How I Do It

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How I Do It Improvised Top‑End Strategy for Surgical Repair of Juxtarenal Abdominal Aortic Aneurysm Madathipat Unnikrishnan

Abstract Juxtarenal abdominal aortic aneurysm (AAA), a variant of infrarenal AAA forms a formidable therapeutic challenge in both open and endovascular strategies in view of its domain bearing viscero‑renal arteries. Reported conventional surgical approach mandates supracoeliac/suprarenal aortic cross clamping that leads to significant renal morbidity and rarely mortality. We describe, a threefold adjuvant in surgical strategy namely division of left renal vein, interrenal aortic cross clamping and transaortic ostial instillation of renal preservation fluid through lower renal artery, that provided safe operating conditions leading to excellent results. Key Words: Interrenal aortic cross clamping, juxtarenal abdominal aortic aneurysm, left renal vein, renal preservation fluid

Introduction Incidence of juxtarenal abdominal aortic aneurysm (JRAAA), constituting not‑so‑uncommon variant of infrarenal abdominal aortic aneurysm (AAA), is variously reported at 2–30% in literature,[1] wherein aneurysm does a butt, but not involve the renal arteries, precluding clamp placement leave alone safe proximal anastomosis. Open surgical or endovascular reconstruction forms a formidable technical challenge in view of the initial need for temporary interruption followed by eventual preservation of viscero‑renal perfusion. Open repair mandates suprarenal or supracoeliac aortic cross clamping that causes renal and visceral ischemia leading to significant morbidity and rarely mortality. Endovascular aneurysm repair is also not an easy proposition for lack of proximal landing zone, which mandates complex endovascular solution (s) for a successful outcome. Herein, we describe an innovative and effective surgical strategy with three fold adjuvants for open repair of JRAAA, hitherto undescribed, for a safe conduct providing excellent results.

also named lumboazygos trunk[4] with connections to azygos or accessory hemizygos system. The flared up aneurysmal aorta yields to safe proximal reconstruction better, when LRV is out of the way [Figure 1a and b] • Inter‑renal aortic cross clamping is achievable in the setting of angulation of proximal aorta, particularly found in juxta renal aortic aneurysms in most occasions and also facilitated by the slightly different levels at which renal arteries take off from aorta. This maneuver facilitates continued perfusion of upper renal and superior mesenteric arteries in contrast to supracoeliac/ suprarenal clamping[5] • Lower renal artery ostium, thus remaining below the cross clamp, at top end of opened up aneurysmal sac, provides access to Pruitt‑Inahara shunt (9 Fr) (LeMaitre Vascular, Burlington, MA, USA) to infuse cold (4°C) renal preservation fluid of about 1 L. Proximal anastomosis is always reinforced with Teflon (polytetrafluoroethylene [PTFE]) felt, carefully encircling the renal ostium, which gets delineated better by the indwelling shunt.

Surgical strategy Surgical adjuvants to open repair has three components namely (1) Division of left renal vein (LRV) flush with inferior vena cava (IVC), (2) Inter‑renal aortic cross clamping and (3) Transaortic cold renal perfusate through lower renal artery ostium.

Methods

Scientific basis for surgical adjuvants • Left renal vein in contradistinction to the right, has four tributaries, inferior phrenic, suprarenal, gonadal[2,3] and more importantly one or two large parieto‑renal veins

A typical patient ‑ 82‑year‑old, otherwise active gentleman presented with JRAAA of 7 cm size. A reformed smoker, his

During 2010–2014, 16 patients with symptomatic large JRAAA who underwent open surgical repair form the basis of this report [Figure 2]. Their age varied from 18 to 82 in this all male cohort, 6 with mild to moderate coronary artery disease and serum creatinine ranging from 1.5 to 2 mg%.

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Department of Cardiovascular and Thoracic Surgery, Division of Vascular and Endovascular Surgery, Sri Chitra Thirunal Institute of Medical Science, Trivandrum, Kerala, India

Website: www.indjvascsurg.org

Address for correspondence: Prof. Madathipat Unnikrishnan, E‑mail: [email protected]

DOI: 10.4103/0972-0820.152829

Indian Journal of Vascular and Endovascular Surgery | Jan-Mar 2015 | Issue 1 | Volume 2

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[Downloaded free from http://www.indjvascsurg.org on Wednesday, April 01, 2015, IP: 14.139.190.66] || Click here to download free Android application for this journ Unnikrishnan: How I do it- juxtarenal abdominal aortic aneurysm repair

general examination was unremarkable with blood pressure recorded 140/90 mm Hg, on the beta blocker (tablet atenolol 25 mg twice daily) for 4 years. His serum creatinine was 1.8 mg% with estimation of glomerular filtration rate of 40 mL/min and coronary angiography showed occluded right coronary artery filling by collaterals. He underwent repair of the aneurysm with improvised surgical strategy, recovered satisfactorily and his serum creatinine was 1.4 mg% following surgical procedure, at discharge from hospital [Figure 3a and b].

Surgical procedure Aneurysm was approached by transperitoneal, midline, and xipho‑pubic laparotomy in every patient. Incision made on retroperitoneum between inferior mesenteric vein on left and duodenum on right extended cephalad up to the inferior border of the pancreas and caudally to bifurcation and extended on to right common iliac artery. LRV was dissected, encircled and divided [Figure 4] to the right of gonadal and adrenal veins and flush with IVC between crossed clamps and sutured off using 5–0 polypropylene suture, using running mattress suture, followed by

a

continuous over and over technique.[2,3] Further dissection was carried out to delineate both renal arteries for the proposed interrenal clamping [Figure 5]. After systemic heparinization (1.5 mg/kg) and cross clamping of aorta and iliac arteries or femoral arteries (when appropriate), aneurysm was opened with backup of cell saver. Proximal anastomosis was performed, reinforced with Teflon felt (PTFE) carefully paying attention to safeguard the patency of lower renal artery ostium, now opened up with indwelling Pruitt-Inahara shunt, infusing cold preservation fluid [Figure 5]. Distal anastomosis was performed to aortic bifurcation or iliac or femoral arteries as dictated by anatomy. Rest of the procedure was completed in the standard fashion.

Results Of the 16 patients, a 68‑year‑old patient who had a tight stenosis of right renal artery undetected preoperatively; on dual antiplatelets following percutaneous coronary intervention (drug eluting stents) 3 months ago; succumbed

b

Figure 1: (a) Picture showing, viz. gonadal, adrenal, lumbar and inferior phrenic tributaries draining into left renal vein (LRV) and drainage of LRV into the inferior vena cava (b) Large lumbar veins joining left renal vein (black arrow) – also called parieto-renal vein, which often drains into azygos/hemiazygos systems by reno-azygos lumbar trunk

a

Figure 2: Computed tomography angiogram, multiplanar reconstruction, showing large juxtarenal abdominal aortic aneurysm closely abutting both renal arteries

b

Figure 3: (a) Computed tomography angiogram, multiplanar reconstruction, showing juxtarenal abdominal aortic aneurysm (b) Postoperative computed tomography angiogram, volume rendered image, at 3 months showing intact repair of a juxtarenal aortic aneurysm, patent renal arteries and normally enhancing kidneys

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Figure 4: Intra-operative picture demonstrating left renal vein (LRV) between clamps prior to division, distal to the drainage of tributaries into LRV, at the top end of aneurysm



acute renal failure when atheromatous debris blocked the higher renal artery ostium, which was identified requiring expedious stenting to tide over the crisis. A Dutch meta‑analysis on repair of JRAAA, including 21 nonrandomized cohort studies from 1986 to 2008, involving 1256 patients, had shown perioperative mortality 2.9% and new onset of dialysis of 3.3%.[6] State‑of‑the‑art endovascular aneurysm repair has been already established as primary therapeutic modality in many centers across the world. Fenestrated, branched, and chimney/snorkel graft techniques are being employed in place of open surgery particularly in compromised patients with good short and midterm results for JRAAA.[7,8] Figure 5: Intra-operative picture showing inter-renal aortic cross clamp in situ and trans-ostial Pruitt-Inahara shunt (arrow) placed into lower left renal artery for delivering renal preservation fluid

to acute renal failure despite postoperative renal angioplasty. Furthermore, his procedure required suprarenal cross clamping in view of the inability to perform interrenal cross clamping of the aorta. Another patient developed acute renal failure due to snow ploughing of right renal artery ostium after interrenal clamping‑this required renal artery stenting. Three patients developed transient increase in serum creatinine, normalizing at discharge from hospital. A total of 15 patients had an uneventful recovery (including the patient who required renal artery stenting) and were discharged from hospital in 8–10 days. At a follow‑up of 8 months to 4 years, patients are well and active [Figure 3b].

Conclusion Complex JRAAA can be operated upon with satisfactory results and preserved renal function at midterm follow‑up, combining adjuvants to the surgical procedure in our experience. This operative procedure of obtaining uninterrupted de novo perfusion to the mesenteric and upper renal artery; cold renal infusate to lower renal artery ostium, along with safe proximal anastomosis facilitated by interruption of LRV; forms proof of concept in the management of complex JRAAA with excellent results.

Acknowledgments I would like to record my special thanks to my colleagues Ajay Savlania, Sidharth Viswanathan, and Shivanesan Pitchai for their hard work and dedication in our vascular unit.

Discussion

References

Juxtarenal abdominal aortic aneurysm, having incidence variously reported at 2‑30% of infrarenal AAA, forms a subset that poses great therapeutic challenge. Conventional open surgical repair using supracoeliac/suprarenal aortic cross clamping implies viscero‑renal ischemia and LRV often coming in the way of safe top end despite mobilization. Studies have reported safety of dividing LRV at IVC end, with no significant consequences, providing required surgical access for aortic cross clamping and performance of tidy proximal aortic anastomosis.[2,3] Interrenal clamping is also facilitated by proximal neck angulation and more often than not, different levels of renal artery origins. Cold (4°C) renal preservation fluid using normal saline with additives (40cc soda bicarbonate, 40 cc mannitol, 20 mg of unfractionated heparin, 100 mg hydrocortisone and 30 mg of papaverine) helps kidney protection during proximal anastomosis. Technique of interrenal clamping was adopted in 40 patients in the group of 120 patients as reported by Mayo Clinic group.[5] In our series of 16 patients, mortality ensued in a 68‑year‑old patient who mandated suprarenal cross clamping and had tight right renal artery stenosis as well. In another patient cross clamp injury resulted in

1. Lawrence PF, Gazak C, Bhirangi L, Jones B, Bhirangi K, Oderich G, et al. The epidemiology of surgically repaired aneurysms in the United States. J Vasc Surg 1999;30:632‑40. 2. Elsharawy MA, Cheatle TR, Clarke JM, Colin JF. Effect of left renal vein division during aortic surgery on renal function. Ann R Coll Surg Engl 2000;82:417‑20. 3. Wang L, Xin SJ, Song Z, Zhang J. Left renal vein division during open surgery of abdominal aortic disease: A propensity score‑matched case‑control study. Eur J Vasc Endovasc Surg 2013;46:227‑31. 4. Li G, Dong J, Lu JS, Zu Q, Yang SX, Li HZ, et al. Anatomical variation of the posterior lumbar tributaries of the left renal vein in retroperitoneoscopic left living donor nephrectomy. Int J Urol 2011;18:503‑9. 5. Knott AW, Kalra M, Duncan AA, Reed NR, Bower TC, Hoskin TL, et al. Open repair of juxtarenal aortic aneurysms (JAA) remains a safe option in the era of fenestrated endografts. J Vasc Surg 2008;47:695‑701. 6. Jongkind V, Yeung KK, Akkersdijk GJ, Heidsieck D, Reitsma JB, Tangelder GJ, et al. Juxtarenal aortic aneurysm repair. J Vasc Surg 2010;52:760‑7. 7. Greenberg RK, Haulon S, O’Neill S, Lyden S, Ouriel K. Primary endovascular repair of juxtarenal aneurysms with fenestrated endovascular grafting. Eur J Vasc Endovasc Surg 2004;27:484‑91.


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8. British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent‑Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012;125:2707‑15.

How to cite this article: Unnikrishnan M. Improvised Top-End Strategy for Surgical Repair of Juxtarenal Abdominal Aortic Aneurysm. Indian J Vasc Endovasc Surg 2015;2:21-4.

Received: December, 2014. Accepted: January, 2015. Source of support: Nil, Conflict of Interest: ???.

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