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15. Thoracoabdominal Aortic Aneurysm Replacement: Proximal Anastomosis
The technique used for the construction of the proximal aortic anastomosis in a patient with a thoracoabdominal aortic aneurysm depends on the extent of the aneurysmal pathology and the relationship of the aneurysm to the orifices of the celiac, superior mesenteric, and the right and left renal arteries.
Proximal Anastomosis Incorporating the Celiac, Superior Mesenteric, and Right Renal Arteries
When the aneurysmal disease starts at the level of the celiac artery and the aorta becomes normal just proximal to the celiac artery (Crawford type IV), one option is to incorporate the orifices of the celiac, superior mesenteric, and both renal arteries in the proximal anastomosis. The anastomosis is appropriately tailored depending on the distance between the right and left renal arteries. In the presence of significant aneurysmal pathology between the right and left renal arteries, only the celiac, superior mesenteric, and right renal arteries are incorporated as a tongue of aortic tissue into the proximal anastomosis. The left renal artery will have to be reimplanted separately.
Reimplantation of the Celiac, Superior Mesenteric, and Right Renal Arteries on an Aortic Patch
When the aneurysmal pathology extends several centimeters proximal to the origin of the celiac artery, the visceral vessels cannot be incorporated in the proximal anastomosis. The proximal anastomosis is performed at the level where the aortic wall is normal. The celiac, superior mesenteric, and renal arteries will be reimplanted as an island. Generally, the left renal artery cannot be included in the island and is to be reimplanted separately. After completion of the distal anastomosis, a partial occluding clamp is applied on the aortic graft in preparation for the reimplantation of the left renal artery. It is important to avoid placing the clamp very close to the suture line, as it may cause an excessive stress on the suture line, resulting in bleeding. Another factor one must consider is to accommodate for the return of the left kidney to its normal anatomical position when selecting the site for the left renal artery reimplantation.
Proximal Anastomosis Incorporating the Celiac, Superior Mesenteric, and Right Renal Arteries
This picture shows the incision line of the procedure as performed through a thoracoabdominal approach or medial visceral rotation, with the left kidney remaining in its posterior location.
Proximal Anastomosis Incorporating the Celiac, Superior Mesenteric, and Right Renal Arteries
This picture shows the incision line if the procedure is performed through a medial visceral rotation, thoracoabdominal or retroperitoneal approach, with the left kidney being mobilized anteriorly.
Proximal Anastomosis Incorporating the Celiac, Superior Mesenteric, and Right Renal Arteries
After opening the aortic aneurysm, the orifices of the celiac, superior mesenteric, and renal arteries are inspected to check if they can all be incorporated together in one tongue.
Most often, however, the celiac, superior mesenteric, and right renal arteries are close to each other and can be incorporated as one island, leaving the left renal artery to be reimplanted separately.
Excise a rectangular piece of the graft as shown here. Start placing the suture a few bites away from the center of the heel.
Proximal Anastomosis Incorporating the Celiac, Superior Mesenteric, and Right Renal Arteries
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