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Transperitoneal Infrapancreatic Approach to the Supraceliac Aorta for Transaortic Paravisceral Endarterectomy
Hassan Chamseddine, Mahmood Kabeil, Yamini Vyas, Jane Chung, Jonathan Kwong, Avkash Patel, Kaitlyn Dunphy, Jae S. Cho
University Hospitals-Case Western Reserve University, Cleveland, OH
Objectives: Exposure and control of the paravisceral and supraceliac aorta is commonly achieved by thoraco-retroperitoneal approach. When a transperitoneal midline approach is used, medial visceral rotation is often utilized. However, the latter requires extensive dissection with limited exposure to the right pelvis and groin. Without medial visceral rotation, the supraceliac aorta is accessed through the lesser sac and the exposure becomes discontiguous, and cumbersome when the aortic clamp or the supraceliac aorta needs to be adjusted or checked. In select patients, the paravisceral aorta and even the supraceliac aorta may be exposed via transperitoneal, midline, infrapancreatic approach, which provides direct and contiguous exposure of the entire paravisceral aorta.
Methods: We present a safe and effective technique of a transperitoneal infrapancreatic approach to the supraceliac aorta for transaortic paravisceral endarterectomy.
Results: A 73-year-old male presented with bilateral lower extremity lifestyle-limiting claudication at 50 yards. Past medical history included hypertension, coronary artery disease, and chronic obstructive pulmonary disease. Surgical history was notable for right-to-left cross femoral bypasss grafting, in addition to balloon angioplasty of the right external iliac artery. Computed tomographic angiography showed severe atherosclerotic disease involving the aortoiliac vessels and a significant atheroma in the paravisceral aorta. An aortobifemoral bypass grafting with transaortic paravisceral endarterectomy was planned. A standard midline transperitoneal incision was made extending from the xiphoid process to just above the symphysis pubis. The retroperitoneum overlying the aorta was incised longitudinally. The left renal vein was circumferentially controlled and preserved without division. Circumferential control of the right and left renal arteries was obtained. Dissection of the suprarenal aorta and paravisceral aorta was continued cephalad with division and ligation of the periaortic tissue and lymphatics at 1-2 o’clock position of the aorta. Use of electrocautery was avoided to prevent lymphatic leak. The superior mesenteric artery (SMA) was isolated and dissected free. The supra-SMA aorta was dissected and prepared for clamping to allow sequential clamping. Dissection was continued towards the celiac axis which was isolated and dissected free. The supraceliac aorta was then prepared for clamp placement. Following systemic heparinization, control of the supraceliac aorta was obtained and an aortotomy made from the infrarenal aorta to the celiac axis. Paravisceral aortic thromboendarterectomy was performed. The aorta was closed primarily down to the infrarenal aorta with sequential clamping so as to minimize visceral ischemic time. The infrarenal aorta was then transected and a woven bifurcated polyester graft sewn end-to-end to the aorta.
Conclusion: The infrapancreatic approach to the paravisceral and supraceliac aorta, in select patients, provides a direct and contiguous access to the paravisceral and supraceliac aorta and right pelvis, while avoiding the need for extensive visceral mobilization. This technique may serve as a valuable tool for surgeons managing complex aortic pathology.
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