An optimized retroperitoneal approach for open aortic repair by partially removing the tenth rib without incising the pleura and diaphragm Yuewei Wang,

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An optimized retroperitoneal approach for open aortic repair by partially removing the tenth rib without incising the pleura and diaphragm Yuewei Wang, MD, Lijia Cui, MD, Fangda Li, MD, Bao Liu, MD, Changwei Liu, MD, Yuehong Zheng, MD Journal of Vascular Surgery Cases and Innovative Techniques Volume 2, Issue 3, Pages 95-100 (September 2016) DOI: 10.1016/j.jvsc.2016.02.010 Copyright © 2016 Terms and Conditions

Fig 1 Patient 1 with pararenal abdominal aortic dissection (AAD) and abdominal aortic aneurysm (AAA). A, Preoperative computed tomography angiography (CTA) showed a pararenal AAD with a patent false lumen and AAA. The celiac axis, superior mesenteric artery, and right renal artery were supplied from the original aortic lumen. The left renal artery was supplied from the false lumen. B, Postoperative CTA showed renal arteries, celiac trunk, and superior mesenteric artery without dilation and dissection. C, The incision originated from the intersection of the tenth rib and the midaxillary line and extended inferomedially to the lateral border of the rectus muscle midway between the umbilicus and the pubis. D, The tenth rib was partially removed to expose the upper abdominal aorta without incising the pleura and diaphragm. E, The suprarenal aorta, left renal artery, and common iliac artery were dissected and controlled with vessel loops. F, The aneurysm was replaced with a bifurcated graft, and the left renal artery was reimplanted. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 95-100DOI: (10.1016/j.jvsc.2016.02.010) Copyright © 2016 Terms and Conditions

Fig 2 Patient 2 with Marfan syndrome (pararenal abdominal aortic dissection [AAD] and abdominal aortic aneurysm [AAA]). A, Preoperative computed tomography angiography (CTA) showed a pararenal AAD and AAA with a tortuous configuration. The left renal artery originated from the false aortic lumen, and the right one was supplied from the true aortic lumen. B, The dissection is above the orifice of the left renal artery. C, The tenth rib was dissected. D, The tenth rib was partially removed. E, The suprarenal aorta, superior mesenteric artery, right renal artery, and left renal artery were dissected and controlled with vessel loops. F, The aneurysm was replaced with a tube graft and a bifurcated graft, and the left renal artery was reimplanted to the graft. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 95-100DOI: (10.1016/j.jvsc.2016.02.010) Copyright © 2016 Terms and Conditions

Fig 3 Patient 3 with abdominal aortic aneurysm (AAA) and left renal artery aneurysm. A, Preoperative computed tomography angiography (CTA) revealed an infrarenal AAA and left proximal renal artery aneurysm. B, Postoperative CTA showed renal arteries, celiac trunk, and superior mesenteric artery without dilation and dissection. C, The incision originated from the intersection of the tenth rib and the midaxillary line and extended inferomedially to the lateral border of the rectus muscle midway between the umbilicus and the pubis. D, The suprarenal aorta, left renal artery, and common iliac artery were dissected and controlled with vessel loops. E, Y-graft was used to reconstruct the left renal artery. F, The aneurysm was replaced with a bifurcated graft, and the left renal artery was anastomosed to the Y limb of the graft. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 95-100DOI: (10.1016/j.jvsc.2016.02.010) Copyright © 2016 Terms and Conditions

Fig 4 The schematic diagram of the surgical procedure. A, The patient was placed in the right lateral decubitus position. The incision originated from the intersection of the tenth rib and the midaxillary line and extended inferomedially to the lateral border of the rectus muscle midway between the umbilicus and the pubis. The tenth rib was partially removed. B, The diaphragm was bluntly dissected from its costal edge and retracted superiorly. The left kidney was mobilized anteromedially to approach the aorta from behind the left renal artery. The abdominal aorta was fully exposed from the origin of the celiac trunk down to the proximal ends of the common iliac arteries. C, The aneurysm was replaced with a bifurcated graft, and the left renal artery was anastomosed to the Y limb of the graft. The back wall of the aorta was left undissected to minimize injury to the lumbar and iliac veins. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 95-100DOI: (10.1016/j.jvsc.2016.02.010) Copyright © 2016 Terms and Conditions