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
Vascular and Endovascular Surg U of O
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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
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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
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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 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
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Retroperitoneal AAA Repair
Horseshoe kidney
• Requires Re-implanting renal branches to the isthmus
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Ruptured AAA
• Avoid left sided ruptures. Unless low down and neck is accessible
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Redo Aortic Surgery
• Remote ABF. Proximal aortic aneurismal degeneration
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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 Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
Canada
Draining Lumbar vein
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Retroperitoneal AAA Repair venous anomalies
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Suprarenal exposure
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Iliac Exposure
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Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Demographics:
251 consecutive Patients (2004-2012)
M : 195 F: 56
Age: 87-52 Av:71.5 Mean: 71
• Co morbidity:
CAD:
112
COPD: (1 or 2 puffers)
40
Diabetes:
44
Obesity: (BMI>30)
46
Hx of smoking:
230
HTN:
165
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Aneurysm Characteristics:
• Primary:
246 patients
• Redo : 5 patients
1 pat. 1 yr post REVAR
2 pats. Secondary ADF, in a Type IV AAA post remote
aortic Sx.
1 pat. IAAs post ruptured AAA repair 4 years earlier
1 pat. Had an AAA 10 years post ABF end to side graft
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Aneurysm Characteristics:
231
15
5
elective
acute /symptomatic
ruptured (3 acute, 2 chronic)
• Other findings:
2 horseshoe kidneys
6 inflammatory
89 IAA. 54 bilat. 15 R. 20 L.
46 patients had previous abdominal surgery.
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Proximal control:
212 infrarenal
33 Suprarenal
6 Supraceliac, type IV AAA repair.
• Type of Repair:
136 Tube graft
89 AIs. 54 Bilat, 15 R, 20 L
24 ABFs.
2 pericardial patch aortic closures
Vascular and Endovascular Surg U of O
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Retroperitoneal AAA Repair: our experience
• Additional procedures:
IMA re-implantation
Renal re-implantation /graft
2 horseshoe kidneys
1 accessory renal
3 left renal grafts.
AxBfem &aortic graft excision
Duodenal closure
5
6
2
2
Vascular and Endovascular Surg U of O
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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%)
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Retroperitoneal AAA Repair: Length of stay
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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 Creatinine
6 ARF: 2 hemofiltration only, 3 transient dialysis, 1 permanent
• Respiratory:
Exacerbation of COPD:5 ( 1 needed home O2)
1 PE
DVT
• Post-op bleed:
6 total. 4 no source was found. 2 splenectomy
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Retroperitoneal AAA Repair: Complications
• GI:
Ischemic colitis: 8 transient, 4 C.diff, 2 colectomies
UGI 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 disease
Acute occlusion of one ABF limb, required urgent revision
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Retroperitoneal AAA Repair: Incisional complications
• 13 patients.
• Wound infection:6
2 proven cultures with purulent drainage
4 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 knot
6 specific complaints about asymmetric bulge
needed reassurance
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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
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Ottawa: The Parliament buildings
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