB, Shah DM, Paty PS, Kaufman JL, Leather RP. Can the retroperitoneal approach be used for ruptured
abdominal aortic aneurysms? J Vasc Surg 1990;11:326-30.
Gregorio A. Sicard, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report
of a prospective randomized trial J Vasc Surg 1995;21
 Facilitate proximal abdominal aortic exposure and
anastomosis, especially in large, pararenal aneurysms or
in situations unfavorable to a transabdominal approach.
Suited to those that pose significant technical
challenges.
Shepard AD, Tollefson DF, Reddy DJ, Evans JR, Elliott JP Jr, Smith RF, Ernst CB Left flank retroperitoneal exposure:
a technical aid to complex aortic reconstruction. : J Vasc Surg. 1991 Sep;14(3):283-91
 Adequate exposure to the proximal right renal artery can
be obtained with acceptable mortality and morbidity.
Shah DM, Darling RC 3rd, Chang BB, Paty PS, Leather RP, Lloyd WE Access to the right renal artery from the left
retroperitoneal approach. : Cardiovasc Surg. 1996 Dec;4(6):763-5.

25. Where to clamp?
 Above the diaphragm
 Adamkiewicz – risk for paraplegia
 In case of ruptured infradiaphragmatic aneurysms
 After control – move the clamp at a more distal level
 Between diaphragm and celiac artery
 Hepatic, intestinal and renal ischemia
 Division of crura (Crawford)
 Between renal artery and superior mesenteric artery
 Renal ischemia
 Potential pancreatic tissue damage and bleeding

26. Risk Factors for Supravisceral Aortic
Clamping
 Time – speed of suture
 Preexisting visceral disease
renal failure
hepatic failure
 Methods for renal protection

27. Is there a cut-off for clamping time?
 Renal failure remains a common
complication after complex aortic surgery,
which greatly increases the risk of
mortality.
 Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients
undergoing thoracoabdominal
 aortic operations. J Vasc Surg 1993;17(2):357–368.
 Bicknell CD, Cowan AR, Kerle MI, Mansfield AO, Cheshire NJ, Wolfe JH. Renal dysfunction and
prolonged visceral ischaemia increase mortality rate after suprarenal aneurysm repair. Br J Surg
2003;90(9):1142–1146.
 Martin GH, O’Hara PJ, Hertzer NR, Mascha EJ, Krajewski LP, Beven EG, Clair DG, Ouriel K.
Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic
segments: early results and late outcome. J Vasc Surg 2000;31(5):851–862.

28. Renal protection
 Schwartz et al. found in a retrospective review of
58 patients, all with TAA IV, that renal failure did
not occur if preoperative renal function was
normal.
A renal ischaemic time of up to 45-50 min seems
safe
 Sarac TP, Clair DG, Hertzer NR, Greenberg RK, Krajewski LP, O’Hara PJ, Ouriel K.
Contemporary results of juxtarenal aneurysm repair. J Vasc Surg 2002;36(6):1104–
1111.
 Breckwoldt WL, Mackey WC, Belkin M, O’Donnell TF. The effect of suprarenal cross-
clamping on abdominal aortic aneurysm repair. Arch Surg 1992;127:520–524.
 Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509
patients undergoing thoracoabdominal aortic operations. J Vasc Surg
1993;17(2):357–368.

29. Medication of Renal Protection
 Cold
perfusion with Ringer’s lactate - Svensson et al.
 PGE1
Reiher L, Vosberg H, Sandmann. Kidney protection in preventing post-ischaemic renal failure during thoracoabdominal aortic aneurysm repair:
does prostaglandin E1 together with cooling provide more protection than cooling alone? Vasa 2001 Feb;30(1):21-3
 Manitol
and adequate IV volume
 Adenosine.
Haruko Sugino, Hideyo Shimada and Kanji Tsuchimoto. Role of Adenosine in Renal Protection Induced by a Brief
Episode of Ischemic Preconditioning in Rats Jpn. J. Pharmacol. 87 (2), 134-142 (2001)
 Fenoldapam
 Calcium Channel Blokers
Dan Tzivoni End Organ Protection by Calcium-Channel Blockers Clin. Cardiol. 24, 102–106 (2001)

30. Approaches to Renal Protection
A. Aoki, K. Sangawa; Repair of a Pararenal Abdominal Aortic Aneurysm with Bilateral Renal Artery Stenosis
Using a Rapid Infusion Pump for Renal Perfusion: Report of a Case. Surg Today (2008) 38:751–755

31. Approaches to Renal Protection
 Renal perfusion using a roller pump
supplied with venous blood from a central
venous catheter under medium-level
heparinization to feed two perfusion
balloon catheters
 Pichlmaier M, Hoy L, Wilhelmi M, Khaladj N, Haverich A, Teebken OE. Renal perfusion with
venous blood extends the permissible suprarenal clamp time in abdominal aortic surgery. J Vasc
Surg. 2008 Jun;47(6):1134-40. Epub 2008 Apr 3.

32. Clamp and Go Era

33. Protection for Mesenteric Ischemia
 Bicknell et al. found a significantly higher mortality rate in patients who had
visceral ischemia for 40–59 min (27%) than in those with ischaemia for <40
min (9%).
 Vermeulen et al. also observed a higher complication rate if mesenteric
ischaemia was longer than 60 min.
Methods of reducing visceral ischemia:
 selective visceral artery perfusion using extracorporeal circulation
 shunting of the visceral arteries via a side-arm of the graft.
 The rationale is relatively weak for using adjunct therapy to reduce visceral
ischemia in uncomplicated repair of TAA IV with a single proximal
anastomosis including the visceral arteries.
 If a separate proximal end-to-end anastomosis is anticipated, mesenteric
shunting is probably beneficial and recommended.
(C.-M. Wahlgren and E. Wahlberg)

34. Conclusions
 Advantages
 No need of pumping system
 No stress about clamping time – increased safety
 Drawbacks:
 Increasing operative time due to axilary canulation
 Increasing operative cost due to canulas
 Cannot be applied when is associated axillary artery
atheromatosis

35. Conclusions
 There is a need for large scale trial in order
to determine:
the precise safety of the method
the utility and indications of the method

36. Special thanks to
Victor Pavel – perfusionist nurse

37. Thank You