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

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

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

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

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

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

Retroperitoneal AAA Repair Horseshoe kidney Requires Re-implanting renal branches to the isthmus Vascular and Endovascular Surg U of O Canada

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

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

Vascular and Endovascular Surg U of O 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

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

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

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

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

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

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: our experience Demographics: 251 consecutive Patients (2004-2012) M : 195 F: 56 Age: 87-52 Av:71.5 Mean: 71 Co morbidity: CAD: 112 COPD: (1 or 2 puffers) 40 Diabetes: 44 Obesity: (BMI>30) 46 Hx of smoking: 230 HTN: 165 Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: our experience Aneurysm Characteristics: Primary: 246 patients Redo : 5 patients 1 pat. 1 yr post REVAR 2 pats. Secondary ADF, in a Type IV AAA post remote aortic Sx. 1 pat. IAAs post ruptured AAA repair 4 years earlier 1 pat. Had an AAA 10 years post ABF end to side graft Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: our experience Aneurysm Characteristics: 231 elective 15 acute /symptomatic 5 ruptured (3 acute, 2 chronic) Other findings: 2 horseshoe kidneys 6 inflammatory 89 IAA. 54 bilat. 15 R. 20 L. 46 patients had previous abdominal surgery. Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: our experience Proximal control: 212 infrarenal 33 Suprarenal 6 Supraceliac, type IV AAA repair. Type of Repair: 136 Tube graft 89 AIs. 54 Bilat, 15 R, 20 L 24 ABFs. 2 pericardial patch aortic closures Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: our experience Additional procedures: IMA re-implantation 5 Renal re-implantation /graft 6 2 horseshoe kidneys 1 accessory renal 3 left renal grafts. AxBfem &aortic graft excision 2 Duodenal closure 2 Vascular and Endovascular Surg U of O Canada

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

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

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 Creatinine 6 ARF: 2 hemofiltration only, 3 transient dialysis, 1 permanent Respiratory: Exacerbation of COPD:5 ( 1 needed home O2) 1 PE DVT Post-op bleed: 6 total. 4 no source was found. 2 splenectomy Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: Complications GI: Ischemic colitis: 8 transient, 4 C.diff, 2 colectomies UGI 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 disease Acute occlusion of one ABF limb, required urgent revision Vascular and Endovascular Surg U of O Canada

Retroperitoneal AAA Repair: Incisional complications 13 patients. Wound infection:6 2 proven cultures with purulent drainage 4 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 knot 6 specific complaints about asymmetric bulge needed reassurance Vascular and Endovascular Surg U of O Canada

Vascular and Endovascular Surg U of O 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

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