Use of the splenic and hepatic arteries for renal revascularization

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Presentation transcript:

Use of the splenic and hepatic arteries for renal revascularization Ashby C. Moncure, M.D., David C. Brewster, M.D., R.Clement Darling, M.D., Robert G. Atnip, M.D., W.Dennis Newton, M.D., William M. Abbott, M.D. Journal of Vascular Surgery Volume 3, Issue 2, Pages 196-203 (February 1986) DOI: 10.1016/0741-5214(86)90003-0 Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 1 Technique of splenorenal arterial anastomosis. A, Patient positioned in modified right lateral decubitus position with left flank elevated 45 degrees from horizontal. B, Thoracoabdominal incision, beginning at lateral border of upper left rectus sheath is carried obliquely into left tenth interspace. C, Diaphragm is incised radially for short distance, and lienocolic ligament is incised, allowing splenic flexure of colon to fall caudally. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 2 Technique of splenorenal arterial anastomosis. A, Posterior surface of pancreas is exposed by turning inferior margin of pancreas anteriorly, leaving spleen in its normal location. B, Gerota's fascia overlying left renal hilum is incised, exposing left renal vein. C, Left renal artery adjacent to vein is identified and encircled. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 3 Technique of splenorenal arterial anastomosis. A, Splenic artery is encircled immediately proximal to left gastroepiploic artery and cleared of branches proximally. B, After proximal occlusion, splenic artery is divided at level of left gastroepiploic artery. C, Splenic artery is spatulated on its inferior surface for short distance. D, Fogarty embolectomy catheter (No. 3) is passed into aorta and backed out through proximal splenic artery with balloon inflated. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 4 Technique of splenorenal arterial anastomosis. A, Left renal artery is occluded proximally and distally and transected near its origin. B, Coronary dilators are used to probe renal artery lumen. C, Superior surface of renal artery is spatulated and end-to-end anastomosis of splenic and left renal arteries is carried out with oblique anastomosis interrupted at four quadrants. D, Spleen is left in place, and path of splenic and renal arteries lies posterior to pancreas. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 5 Technique of hepatorenal reconstruction. A, Right subcostal incision extends from tip of right eleventh rib to just across midline. B, Hepatoduodenal ligament incised. C, Hepatic artery is isolated proximally and distally to gastroduodenal artery. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 6 Technique of hepatorenal reconstruction. A, Descending duodenum is mobilized by Kocher's maneuver. B, Confluence of right renal vein and inferior vena cava is identified and adjacent renal artery encircled. C, Reversed greater saphenous vein segment is anastomosed to side of hepatic artery either proximal to, at, or distal to the origin of the gastroduodenal artery. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 7 Technique of hepatorenal reconstruction. A, Right renal artery is occluded, transected, and probed with coronary dilators. IVC = inferior vena cava. B, End-to-end oblique anastomosis is constructed between spatulated ends of right renal artery and reversed saphenous vein segment, interrupted at four quadrants. C, Since renal artery rotates cephalad, vein graft is short, and occasionally right renal artery can be directly anastomosed to side of hepatic artery, usually at site of gastroduodenal artery. D, If two renal arteries are present, or right renal artery bifurcates immediately, lower pole artery can be anastomosed into side of vein graft, after completion of end-to-end anastomosis between vein graft and upper pole renal artery. Journal of Vascular Surgery 1986 3, 196-203DOI: (10.1016/0741-5214(86)90003-0) Copyright © 1986 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions