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Table of Contents
CASE REPORT  
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 236-239
Open surgical repair of abdominal aortic aneurysm: Proximal aortic control by endoaortic balloon - A novel approach


1 Department of Anesthesia, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India
2 Department of Cardiothoracic and Vascular Surgery, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India

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Date of Submission08-Jan-2012
Date of Acceptance19-Apr-2012
Date of Web Publication4-Jul-2012
 

   Abstract 

Patients with infrarenal abdominal aortic aneurysm with unfavorable anatomy for endovascular aneurysm repair have to undergo open surgical repair. Open surgery has its own morbidity in terms of proximal clamping and declamping, bleeding and prolonged hospital stay and mortality. We present two such patients with juxtarenal abdominal aortic aneurysm who underwent open surgical repair. The proximal aortic control during open surgical repair of the aneurysm was achieved by endoaortic balloon occlusion technique.

Keywords: Abdominal aortic aneurysm, Endoaortic balloon occlusion, Abdominal aortic aneurysm repair

How to cite this article:
Soundaravalli B, Palaniappan M, Sundar R, Chandrasekar P. Open surgical repair of abdominal aortic aneurysm: Proximal aortic control by endoaortic balloon - A novel approach. Ann Card Anaesth 2012;15:236-9

How to cite this URL:
Soundaravalli B, Palaniappan M, Sundar R, Chandrasekar P. Open surgical repair of abdominal aortic aneurysm: Proximal aortic control by endoaortic balloon - A novel approach. Ann Card Anaesth [serial online] 2012 [cited 2019 Nov 22];15:236-9. Available from: http://www.annals.in/text.asp?2012/15/3/236/97981



   Introduction Top


The surgical treatment of abdominal aortic aneurysms (AAA) has traditionally involved a major open procedure, which is associated with significant morbidity and mortality. [1] The management of infrarenal AAA has changed considerably since 1980, when the concept of endovascular aneurysm repair (EVAR) was introduced. This technology has reduced the mortality significantly when compared with open surgical repair. [2] However, not all AAA present with favorable anatomy for EVAR. The decision to treat a large AAA (5.5 cm or larger) with open surgical repair or EVAR or medical management usually depends on three variables: AAA size, AAA morphology and the patient's surgical risk. [3] To our knowledge, the endoaortic balloon occlusion technique has only been used for emergency endoclamping in ruptured AAA and during endovascular procedures. We describe elective use of endoaortic balloon occlusion during repair of juxtarenal AAA.


   Case Reports Top


Case 1

A 63-year-old, 81 kg gentleman, a chronic smoker and hypertensive, was diagnosed to have juxtarenal AAA when evaluated for low-back pain. Clinical examination revealed a resting heart rate of 70/min, and his BP was 150/90 mmHg. He was on amlodipine and nebivolol 5 mg each for control of his BP. Hematological and biochemical investigations were within normal limits. ECG revealed left ventricular (LV) hypertrophy and transthoracic echocardiography showed good LV systolic function with diastolic dysfunction. He had normal coronaries on angiogram and his computerized tomography (CT) aortogram depicted a complex juxtarenal AAA with involvement of right common and internal iliac arteries and a fusiform aneurysm of left common iliac artery [Figure 1].
Figure 1: Computerized tomography aortogram showing juxtarenal aneurysm and fusiformaneurysm of the left common iliac artery

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As the anatomy was not suitable for EVAR in our institution, he was scheduled for an open surgical repair. It was decided to place an endoaortic balloon for proximal control in the cardiac catheterization laboratory prior to shifting him to the operation room (OR). On the day of surgery, the patient received antihypertensive medicines and premedicated with 10 mg of morphine sulfate and 0.2 mg of glycopyrrolate given intramuscularly. Under local anesthetic infiltration, vascular access was obtained in the left forearm with a 16G venous cannula and his right internal jugular vein canulated with a 7 F three-lumen catheter and 8.5 F sheath (Edwards life sciences -Irvine, CA, USA). The left radial artery was cannulated with a 20G arterial cannula. An 18G epidural cannula (Perifix) was inserted at the L2-L3 level for postoperative analgesia. The patient was then shifted to the catheterization laboratory for placement of an endoaortic balloon. Under strict aseptic precaution, his right brachial artery was cannulated with an 11F sheath (Avanti plus; Johnson and Johnson, Florida, U.S.A) after heparinizing with 5000 units, an endoaortic balloon, after checking its integrity (Medtronic Balloon Reliant Galway, Ireland), was inserted and positioned at the level of the celiac trunk. The balloon had a 46 mm inflating diameter; and an inflating volume of 25-30 mL, was found enough to occlude the aorta [Figure 2].
Figure 2: Endoaortic balloon positioned just above the celiac trunk

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The patient was then brought back to the OR. Monitoring in the OR included 5-lead ECG with ST analysis, pulse oximetry, direct arterial pressure measurement, end-tidal CO 2 , temperature and urine output. Anesthesia was induced with a sleep dose of thiopentone and 150 μg of fentanyl, and tracheal intubation was facilitated with 8 mg of vecuronium. The airway was secured with a 8.5 mm portex endotracheal tube. Anesthesia was maintained with oxygen in air, isoflurane and intermittent doses of vecuronium. Eight milliliters of 0.25% bupivacaine was given through the epidural catheter as supplemental analgesic. Venous reservoir with a roller pump was organized for autotransfusion.

A midline trans-peritoneal laparotomy was performed. The AAA was calcified and started about 0.5 cm below the origin of renal arteries and it was extending into the left common iliac artery. Both the external iliac arteries were normal. Systemic anticoagulation was achieved with heparin 1 mg/kg. Proximal vascular control was achieved by inflating the endovascular balloon with normal saline till pulsation over the aneurysm disappeared. A 16 mm × 8 mm (diameter) Dacron Y graft (Intergard, Maquet, LaCiotat Cedex, France) was chosen and after completion of the proximal anastomosis vascular clamps were applied on the graft; then, the balloon was deflated. Distally, the grafts were anastomosed to the external iliac arteries. The endoaortic balloon occlusion time was 23 min. He had stable hemodynamics both during and after deflation of the balloon. Back-bleeding from the common iliac artery into the aneurysmal sac was closed with a pledgetted suture and the aneurysmal sac was closed over the graft. Heparin was reversed with protamine and the abdomen was closed in layers. The procedure lasted for about 5 h; intraoperatively, the patient received about 5 L of crystalloids and three units of whole blood. The patient was electively ventilated for 8 h and subsequently extubated. The serum creatinine level rose up to 0.3 mg% from 1.4 mg% and then came down to the normal level within 72 h. He had an uneventful recovery. He was discharged on the 10 th day.

Case 2

A 64-year-old 84 kg obese male hypertensive and a chronic smoker was referred to our institution with a diagnosis of AAA. His hematological and biochemical parameters were within normal limits. CT aortogram revealed a large infrarenal AAA measuring 139 mm × 93 mm × 73 mm. The luminal diameter was 85 mm × 33 mm, with an eccentric thrombus extending into the proximal right common iliac artery [Figure 3]. There was no active leak. The neck of the aneurysm was 2 cm × 1.9 cm, and was 4 mm below the origin of the right renal artery and 2.7 mm below the origin of the left renal artery. Coronary angiogram showed triple-vessel disease.
Figure 3: Computerized tomography aortogram showing large infrarenal aneurysm up to bifurcation

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Clinical examination revealed a resting heart rate of 68/min with a BP of 140/90 mmHg. He had truncal obesity with anticipated difficult airway and intubation. The patient was treated with metoprolol 50 mg for control of BP. An open surgical repair of his AAA was planned. He received the standard monitoring as the previous patient and no epidural was planned as he was in pain.

Initially, in the catherization laboratory under local anesthesia, an 11 F endoaortic balloon catheter was introduced through the left brachial artery after heparinization, and it was positioned just above the celiac trunk. The integrity of the balloon and the inflation volume necessary to produce total occlusion of the aorta were checked by fluoroscopy in the catheterization laboratory using contrast, and the patient was shifted to the OR. He received a standard general anesthetic like the previous patient, except that he was intubated using suxamethonium.

Midline laparotomy showed a large juxtarenal AAA stopping just short of aortic bifurcation with sealed rupture. Systemic anticoagulation was achieved with heparin 1 mg/kg. A venous reservoir and roller pump were kept ready for autotransfusion. Proximal control was achieved by inflating the balloon with 15 mL of normal saline at which the aortic pulsations disappeared. By titrating nitroglycerine infusion, the heart rate and BP were optimized during the endoaortic occlusion. A 16 mm × 8 mm tubular graft (InterGard) was used and the proximal anastomosis was completed just below the renal arteries. Thereafter, the clamp was applied on the graft and then the balloon was deflated. The total endoaortic balloon occlusion time was 29 min. Distal anastomosis was onto the aorta just above the bifurcation, with a graft clamp time of 14 min. After obtaining hemostasis, the balloon was removed and the residual effect of heparin was reversed with protamine. The aneurysmal sac was then closed over the graft and the abdomen was closed in layers. The procedure lasted 3 h and apart from crystalloids, the patient received two units of blood in the OR. He was ventilated for about 10 h in the Intensive Care Unit (ICU) and then extubated. Renal function remained normal. On the 7 th postoperative day, he developed a mild left hemiparesis. CT brain showed acute infarct in the anterior cerebellum and lacunar infarct in the frontal lobe. He was managed conservatively with anti-edema measures and the weakness improved in about 48 h. He was discharged on the 12 th day in a stable condition with no neurological deficit.


   Discussion Top


With progressive reduction of in-hospital mortality, the patient longevity after AAA repair is an important factor in clinical decision-making with regard to the choice of procedure as well as for optimization of medical therapy. Open surgical repair is little riskier in the short term, but it fixes the problem for good and it does not need lifelong follow-up. On the other hand, EVAR is less risky in the short term, but needs a lifelong surveillance. [4]

The open surgical repair is a major surgical procedure and involves opening of the peritoneal cavity, longer operative time, significant blood loss, increased transfusion requirements and increased length of ICU and hospital stay. [5] Additionally, there are problems of clamping the aorta either suprarenally or infrarenally. If suprarenally clamped, there is a possibility of subsequent renal damage. The magnitude of declamping shock is usually not worrisome if the aorta is clamped infrarenally.

In both our patients, the presence of endoaortic balloon gave us the proximal control that was needed during the proximal anastomosis. There was no constraint with regard to the cuff of the aorta that needed to be excised for the proximal anastomosis as it was devoid of clamps. Hence, a healthy section of aorta just distal to the renal artery was used for the anastomosis. This technique gives a good open end of aorta for anastomosis and reduced time for proximal anastomosis to < 30 min in both the cases. As the proximal end is open, one can clearly visualize the renal orifices so that any technical compromise is averted. Although the balloon was positioned suprarenally, we did not have too much of hemodynamic alterations with inflation of the balloon. The technique of endoaortic balloon occlusion is equivalent to conventional aortic cross clamping in terms of increases in preload and afterload; however, the technique ensures good surgical exposure thereby allow expeditious proximal anastomosis and in turn decreases aortic occlusion time.

We optimized the afterload by using a balanced anesthetic technique with opioid and inhalational agent and nitroglycerine infusion. Patients were given beta blocker preoperatively. Preload could be reduced using controlled phlebotomy, [6] but our patients tolerated the hemodynamics with nitroglycerine infusion, beta blockade and inhalational anesthetic agent. When the endoaortic balloon was positioned (our cardiologist confirmed the position by fluroscopy), there was no major lumbar artery at that level. However, positioning and placement of the endoaortic balloon involve shifting the patient to the catherization laboratory and back to the OR, and exposure to the contrast agent and fluoroscopy. Philipsen reported the use of rapid endovascular balloon occlusion by the percutaneous approach in unstable patients with ruptured AAA for stabilization followed by EVAR or open surgical repair. [7] Our experience with EVAR prompted us to adopt the technique of endoaortic balloon occlusion for proximal control in the above two patients who presented with complex anatomy.

Conventional open surgical repair of AAAs has been the gold standard. EVAR has revolutionized the treatment of infrarenal AAAs. However, only about 60% of all infrarenal AAAs are amenable to EVAR treatment. [8] EVAR has proven itself in the short term as a safe and less-invasive method of treating AAAs even in high-risk patients. Although there are anatomic limitations of the available devices, these continue to lessen with increased use of branched and fenestrated grafts, which allow for the repair of the aneurysm involving the critical branch vessel. [9] Predictably, as shown by many innovations in surgical approaches, there is a pendulum effect. Open surgical repair is preferred for younger patients with low operative risk, and EVAR is preferred for older patients with higher operative risk. However, given the similarity in overall outcome, patient preference must be weighed in decision making. It is apparent that technologic advances in both endovascular devices and anesthetic technique will further increase the number of patients who will be candidates for EVAR. Endovascular balloon occlusion for proximal control in AAA surgery is a valuable treatment option as it is less risky, easy to perform and minimizes the structural damage of the adjoining organs while maximizing the surgical exposure. [7]


   Acknowledgment Top


We are grateful to Dr. R. Muthukumar - our colleague, for his technical help in preparing this manuscript.

 
   References Top

1.Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328:1167-72.  Back to cited text no. 1
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2.Chagpar RB, Harris JR, Lawlor DK, DeRose G, Forbes TL. Early mortality following endovascular versus open repair of ruptured abdominal aortic aneurysms. Vasc Endovascular Surg 2010;44:645-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Smaka TJ, Cobas M, Velazquez OC, Lubarsky DA. Perioperative management of endovascular abdominal aortic aneurysm repair: update 2010. J Cardiothorac Vasc Anesth 2011;25:166-76.  Back to cited text no. 3
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4.Brewster DC, Geller SC, Kaufman JA, Cambria RP, Gertler JP, LaMuraglia GM, et al. Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair. J Vasc Surg 1998;27:992-1003; discussion 1004-5.  Back to cited text no. 4
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5.Brown MJ, Nicholson ML, Bell PR, Sayers RD. Cytokines and inflammatory pathways in the pathogenesis of multiple organ failure following abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2001;22:485-95.  Back to cited text no. 5
    
6.Neema PK, Vijayakumar A, Manikandan S, Rathod RC. Infrarenal abdominal aortic aneurysm repair in presence of coronary artery disease: optimization of myocardial stress by controlled phlebotomy. Ann Card Anaesth 2009;12:133-5.  Back to cited text no. 6
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7.Philipsen TE, Hendriks JM, Lauwers P, Voormolen M, d'Archambeau O, Schwagten V, et al. Innovations: The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm. Innovations (Phila) 2009;4:74-9.  Back to cited text no. 7
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8.Hinchliffe RJ, Hopkinson BR. Endovascular repair of abdominal aortic aneurysm: current status. J R Coll Surg Edinb 2002;47:523-7.  Back to cited text no. 8
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9.Subramaniam B, Singh N, Roscher C, Augoustides JG. Innovations in Treating Aortic Diseases: The Abdominal Aorta. J Cardiothorac Vasc Anesth. 2011 Jan 7. [In press].  Back to cited text no. 9
    

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Correspondence Address:
Balakrishnan Soundaravalli
Department of Anesthesia, G.K.N.M Hospital, Coimbatore- 641 037
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.97981

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