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

8. 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

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

10. 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

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

18. Vascular and Endovascular Surg U of O
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 ( ) M : F: 56 Age: Av: Mean: 71
Co morbidity: CAD: COPD: (1 or 2 puffers) 40 Diabetes: Obesity: (BMI>30) 46 Hx of smoking: 230 HTN: 165
Vascular and Endovascular Surg U of O
Canada

22. Retroperitoneal AAA Repair: our experience
Aneurysm Characteristics:
Primary: 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

23. 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

24. 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

25. Retroperitoneal AAA Repair: our experience
Additional procedures: IMA re-implantation 5 Renal re-implantation /graft 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

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 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

29. 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

30. 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

31. 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

32. Ottawa: The Parliament buildings
Vascular and Endovascular Surg U of O
Canada