|Year : 2022 | Volume
| Issue : 2 | Page : 129-133
Open repair for juxta-renal aortic occlusion in high-risk patients
Ashutosh Kumar Pandey1, Sriram Manchikanti1, Neelamjingbha Sun1, Akash Rajeev1, Aditya Gupta1, C Sreekumar Ramachandran2, Madathipat Unnikrishnan3, Shivanesan Pitchai1
1 Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of General Surgery, Medical College and Hospital, Trivandrum, Kerala, India
3 Department of Vascular Surgery, SUT Hospital Pattom, Trivandrum, Kerala, India
|Date of Submission||21-Oct-2021|
|Date of Decision||17-Dec-2021|
|Date of Acceptance||05-Jan-2022|
|Date of Web Publication||13-Jun-2022|
Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
Background: Juxtarenal aortic occlusion (JRAO) is an infrequent form of aortic occlusion, resulting from a proximal progression of a distal aortic thrombus. The occlusion at or above the level of renal arteries may present with features of renal failure or intestinal ischemia along with increased severity of pelvic and limb ischemia. Surgical treatment of JRAO is complex and usually involves suprarenal clamping and poses a significant morbidity and mortality risk. Nevertheless, the current literature supports superiority of surgical bypass with excellent long-term outcomes and remains the preferred modality in JRAO. We reviewed the results of open surgical bypass in JRAOs, done at our center over a 5-year period. Materials and Methods: A retrospective analysis of 35 patients who underwent JRAO over the past 5 years was performed. Demographic data, comorbidities, clinical presentation, and surgical results were analyzed. Results: Of the 35 patients who underwent open surgical bypass, 34 were male, and one was female. The median age of the cohort was 56 years. All the patients had either disabling claudication, rest pain or tissue loss at presentation. The notable comorbid conditions were hypertension (91%), diabetes (51%), coronary artery disease (71%), and chronic obstructive pulmonary disease (37%). Direct aortic reconstruction was done in all cases, seven patients with critical limb ischemia underwent sequential infra-inguinal bypass, additional mesenteric bypass was done in one patient, renal artery revascularisation was done in three patients in the form of endarterectomy for two patients and aortorenal bypass in one patient. There was no perioperative mortality, and a 93% cumulative graft patency rate was noted. Conclusion: Open surgical reconstruction is a safe method for JRAO even in patients with comorbidities and offers excellent perioperative and long-term results.
Keywords: Aortic endarterectomy, aortobifemoral bypass, juxtarenal aortic occlusion, surgical aortic reconstruction
|How to cite this article:|
Pandey AK, Manchikanti S, Sun N, Rajeev A, Gupta A, Ramachandran C S, Unnikrishnan M, Pitchai S. Open repair for juxta-renal aortic occlusion in high-risk patients. Indian J Vasc Endovasc Surg 2022;9:129-33
|How to cite this URL:|
Pandey AK, Manchikanti S, Sun N, Rajeev A, Gupta A, Ramachandran C S, Unnikrishnan M, Pitchai S. Open repair for juxta-renal aortic occlusion in high-risk patients. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jun 26];9:129-33. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/129/347247
| Introduction|| |
Infrarenal aortic occlusion has been classified into distal, which spares origin of inferior mesenteric arteries, and proximal or juxtarenal occlusion., Juxtarenal aortic occlusion (JRAO) refers to occlusion approaching the level of renal arteries which results from proximal progression of a distal thrombus. The proximal progression in JRAO can lead to increased severity of limb symptoms and may manifest as renal failure, intestinal ischemia, and paraplegia in some cases.,
Complete aortoiliac occlusion is less common, and juxtarenal occlusion is seldom seen, with reported incidence of 3%–5% in patients with aortoiliac occlusive disease., In the last decade endovascular treatment has outnumbered open bypass for infrarenal aortic disease due to less invasiveness and better perioperative outcomes., This has not been the scenario in JRAO where open aortic reconstruction is still described as a gold standard., Very few reports describe endovascular treatment of JRAO.,
We present our retrospective evaluation for open surgical bypass in 35 patients with JRAO over the past 5 years at our center.
| Materials and Methods|| |
This was a single-center retrospective cohort study, evaluating all cases of JRAO operated over a period from August 2015 to November 2020 (63 months). The study was approved by Institutional Review Board and Ethical Committee and all patients had signed informed consent forms. The operative and follow-up data were collected from the medical records database.
Patients with Juxtarenal occlusion who underwent open bypass were included in the study. The patients with aortic aneurysm and acute occlusion were excluded from the study.
The study was conducted after ethical approval from the institutional review board. All the patients signed written informed consent before surgery.
Preoperative patient characteristics
Data was collected with respect to gender, age, comorbidities, and clinical presentation for all patients. The comorbidities were classified as: smoking (current or previous cigarette smoking); hypertension (on antihypertensive medication or blood pressure recording ≥140/90 mmHg); coronary artery disease (history of myocardial infarction and/or coronary angioplasty and/or angina and or prior coronary bypass surgery); renal failure (Estimated Glomerular filtration rate [eGFR] <60 ml/min/1.73 m2); diabetes (on hypoglycaemic medication and/or insulin and/or fasting glycemia >126 mg/dL). Clinical presentation was categorized as claudication (pain in lower limbs on walking, decreases with rest) or critical ischemia (presence of pain at rest/tissue loss).
The patients underwent clinical assessment in the form of detailed history and examination, the findings of which were documented in digital format. Lower limb circulation was assessed with pulse examination and ankle-brachial index, which were recorded. Diagnosis was confirmed in all cases on the basis of a computed tomography (CT) angiogram. The preoperative evaluation of all patients was done with baseline blood investigations, chest X-ray, electrocardiogram (ECG), and echocardiogram. Routine preoperative coronary angiography is not done for all patients at our center. The patients with abnormalities on ECG or echocardiogram were planned for further evaluation after multidisciplinary meet involving cardiologist, anesthetist, and surgical team. Pulmonary physiotherapy was started for all patients in the form of incentive spirometry in the preoperative period and adherence to bronchodilators was maintained for patients with chronic obstructive pulmonary disease. Aspirin and statin were continued for all patients in the perioperative period.
All the patients were operated under general anesthesia, with epidural analgesia. Groin exploration was done first in all cases to assess femoral outflow. For patients requiring a distal bypass the popliteal artery was also exposed. Abdominal access was with a xipho-pubic laparotomy followed by aortic exposure. The left renal vein was mobilized and retracted cranially for suprarenal aortic exposure. Renal arteries were identified bilaterally and controls taken. Before aortic cross-clamping, heparin (1 mg/kg) was administered, and diuresis was induced by the infusion of mannitol (0.5 g/kg). A suprarenal clamp was then applied, and a vertical aortotomy followed by thrombectomy of aorta was done for an end to side graft anastomosis, whereas infrarenal aortic transection and aortic endarterectomy were done for end-end bypass [Figure 1]. After proximal endarterectomy and confirmation of renal back bleed the clamp was repositioned to infrarenal aorta. Aortic reconstruction in all cases was done with polyester Y-graft of appropriate size [Figure 2]a. Distal anastomosis was done in an end to side manner to the femoral arteries. Sequential infrainguinal bypasses in all cases were done with reverse saphenous vein grafts. Mesenteric bypass in one case was done in a C-loop configuration with inflow from graft limbs [Figure 2]b. The average duration of suprarenal clamp was 7 min, ranging from 5 to 14 min. All patients were administered antibiotic coverage for 24 h.
|Figure 1: Illustration demonstrating vertical aortotomy (a) Thrombus extending above level of renal arteries; (b) Vertical aortotomy and endarterectomy under suprarenal clamp; (c) closure of proximal aortotomy and shifting of clamp to infrarenal aorta to allow for end to side anastomosis|
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|Figure 2: Intraoperative Images: (a) Aortobifemoral graft configuration; (b) Mesenteric bypass, in a C-loop configuration|
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Morbidity and mortality
Perioperative mortality was defined as any in-hospital mortality or within a month of surgery. Myocardial infarction was defined as chest pains combined with elevated troponin and new abnormal ECG findings. Pulmonary morbidities were defined as a need for prolonged mechanical ventilation (>72 h); reintubation or emergence of respiratory infection or atelectasis confirmed by clinical and radiological examination. Postoperative renal dysfunction was defined as >25% increase in eGFR values. The analyzed postoperative morbidities were bleeding or graft occlusion requiring re-exploration and complications related to the surgical wound. The time spent in intensive care and duration of hospital stay was also recorded for all patients.
The follow-up examination included assessment of vital parameters and patency of bypass. The patients were also followed up for any intercurrent conditions such as cardiac events, graft complications, renal dysfunction, and deaths from any cause.
Continuous variables are expressed as means ± standard deviations or medians and variances. The graft patency rate at follow-up was calculated by life table analysis. Microsoft Excel was used for the calculation of median, mean, and variances. No specific statistical tests were performed because of the small sample size and the narrow time frame covered by the study.
| Results|| |
The study cohort was predominantly male patients (n = 34), and only one female patient, the median age was 56 years (range: 35–74). The majority were smokers (n = 33, 94%), and hypertensives (n = 32, 91%). About half of the patients were diabetics (n = 18, 51%) and preoperative renal dysfunction was present in three patients. Ischemic heart disease was present in 25 patients (71%) and obstructive pulmonary disease in 13 patients (37%); thus, a majority patients were at a high risk for preoperative events [Table 1].
Severe claudication was present in majority patients (n = 25, 71%), and 10 patients (28%) had critical limb in the form of rest pain or tissue loss. One patient presented with acute renal failure due to acute suprarenal progression of the juxtarenal occlusion [Table 2].
Reconstruction in the form of aortobifemoral bypass after aortic thromboendarterectomy was done for all patients [Figure 2]a. Sequential bypass to popliteal artery was done for seven patients with critical limb and distal lesions. Mesenteric bypass was done in one patient with celiac occlusion and ostial disease in superior mesenteric artery [Figure 2]b. Renal endarterectomy was done in two patients, and a renal artery bypass was done for one patient with inflow taken from the main body of graft.
The median duration of hospital stay after surgery was nine days (range: 6–18 days), the median duration of intensive care unit stay was 1 day (range: 1–8 days). There were no perioperative mortalities. Cardiac morbidity in the form of myocardial infarction was seen in three patients-two patients were medically managed, whereas one required percutaneous coronary intervention. Respiratory infection was present in three patients, and they responded well to respiratory physiotherapy and antibiotics. Transient renal dysfunction was present in three patients, none required hemodialysis [Table 3]. Renal function tests returned to baseline in all three patients by 1 month follow-up.
One patient had thrombosis of graft limb in immediate postoperative period, for which re-exploration and embolectomy was done. The graft thrombosis was due to a proximal plaque which shifted in one of graft limbs. Two patients were reexplored for bleeding in the postoperative period.
The median follow-up was 34 months, over this time period four of the 35 operated patients were lost to follow-up. There was one mortality at 2 years postsurgery because of cerebrovascular accident. Graft thrombosis developed in two patients due to progression of outflow disease, none required amputation. The cumulative graft patency rate in follow up was 93% [Figure 3].
|Figure 3: Cumulative patency rates after aortobifemoral bypass using life table analysis|
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| Discussion|| |
The clinical trial of aortoiliac occlusive disease comprising of claudication, absent pulses and erectile dysfunction in men was described in 1814 by Robert graham and was named a century later after Leriche.,, Leriche also described the underlying mechanism and proposed surgical excision of occluded segment followed by graft interposition as a treatment.
The proposed pathogenesis of infrarenal aortic occlusion is proximal progression of the thrombus, where patency of suprarenal aorta is maintained by low resistance renovascular bed. The propagation of thrombus to the level of renal arteries or superior mesenteric artery may lead to increased morbidity and severity of clinical symptoms., Surgical bypass in JRAO needs expertise as it involves access to suprarenal aorta, control of renal arteries and aortic thromboendarterectomy. Various techniques have been described to reduce the morbidity of suprarenal clamp by reducing the effective clamp time.,, Rarely a supra-celiac clamp is also required in cases where suprarenal control is not technically feasible.
Endovascular treatment is evolving as first-line treatment for infrarenal aortic occlusion in view of lower morbidity, lesser invasiveness, and comparable secondary patency to open surgery.,, Endovascular repair in JRAO offers a less invasive alternative but is associated with peri-procedural complications related to thrombus dislodgement, branch vessel coverage leading to acute kidney injury, spinal ischemia, or limb ischemia.,, Further, the technical success rate of surgery approaches 100% which is not the case with endovascular revascularisation., The patency rates with endovascular intervention in JRAO are lower than open bypass, reported to be in the range of 80%–90%.,, On the other hand the cumulative patency for aorto-bifemoral bypass has been reported in the range of 75%–95% at 5 years and 70%–75% at 10 years.,
Open surgery hence remains the superior option in JRAO as it offers better long-term patency as well as being a cost-effective option., However, effective surgical bypass for juxtarenal occlusion remains a challenging surgery with a nonnegligible rate of perioperative complications., At our center we aim to reduce the surgical morbidity by a protocol-based management of JRAO and an effective coordination between all involved teams at all phases of treatment. Throughout the treatment course, all measures are taken to reduce additional metabolic stress to patient. Preoperative optimization is initiated at the first visit with chest physiotherapy and ensuring adherence to hypertensive and glycaemic control measures. Intraoperatively emphasis is given on reducing blood loss, short suprarenal clamp time, and measures to avoid aortic clamping/declamping related hemodynamic disturbances. Postoperatively, adequate pain control, resumption of chest physiotherapy, and maintenance of adequate volume status and hematological parameters is ensured.
There are limitations inherent to this study, as it is a retrospective analysis and a small sample size with variable follow-up; however, results are encouraging. A major proportion of patients in study cohort had coronary artery disease, and obstructive pulmonary disease was present in one third of patients. Nevertheless, the peri-operative morbidity rates were not very high and no mortality was noted due to the same. These data will certainly benefit in comparison with future results using endovascular techniques.
| Conclusion|| |
Surgical repair of juxtarenal occlusion should be regarded as the treatment of choice. Good outcomes can be achieved in patients with comorbidities with proper optimization and institutional experience.
The authors acknowledge the anesthesia team and supporting staff at SCTIMST.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]