Open aortic surgery

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.[1] In OAS for abdominal aortic aneurysm, the aneurysmal portion of the aorta is replaced with a graft, usually made of dacron or PTFE.

Open aortic surgery
Simulated open aortic surgery for an infrarenal aortic aneurysm. The clamp seen is above the aneurysm and below the renal arteries
Other namesOpen aortic repair
SpecialtyVascular Surgery

OAS is distinct from aortic valve repair and aortic valve replacement, as OAS describes surgery of the aorta, rather than of the heart valves. When the aortic valve is diseased in addition to the ascending aorta, the Bentall procedure is used to treat the entire aortic root. An axillary-bifemoral bypass is another type of vascular bypass used to treat aortic pathology, however it is not true open aortic surgery as it reconstructs the flow of blood to the legs from the arm, rather than in the native location of the aorta.

Medical uses

OAS is used to treat patients with aortic aneurysms greater than 5.5 cm in diameter, to treat aortic rupture of an aneurysm any size, to treat aortic dissections, and to treat acute aortic syndrome. It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the valve-sparing aortic root replacement.

Prior to the advent of EVAR, OAS was the only surgical treatment available for aortic aneurysms. It is still preferred at some institutions and by some patients as it may be more durable than EVAR[2] and does not require post-operative surveillance CT scans.

OAS is sometimes required for patients who have previously undergone EVAR but need further treatment, such as for degeneration of the EVAR seal zones leading to continued aneurysm growth. OAS is also sometimes required in cases of EVAR graft infection where the stent graft is removed to treat the infection.[3]

Reasons to avoid

The shift away from open aortic surgery towards endovascular surgery since 2003 has been driven by worse perioperative mortality associated with OAS, particularly in patients in relatively frail health.[4] Unlike endovascular repair, there are no strict anatomic contra-indications to open repair; Rather, open repair is viewed as the fall back option for patients with unfavorable anatomy for endovascular repair.[5] The main drawback of open repair is the larger physiologic demand of the operation, which is associated with increased rates of short term mortality in most studies.

Technique
Front wall suture line of an infrarenal open aortic repair with a dacron bifurcated graft

Open surgery typically involves exposure of the dilated portion of the aorta and insertion of a synthetic (Dacron or Gore-Tex) graft (tube). Once the graft is sewn into the proximal (toward the patient's head) and distal (toward the patient's foot) portions of the aorta, the aneurysmal sac is closed around the graft. Alternatively, the anastomosis can be carried out with expandable devices, a simpler and quicker procedure [6][7]

The aorta and its branching arteries are cross-clamped during open surgery. This can lead to inadequate blood supply to the spinal cord, resulting in paraplegia, when repairing thoracic aneurysms. A 2004 systematic review and meta analysis found that cerebrospinal fluid drainage (CFSD), when performed in experienced centers, reduces the risk of ischemic spinal cord injury by increasing the perfusion pressure to the spinal cord.[8] A 2012 Cochrane systematic review noted that further research regarding the effectiveness of CFSD for preventing a spinal cord injury is required.[9]

Approach

The infrarenal aorta can be approached via a transabdominal midline or paramedian incision, or via a retroperitoneal approach.

The paravisceral and thoracic aorta are approached via a left-sided posteriolateral thoracotomy incision in approximately the 9th intercostal space.[10] For a thoracoabdominal aortic aneurysm, this approach can be extended to a median or paramedian abdominal incision to allow access to the iliac arteries.

Sequential aortic clamping

At medical centers with a high volume of open aortic surgery, the fastest option for open aortic surgery was sequential aortic clamping or "clamp-and-sew", whereby the aorta was clamped proximally and distally to the diseased segment, and a graft sewn into the intervening segment.[11] This technique leaves the branches of the aorta un-perfused during the time it takes to sew in the graft, potentially increasing the risk of ischemia to the organs which derive their arterial supply from the clamped segment. Critics of this technique advocate intra-operative aortic perfusion.[12] In infrarenal aneurysms, the relative tolerance of the lower extremities to ischemia allows surgeons to clamp distally with low risk of ill effect.

Techniques to limit Ischemia

A number of techniques exist for maintaining perfusion to the viscera and spinal cord during open thoracoabdominal aortic aneurysm repair, including left heart bypass, balloon perfusion catheter placement in the visceral arteries, selective spinal drainage and cold crystalloid renal perfusion.[13] There is limited evidence supporting these techniques.[14]

Graft configuration

The abdominal aorta is anastomosed preferentially to the main limb of a tube or bifurcated graft in an end-to-end fashion to minimize turbulent flow at the proximal anastomosis. If normal aorta exists superior to the iliac bifurcation, a tube graft can be sewn distally to that normal aorta. If the distal aorta is diseased, a bifurcated graft can be used in an aorto-billiac or aorto-bifemoral configuration. If visceral vessels are involved in the diseased aortic segment, a branched graft can be used with branches sewn directly to visceral vessels, or the visceral vessels can be separately revascularized.

Reimplantation of the inferior mesenteric artery

Because of collateral blood flow from the superior mesenteric artery (SMA) via the marginal artery, the inferior mesenteric artery usually does not have to be reimplanted into the aortic graft when performing an open abdominal aortic aneurysm repair.

Risks and complications

OAS is widely recognized as having higher rates of perioperative morbidity and mortality than endovascular procedures for comparable segments of the aorta. For example, in infrarenal aneurysms, perioperative mortality with endovascular surgery is approximately 0.5%, against 3% with open repair.[15]

Other risks and complications with OAS depend on the segment of aorta involved, and may include renal failure, spinal cord ischemia leading to paralysis, buttock claudication, ischemic colitis, embolization leading to acute limb ischemia, infection, and bleeding.

Recovery after OAS

Recovery time after OAS is substantial. Immediately following surgery, patients can expect to spend 1–3 days in the intensive care unit, followed by 4–10 days on the hospital ward. After discharge, patients will take 3–6 months to fully recover their energy and return to their pre-operative daily activities.

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See also

References
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  2. Conrad MF, Crawford RS, Pedraza JD, et al. (October 2007). "Long-term durability of open abdominal aortic aneurysm repair". J. Vasc. Surg. 46 (4): 669–75. doi:10.1016/j.jvs.2007.05.046. PMID 17903647.
  3. Chaufour, X; Gaudric, J; Goueffic, Y; Khodja, RH; Feugier, P; Malikov, S; Beraud, G; Ricco, JB; AURC (French University Surgeons Association), collaborators. (February 2017). "A multicenter experience with infected abdominal aortic endograft explantation". Journal of Vascular Surgery. 65 (2): 372–380. doi:10.1016/j.jvs.2016.07.126. PMID 27720319.
  4. Lederle FA, Freischlag JA, Kyriakides TC, et al. (November 2012). "Long-term comparison of endovascular and open repair of abdominal aortic aneurysm". N. Engl. J. Med. 367 (21): 1988–97. doi:10.1056/NEJMoa1207481. PMID 23171095.
  5. Paravastu SC, Jayarajasingam R, Cottam R, Palfreyman SJ, Michaels JA, Thomas SM (2014). "Endovascular repair of abdominal aortic aneurysm". Cochrane Database Syst Rev. 1 (1): CD004178. doi:10.1002/14651858.CD004178.pub2. PMID 24453068.
  6. Aluffi A, Berti A, Buniva P, Rescigno G, Nazari S (2002). "Improved Device for Sutureless Aortic Anastomosis: Applied in a Case of Cancer". Tex Heart Inst J. 29 (1): 56–9. PMC 101273. PMID 11995854.
  7. Nazari S, Salvi S, Visconti E, et al. (June 1999). "Descending aorta substitution with expandable ends prosthesis. Case report". J Cardiovasc Surg (Torino). 40 (3): 417–20. PMID 10412932.
  8. Cinà, C.; Abouzahr, L.; Arena, G.; Laganà, A.; Devereaux, P.; Farrokhyar, F. (2004). "Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis". Journal of Vascular Surgery. 40 (1): 36–44. doi:10.1016/j.jvs.2004.03.017. PMID 15218460.
  9. Khan, Shaukat Nawaz; Stansby, Gerard (2012-10-17). "Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery". The Cochrane Database of Systematic Reviews. 10: CD003635. doi:10.1002/14651858.CD003635.pub3. ISSN 1469-493X. PMC 7173760. PMID 23076900.
  10. Coselli, Joseph (2008). "Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures". Semin Vasc Surg. 21 (1): 13–20. doi:10.1053/j.semvascsurg.2007.11.009. PMID 18342730.
  11. Estrera AL, Miller CC, Chen EP, et al. (October 2005). "Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage". Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID 16181856.
  12. Estrera AL, Miller CC, Chen EP, et al. (October 2005). "Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage". Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID 16181856.
  13. Coselli, Joseph (2008). "Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures". Semin Vasc Surg. 21 (1): 13–20. doi:10.1053/j.semvascsurg.2007.11.009. PMID 18342730.
  14. Hsu, CC; Kwan, GN; van Driel, ML; Rophael, JA (14 March 2012). "Distal aortic perfusion during thoracoabdominal aneurysm repair for prevention of paraplegia" (PDF). The Cochrane Database of Systematic Reviews. 3 (3): CD008197. doi:10.1002/14651858.CD008197.pub2. PMID 22419329.
  15. Schermerhorn, Marc (2008). "Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population". N Engl J Med. 358 (5): 464–74. doi:10.1056/NEJMoa0707348. PMID 18234751.
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