Ann Thorac Surg 2007;83:2216-2219
© 2007 The Society of Thoracic Surgeons
Case Reports
Thoracoabdominal Aortic Aneurysm Associated With Abdominal Aortic and Visceral Arterial Occlusion in a Hemodialysis Patient
Masato Nakajima, MD*,
Koji Tsuchiya, MD,
Okihiko Akashi, MD,
Hironobu Morimoto, MD,
Kaori Kato, MD
Department of Cardiovascular Surgery, Yamanashi Central Hospital, Kofu City, Yamanashi, Japan
Accepted for publication November 28, 2006.
* Address correspondence to Dr Nakajima, Yamanashi Central Hospital, Department of Cardiovascular Surgery, 1-1-1 Fujimi, Kofu City, Yamanashi, 400-0027, Japan (Email: m-nakajima2a{at}ych.pref.yamanashi.jp).
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Abstract
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We report an extremely rare case of saccular thoracoabdominal aortic aneurysm associated with high abdominal aortic occlusion including the superior mesenteric and bilateral renal arteries in a patient requiring hemodialysis. Successful repair of the aneurysm and concomitant revascularization of the lower extremities was achieved using femoro-femoral bypass for perfusion of the lower body along with the visceral and intercostal arteries.
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Introduction
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Although the results of surgical repair of thoracoabdominal aneurysm (TAAA) continue to improve, associated complicated lesions, including visceral arterial occlusive disease or chronic renal failure have the potential to increase mortality and morbidity. We experienced an extremely rare case of saccular TAAA associated with high abdominal aortic occlusion, which included the superior mesenteric and bilateral renal arteries in a patient requiring hemodialysis. Femoro-femoral bypass was used for perfusion of the lower body and for selective visceral and intercostal arteries, as well as for hemodialysis, during the procedure. This enabled us to achieve successful repair of the aneurysm and concomitant revascularization of the lower extremities.
A 50-year-old man was referred to our hospital for detailed examination of progressive thoracoabdominal aortic aneurysm and chronic bilateral limb ischemia. The patient had a 3-year history of hemodialysis for chronic renal failure and had pointed out abdominal aortic obstruction and proximal abdominal aortic dilatation before induction of regular hemodialysis. He had no symptoms, such as leg pain or intermittent claudication, due to leg ischemia. However, a recent computed tomographic scan showed duplicated saccular aneurysms, 35 mm and 69 mm in diameter, located on the thoracoabdominal aorta just below the diaphragm and associated with occlusion of the juxtarenal abdominal aorta (Figs 1A,
1B). Although the celiac trunk was observed to branch from the anterior wall of the aneurysm, the superior mesenteric and bilateral renal arteries were not identified. Digital subtraction angiography revealed occlusion of the superior mesenteric artery and both renal arteries, and a collateral circulation connecting the celiac artery to the proximal superior mesenteric artery and the inferior mesenteric artery (Fig 2A). The bilateral iliac arteries were supplied by relatively good collateral flow, mainly from the inferior epigastric arteries (Fig 2B). Surgical resection of the aneurysm in combination with revascularization was electively conducted.
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Fig 1. (A, B) Preoperative computed tomographic scan showing duplicated saccular aneurysms, 35 mm and 69 mm in diameter, located on the thoracoabdominal aorta just below the diaphragm.
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Fig 2. (A) Preoperative digital subtraction angiography revealed duplicated saccular thoracoabdominal aneurysms along with occlusion of the superior mesenteric artery, both renal arteries, and the proximal abdominal aorta. (B) The bilateral iliac arteries were supplied by relatively good collateral flow, mainly originating from the inferior epigastric arteries.
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After induction of anesthesia, the aneurysm and the involved visceral arteries were exposed through a thoracotomy at the eighth intercostal space and a retroperitoneal approach using a spiral skin incision. The bilateral femoral arteries were also exposed and an 8-mm prosthetic graft was sutured to the left femoral artery for establishing normothermic partial cardiopulmonary bypass in combination with femoral venous drainage after heparinization. After cross-clamping the aorta just below the relatively large intercostal arteries, the aneurysm was opened and a massive, old thrombus was removed. The celiac trunk and left first lumbar artery were perfused. Back bleeding from one intercostal artery and the right first lumbar artery was controlled using a balloon occlusion catheter. A composite graft was prepared using a "Y"-shaped prosthetic graft (18 x 9 mm in diameter) with a separate short graft sutured to the left limb. This graft was anastomosed to the aorta just below the twelfth intercostal artery, and the first lumbar artery was reconstructed with an additional graft from the left limb. The right limb of the graft was anastomosed to the celiac trunk, and the left limb was anastomosed to the left external iliac artery. After separation from cardiopulmonary bypass, femoro-femoral bypass was performed using the previous graft for perfusion, and the procedure was completed. Cardiopulmonary bypass time, spinal cord ischemic time, and operation time was 89, 28, and 303 minutes, respectively. Hemofiltration was performed during cardiopulmonary bypass. Pure red blood cells were prepared and washed out by a cell saver to reduce potassium content. They were transfused during cardiopulmonary bypass to increase the patient’s hematocrit level to greater than 30% at the time of weaning from bypass. A total 16 units of pure red blood cells and 20 units of platelet were required. Postoperative computed tomography showed complete resection of the aneurysm and good patency of the reconstructed branches (Fig 3). The patient recovered well and was discharged without complications on postoperative day 16 and is doing well after 15 months of follow-up.
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Fig 3. Postoperative computed tomographic scan showing complete resection of the aneurysm and good patency of the reconstructed branches.
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Comment
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Thoracoabdominal aneurysm (TAAA) associated with visceral arterial occlusive disease is relatively rare and can result in disastrous complications such as gangrene of the intestine or renal failure after repair. Svensson and colleagues [1] reported an excellent surgical outcome of TAAA repair for 271 of 1,509 patients (14%) with associated visceral arterial occlusive disease [2]. However, TAAA associated with both visceral arterial occlusive disease and abdominal aortic occlusion is extremely rare and can present considerable obstacles to successful surgical repair.
Organ protection during aneurysm repair is a difficult task in this complicated situation. Although perfusion support is the primary and most effective method for organ protection, establishing cardiopulmonary bypass was difficult in the present case owing to the presence of visceral and abdominal aortic occlusion. Kunimoto and colleagues [3] established a successful distal perfusion system during TAAA repair in a patient with aortic occlusion by cannulating the femoral vein and the descending thoracic aorta, initially, after selective perfusion of the viscera. We secured the femoral artery for establishment of cardiopulmonary bypass, which was believed to be essential for performing selective active perfusion to the celiac trunk and intercostal arteries during aortic cross clamping. Thus, despite occlusion of the abdominal aorta, adequate flow (greater than 1.5 L/minute) was maintained by femoral arterial perfusion, probably due to rich collateral arterial vascularization. We believe that establishing an optimal perfusion system during these complicated cases is the most important element in the accomplishment of a successful repair.
Preoperative renal dysfunction increases the operative mortality and morbidity in patients with TAAA and thoracic aortic aneurysm [4]. In patients with renal arterial occlusive lesions, concomitant revascularization, including bypass grafting, reimplantation, or endarterectomy is recommended for reduction of the risk of ischemic complications after repair [1]. However, in patients with chronic renal failure requiring hemodialysis, especially when complicated with bilateral renal arterial occlusion, as in the present case, renal reconstruction will not be beneficial. We undertook perioperative hemodialysis and intraoperative hemofiltration combined with cardiopulmonary bypass in this patient and obtained a successful result with a difficult case.
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References
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- Svensson LG, Crswford ES, Hess KR, Coselli JS, Safi HJ. Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients J Vasc Surg 1992;16:378-389.[Medline]
- Coslli JS, Conklin LD, LeMaire SA. Thoracoabdominal aortic aneurysm repair: review and update of current strategies Ann Thorac Surg 2002;74:S1881-S1884.[Abstract/Free Full Text]
- Kunimoto R, Goto H, Utoh J, Kitamura N. Thoracoabdominal aortic aneurysm combined with aortic occlusion Ann Thorac Surg 2000;69:623-625.[Abstract/Free Full Text]
- Morishita K, Kawaharada N, Fukada J, et al. Midterm results of surgical treatment of thoracic aortic disease in dialysis Ann Thorac Surg 2005;80:96-100.[Abstract/Free Full Text]
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Abstract
Introduction
