Pararenal abdominal aortic aneurysm – preparation is the key to successful repair

Mahalakshmi1*, Valarmathy2, Esthar Rani3

1Scrub Nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

*Correspondence

Introduction

Pararenal Abdominal Aortic Aneurysm (PRAAA) is a complex surgical procedure which carry a higher risk than conventional Abdominal Aortic Aneurysm (AAA) repair: prolonged operative and renal ischemia time, need to reconstruct the renal arteries and the possibility of postoperative renal failure. Perioperative anesthesia management helps in a great way for the smooth, safe and effective conduct of the surgery and recovery of the patient. Effective renal protection, perfusion and reconstruction of the renal arteries is the key is determining the successful outcome of these group of patients.

Case Presentation

A 41-year-old male was suffering from with abdominal pain in his left flank. He was evaluated elsewhere where he was found to a ureteric calculus which resolved with conservative management. The imaging performed for the evaluation of the abdominal pain revealed aneurysm of the abdominal aorta. Magnetic Resonance Angiogram was performed considering the raised renal function values (Fig 1). The dimensions of the aneurysm measured 12.9 x 8.2 x 6.5 cm which extended from the origin of the Superior Mesenteric Artery to the bifurcation of the Aorta. The patient was diagnosed to have an Abdominal Aortic Aneurysm (pararenal) and was planned for the definitive treatment.

Fig (1): Abdominal Aortic Aneurysm involving the renal arteries; dotted circle

Clinical challenges involved in the surgical execution

  • Pararenal Aortic aneurysm Involvement of the renal arteries Raised renal parameters.
  • Need for intraoperative renal perfusion strategy Autologous conduit for the renal arteries Postoperative hemodialysis

Preoperative preparation

Counselling and informed consent from the patient and family members: The patient and family members were explained in detail about the nature of the disease, the options of treatment, the complexity of the procedure, the risks involved and the expected outcome. They were given adequate time to arrive at a decision, understanding what they were going to undergo without any pressure but were reassured that all possible measures would be taken to perform the procedure safely and to improve the health of the patient. Once the family members provided an informed consent, a detailed video consent as well as a written consent of the same was recorded.

General hygiene preparation: A dental checkup to rule out caries tooth (to prevent implantation of bacteria in the prosthetic graft) and Chlorhexidine bath were ensured prior to the day of surgery.

Universal precautions: The patient had tested positive for hepatitis B antigen and was treated elsewhere. His repeat antigen testing didn’t reveal any positivity while the antibody tests remained positive; however, the case details were discussed with the medical gastroenterologist who reassured that the viral load would have reduced below the level of detection in the serum. Yet, universal precautions had to be ensured throughout the procedure which were discussed, ensured and implemented.

Arranging appropriate instruments and materials

Being a highly demanding and uncommon procedure, some of the materials and instruments required for the procedure were not easily available: a thorough checklist was prepared for the materials and the instruments, coordinated the same with the surgical team and were arranged well in advance to the day of surgery. Some of the instruments that were used were:

  • Prosthetic grafts (Polyester) of required sizes – arranged from vendor
  • Body warmer – A vital gadget to maintaining the core body temperature of the patient as the bowels would be exposed during the surgery which would lead to hypothermia.
  • Rifampicin tablets to be sterilised (Fig 2)

Fig (2): Rifampicin tablets sterilised by ETO; Polyester grafts are soaked in rifampicin which augments protection against infections)

  • Cold Ringer Lactate solution to perfuse the kidney
  • Activated Clotting Time machine (to ensure optimal dose of Heparin administration during the surgery. Fig 3)

Fig (3): Helps to monitor and ensure effective anticoagulation during the surgery

Graftsol (organ perfusion solution); to be available in case needed intraoperatively (Fig 4)

 

Fig (4): Organ perfusion solution to perfuse the right kidney)

Polypropylene suture materials (Fig 5)

Fig (5): Iodine adhesive band and other Polypropylene sutures were arranged and kept ready for the procedure)

Specific vein cannulas to ensure perfuse the kidney through the renal arteries (Fig 6)

Fig (6): Specific cannulas are used which facilitate the perfusion of the kidneys

  • Book-Walter retraction system
  • Polytetrafluoroethylene (PTFE) felt (for buttressing the suture lines if needed) (Fig 7)
  • Medium and long monopolar tips to ensure reaching the retroperitoneal tissues
  • Head light for better illumination
  • Adequate blood products including PRBC, Platelets, and FFP were arranged

Fig (7): PolyTetraFluroEthylene material used to buttress the sutrure line)

Surgery procedure

Induction and anesthesia

The nature of the surgical procedure and the expert help expected from the anesthesiology colleagues is always discussed a day or two prior to the surgery: this helps in the appropriate placement of the monitoring cannulas, drugs when needed from the surgical point of view, the nature of the radial arteries prior to placement of invasive BP monitoring, arterial blood gases requirement, timing of the antibiotics and monitoring of the urinary output.

  • Central venous access – Left Subclavian vein
  • HD catheter – Right Internal Jugular Vein (for dialysis requirement in the postop period)
  • Arterial line – Right Brachial artery
  • Epidural line (for postop pain management)
  • General Anesthesia (GA)
  • Meropenem – 30 minutes prior to induction
  • Teicoplanin – 30 minutes prior to placement of the Prosthetic graft
  • Patient was positioned in supine position and appropriate gel pads were placed at the pressure points.

WHO checklist is recited aloud: the entire team (surgeons, assisting staff, anesthesiologists, technicians) become more focused in executing the procedure in a safe and effective manner.

Surgical procedure

  • Adhesive povidone iodine (IOBAN) sheet is applied
  • A midline laparotomy is performed
  • Bilateral upper thigh GSV and basilic vein from the arm were harvested and patency was checked
  • Basilic vein anastomosed to the side of the Polyester graft to perfuse the kidneys (Fig 8)

Fig (8): The Basilic vein (yellow star marks) was anastomosed to the sides of the Polyester graft (arrow mark) to create the “neo-renal arteries”).

  • IMV ligated
  • Left renal vein identified and protected
  • Left renal artery could not be identified even with guidance from intraoperative USG
  • Supra celiac aortic control was taken
  • Control of bilateral common Iliac arteries was taken (Fig 9 )

Fig (9): Impending rupture the aortic aneurysm (Arrow mark) with control of the iliac arteries).

  • Prosthetic graft was soaked in Rifampicin
  • The basilic veins were sutured to the sides of the graft for perfusing the renal arteries
  • Heparin 3000 units IV administered
  • ACT monitoring done hourly
  • Before administering heparin, right renal artery was divided: proximal end ligated, distal end infused with organ perfusion solution (Graftsol – 500ml)
  • Cold RL applied over the right kidney
  • After 3 mins from the heparin administration, distal followed by proximal aorta clamping was performed.
  • Right renal artery and vein were identified and controls were taken
  • Aneurysmal sac opened vertically and thrombus evacuated
  • Left renal vein was ligated
  • Proximal anastomosis was performed (16 Fr Foley’s inserted with bulb inflated into the proximal aorta to facilitate hemostasis)
  • Distal anastomosis was performed
  • Left side of the Basilic vein graft (in the prosthetic graft) was ligated because of unidentified left renal artery (Fig 10 )

Fig (10): Basilic vein (arrow mark) attached to the side of the Polyester graft and inturn serves as the supply to the right renal artery)

  • Proximal followed by distal declamping was performed
  • Right renal artery anastomosed with right side GSV graft (in the prosthetic graft)
  • Complete hemostasis was achieved
  • Laparotomy closure was done

Postoperative nursing care

Aggressive nursing care was instituted from the moment the patient was shifted to the Intensive care unit. The patient was transfused with 11 PRBC, 9 FFP, 6 Cryoprecipitates and 6 Platelet transfusions in order to counteract the massive blood loss in this patient. Preemptive CRRT (Continuous renal Replacement Therapy) was initiated in the postoperative period. His right kidney gradually resumed its function and started to produce urine which was to the tune of 100 to 150 ml / hour by 3rd postoperative day. The inotropic support gradually weaned and stopped. He was extubated in the 2nd postoperative period. He developed pleural effusion in the right side which was drained with a pigtail. The drains were subsequently removed, and he made good recovery gradually.

Outcome & follow up

The patient is doing well in the follow up. His serum creatinine stays in the 2.5 to 3 mg% range; however, he doesn’t need any dialysis; he is ambulant and his quality of life has improved.

Conclusions

The patient presented several surgical challenges: Serology Positive patient with low viral load, complex Abdominal Aortic Aneurysm with the renal arteries originating from the aneurysmal sac, non-opacification of the origin of the renal arteries, need for creating an indigenous arterial supply to the renal arteries, periurethral catheter to occlude the proximal blood flow from the aorta, anticipation and the need for massive transfusion, the need for hemodialysis in the postoperative period.

Though considered a complex procedure with challenges at various levels during the peri-operative period: laparotomy +abdominal aortic aneurysm repair + Right renal artery re implantation can be performed safely and a good outcome can be obtained consistently by good coordinated team work between the surgical team , anesthesia team, critical care team, surgical nursing staff and the post-operative nursing staff. Standardization of the entire process from pre-operative preparation to intra operative surgical steps, post-operative care by breaking it into smaller steps with standard operating procedure for each step along with checklists and pathways makes this prolonged and complex procedure performed safely with very low mortality and morbidity to obtain a good outcome.

Acknowledgement

Surgeons and anesthetist:

Dr.Arunagiri viruthagiri MS, DNB, M.ch (Vascular surgeon)

Dr.Nedounsejiane mandjiny MBBS, MS, M.ch (Vascular surgeon)

Dr.Khaja Mohideen.S MD (Anesthesia), DNB (Anesthesiology)

Dr.Nirmal kumar.S MBBS, DA, DNB (Anesthesiology)

Critical team members: Dr.Ramanathan and team

Operation theatre incharge: Sr.Valarmathi.M

Scrub nurse: Sr.Mahalakshmi

Circulatory nurse: Sr.Nivetha

Technician: Sr.Lalitha

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