Retroperitoneal Approach to AAA Repair

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