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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. 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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  1. 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

  2. Ottawa Canada The Nations Capital. Pop 990,000 Vascular and Endovascular Surg U of O Canada

  3. 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

  4. 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

  5. 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

  6. 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

  7. Retroperitoneal AAA RepairHorseshoe kidney • Requires Re-implanting renal branches to the isthmus Vascular and Endovascular Surg U of O Canada

  8. Ruptured AAA • Avoid left sided ruptures. Unless low down and neck is accessible Vascular and Endovascular Surg U of O Canada

  9. Redo Aortic Surgery • Remote ABF. Proximal aortic aneurismal degeneration Vascular and Endovascular Surg U of O Canada

  10. 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

  11. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  12. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  13. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  14. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  15. Draining Lumbar vein Vascular and Endovascular Surg U of O Canada

  16. Retroperitoneal AAA Repair venous anomalies Vascular and Endovascular Surg U of O Canada

  17. Suprarenal exposure Vascular and Endovascular Surg U of O Canada

  18. Iliac Exposure Vascular and Endovascular Surg U of O Canada

  19. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  20. Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. Retroperitoneal AAA Repair: Length of stay Vascular and Endovascular Surg U of O Canada

  28. 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

  29. 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

  30. 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

  31. 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

  32. Ottawa: The Parliament buildings Vascular and Endovascular Surg U of O Canada

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