Combined aortorenal reconstruction: is there an optimum method of exposure?

OBJECTIVE: To determine the advantages and disadvantages of two different transabdominal approaches to expose the pararenal aorta; infacolic (IC) and medical visceral rotation (MVR). DESIGN: Retrospective study. METHODS: We reviewed a consecutive series of concurrently treated patients undergoing combined aortorenal reconstruction using one of these two approaches (IC n = 45; MVR n = 30). RESULTS: The two groups were identical with respect to demographics, risk factors and associated illnesses. Aortic aneurysmal disease predominated among MVR patients, and occlusive disease among IC patients (p = 0.001). The most common aortic reconstruction was aortofemoral bypass grafting. Renal revascularisation was most often performed for symptoms; only in the MVR group it was the result of involvement by aortic aneurysmal disease (p = 0.000). Thromboendarterectomy was the most common renal reconstruction, though performed only 10 times in the MVR group (p = 0.01). Except for supraceliac aortic cross-clamping, which was required more often in the MVR group (p = 0.004), operative details did not differ between the groups. Although the overall perioperative mortality and complication rate were equal, intraoperative splenic injury occurred solely in the MVR group (p = 0.001), and these patients experienced more pulmonary complications (p = 0.004) and they were hospitalised longer than the IC group (29.7 +/- 35.8 vs. 17.2 +/- 15.4 days; p = 0.04). CONCLUSIONS: MVR has increased morbidity, but its unrestricted continuous exposure is optimum for combined aortorenal reconstruction involving pararenal aneurysmal disease. Pararenal occlusive disease is adequately exposed in most cases by the IC approach.

Preoperative embolization of carotid body tumors: when is it appropriate?

To determine when to use preoperative embolization, we retrospectively reviewed a consecutive series of concurrently treated patients who underwent carotid body tumor resection between 1984 and 1994. Eleven nonembolized tumors (N-EMB group) and 11 embolized tumors (EMB group) were resected. The two groups were similar with respect to demographics and presentation, with the exception that more patients in the EMB group complained of painful neck masses. There was no significant difference in the pretreatment size of the neck mass between the two groups (N-EMB = 4.3 +/- 1.5 cm; N-EMB = 5.1 +/- 2.1 cm). Zero to 6 days after embolization, surgical resection was performed. There was no difference in the distribution of tumors, which were grouped according to Shamblin's classification, between the N-EMB and EMB patients. Two patients in each group required resection of the internal carotid artery, whereas a total of seven cranial nerves were resected. There were no differences in blood loss, number of blood transfusions, operative time, or perioperative morbidity between the N-EMB and EMB groups. Ten patients had new cranial nerve deficits and four of these patients required treatment for tenth nerve paralysis. Overall the total hospital stay was similar in the two groups, but the EMB group had a significantly longer preoperative stay compared to the N-EMB group (1.5 +/- 0.8 vs. 0.8 +/- 0.4 days; p = 0.02). These data show that preoperative embolization does not significantly improve outcome in patients undergoing resection of carotid body tumors measuring 4 to 5 cm. Therefore, in this era of costcontainment, preoperative embolization should not be used in the treatment of midsized carotid body tumors.

Optimal exposure of the proximal abdominal aorta: a critical appraisal of transabdominal medial visceral rotation.

PURPOSE: Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. METHODS: One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). RESULTS: There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed. CONCLUSIONS: Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.

The medial visceral rotation approach to the proximal abdominal aorta: how to assemble and use the omni-tract® retractor system.

Debakey, Creech and Morris were the first to report that unrestricted exposure of the distal thoracic and entire abdominal aorta could be achieved by a thoracoabdominal approach with rotation of the viscera from left to right in a plane anterior to the left kidney. Approximately ten years later, Shirkey and colleagues described the technique of transabdominal medial visceral rotation in a plane anterior to the left kidney to expose an injury to the proximal superior mesenteric artery. Shortly thereafter, Buscaglia, Blaisdell and Lim reported their experience in treating 46 patients with penetrating abdominal vascular injuries. They advocated the use of left to right medial rotation of the viscera to approach the aorta and its branches and the use of right to left medial rotation of the viscera to approach the inferior vena cava. They also described modifying the approach, by rotating the left kidney anteriorly and medially to access the posterolateral aorta. Subsequently, transabdominal medial visceral rotation became a popular approach for the treatment of traumatic injuries to the proximal abdominal aorta. The first published description of this approach in the elective sitting came from Crawford who used it to expose complex aneurysms involving the paravisceral and pararenal aorta.