Inflammatory thoracoabdominal aneurysm
(Portuguese PDF version)

Eduardo Faccini Rocha,1 George Carchedi Luccas,2 Luis Baldini Neto3

1. Hired physician, Peripheral Vascular Surgery, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.
2. Professor, Peripheral Vascular Surgery, Faculdade de Ciências Médicas, UNICAMP, Campinas, SP, Brazil.
3. Resident physician, Vascular Surgery, Faculdade de Ciências Médicas, UNICAMP, Campinas, SP, Brazil.

Correspondence:
Eduardo Faccini Rocha
Rua Cônego Januário Barbosa, 427
CEP 18030-200 - Sorocaba, SP, Brazil
Phone: (15) 3231.6189
E-mail: eduardofaccinirocha@bol.com.br

ABSTRACT

The authors report an unusual case of a patient with a type IV thoracoabdominal inflammatory aneurysm. This patient was submitted to surgery through a thoracoabdominal incision, medial visceral rotation with difficulty due the adherences and visceral perfusion during the supraceliac clamping with a modified assisted circulatory device.

Key-words: abdominal aortic aneurysm, inflammation, thoracic aortic aneurysm.

J Vasc Br 2005;4(3):301-6

Since the first successful repair of an abdominal aortic aneurysm, made by Charles Dubost, in March 29 1951, with a homologous graft, the elective surgery of these aneurysms has become a routine procedure, with relatively low morbidity and mortality rates.1 However, some factors may considerably increase the complexity of the aneurysm repair surgery. Among them, we can mention thoracoabdominal (TAA), pararenal, mycotic or infectious, inflammatory aneurysms, reoperations, associated venous anomalies2 and others.

The occurrence of an inflammatory aneurysm affecting the thoracoabdominal aorta is rare.3,4 In these cases, the need for supraceliac clamping, associated with multiple adherence of the inflammatory process, make the surgery a great challenge for the vascular team.

CASE REPORT

E.H, 65 years old, male, referred to the vascular surgery outpatient clinic at Hospital das Clínicas at UNICAMP, complaining of abdominal discomfort for 2 months. He presented the following antecedents: smoking, chronic renal insufficiency due to postrenal causes being followed up by the nephrology service.

At physical examination, he presented good general status, with blood pressure of 130 x 80 mmHg, painless pulsatile mass in the mesogastrium measuring around 6 cm of diameter and the DeBabey sign was present. All pulses were present and without murmur.

The tomography showed an aneurysm starting at the emergence of the superior mesenteric artery and a larger diameter of 8 cm below the renal arteries, with signs of thickening of its wall in the entire circumference (Figure 1).

click hereFigure 1 - Aneurysm in the exit point of the renal artery with aortic wall thickening.

At the preoperative assessment, the cardiologic risk was estimated in 10% (Goldman II): echocardiography showing light aortic and mitral insufficiencies, ejection fraction of 58.87%, besides the pulmonary assessing, which identified high risk for complications (VEF1 of 112% and pO2 of 71.2 mmHg, pCO2 of 36 mmHg and O2 saturation of 96%). The patient presented serum creatinine levels of 1.9 mg/dl.

He received an indication for surgical repair with monitoring with Swan-Ganz catheter, central venous access, mean blood pressure in right radial, selective orotracheal intubation and device for intraoperative blood recovery (Cats by Fresenius).

The patient was placed in the right lateral decubitus position, with scapular rotation of 70 degrees and pelvic rotation of 30 degrees. The approach and repair of the right common femoral vein were performed for further catheterization for the modified assisted circulatory device (MACD), which consisted of the association of an assisted circulatory device with a rapid venous infusion pump. In this case, we did not use the cardiotomy reservoir of the arterial line. The reservoir was used for venous infusion of Ringer lactate. Filters or heat switchers were not used either, and a neonatology oxygenator, aiming at reducing the heparin dose required for this circuit (active coagulation time desired of 300 s), without much difference from the heparinization used with the clamp and go technique. The necessary flow for visceral perfusion is approximately 60 ml/min per artery, and the neonatology oxygenator has a capacity for up to 1,000 ml/min.

Another great advantage of the circuit is the rapid venous infusion through the Biopump with the shunt associated with the circuit. Thus, a venous pump is obtained with insignificant extra costs (three connections in Y and a reservoir). This volume infusion through the pump coincides exactly with the end of the proximal and distal anastomosis, when an extra volume is needed, due to the hypotension that will follow after the removal of the clamps (Figures 2 and 3).

click hereFigure 2 - Modified assisted circulatory device, with selective perfusion of visceral trunks. Note that the circuit of venous infusion is clamped, only allowing the flow for the viscera.

click hereFigure 3 - Modified assisted circulatory device, with clamping of the selective perfusion of the visceral trunks. Note that the circuit of venous infusion is open, which allows Ringer infusion for the femoral vein.

Next, the thoracophrenolaparotomy was performed, starting from the ninth left intercostal space in the median axillary line, extending up to the median line of the abdomen, with an extension to the pubic symphysis. A partial opening of the diaphragm was made, with a semicircular incision and medial visceral rotation. It was a difficult procedure, due to the extensive inflammatory process and diffuse bleeding of the retroperitoneum. The aorta was then exposed, from the thoracoabdominal transition until the iliac arteries. There was an intense "porcelain-like" inflammatory activity, which affected the whole abdominal aorta, as well as important ureteral adherence (Figure 4).

click hereFigure 4 - "Porcelain" aspect of the infrarenal portion of the thoracoabdominal aneurysm before the medial visceral rotation.

A proximal repair was performed above the celiac trunk and a distal repair in the iliac arteries. After the systemic heparinization with activated coagulation time (ACT) around 300 seconds, a 20 F venous cannula (Tecnobio Ind. Com. Repr. Ltda.) was introduced in the right common femoral vein, until it reached the inferior vena cava, being connected to the MACD.

Next, a proximal and distal clamping was performed, and the aneurysm was opened (there was a 2-3-cm thick layer) from the celiac trunk to the aortic bifurcation. The 9F Pruitt catheters were introduced in the visceral ostium, and the oxygenated perfusion at normothermia, maintaining a perfusion pressure of 60 mmHg (total flow between 300-350 ml/min).

An aorto-aortic 24 mm/30 cm Dacron graft interposition was performed (Hemashield Gold Woven double velour), with proximal oblique anastomosis involving the right renal artery, superior mesenteric artery and celiac trunk. The left renal artery was separately reimplanted in the prosthesis. At the end of the proximal anastomosis, the visceral perfusion catheters were removed, and a rapid volume infusion via MACD was started.

Before releasing the distal clamps, a new rapid crystalloid infusion was made, through the MACD, in order to avoid hypotension. After the patient was hemodynamically stable, the femoral venous cannula was removed, the heparin was reverted with protamine and the closure of the thoracic and abdominal cavities was started.

The visceral ischemia time was 60 minutes for the left renal artery and 40 minutes for the other visceral arteries. The crystalloid volume injected by the MACD was 3,800 ml.

The patient remained at the ICU for 4 days. He was extubated and remained without vasoactive drugs since the first postoperative day, with serum creatinine value of 1.7 mg/dl. The diet was introduced on the third day, and the patient was discharged in good conditions only after 15 days, due to the thoracic drain with high debt and pneumonia.

DISCUSSION

The first successful repair of abdominal aortic aneurysm is credited to Dubost, in 1951, and the first surgery of TAA to Etheredge, in 1954.1,5,6 Despite several medical and technical advances, the challenges of the vascular surgeon regarding these diseases are still considerable, particularly with regard to postoperative complications, including paraplegia, renal insufficiency, myocardial infarction, respiratory complications, coagulation disorders, among others.6,7

A study on the natural history of TAA evolution shows that only 24% of patients conservatively treated will be alive 2 years after the diagnosis of the disease, considering that 50% of deaths are due to rupture of the aneurysm.1,5

The incidence of TAA is around 5-10% considering aortic aneurysms, and the type IV TAA represents 19 to 23% of TAA.1,8,9 Regarding TAA, the Crawford type IV (which involves only the abdominal aorta, including the visceral trunks) is the one that presents the lowest risk of intra- and postoperative complications. However, when compared to the repair of infrarenal and pararenal aneurysms, it presents considerably higher morbidity and mortality rates.10 Mortality rates for this type of aneurysm are around 3.1 to 20% in elective surgeries, with bone marrow ischemia around 1.3 to 4.5% and occurrence of renal insufficiency in 8.8 to 14% of cases.4-12

In 1972, Walker introduced the term inflammatory abdominal aortic aneurysm (although James and DeWeerd had described the disease in 1935 and 1955, respectively), in which there is a whitish thickening of the vessel wall and extensive fibrosis involving adjacent tissues.4,13 These aneurysms increase the risk of complications during and after the surgery, due to multiple adherence found between the duodenum (100%), left renal vein (48-51%), inferior vena cava (63-70%), ureters (20-44%), small intestine (20%) and sigmoid (5-20%).10 They are symptomatic in 80% of cases and present an incidence of 3 to 12% among aortic aneurysms. They rarely reach the aorta above the emergence of the renal arteries.1,13 The prevalence is in male (6-30:1), in young patients and smokers, with regard to non-inflammatory aneurysms.13

Between 1957 and 1984, Crawford and Stowe treated 30 patients with inflammatory aortic aneurysm - only six (20%) of these affected the aorta above the renal arteries. They reported only one death during 30 days after the surgical repair of these cases.3

Arroyo found 17.2% of type IV TAA associated with inflammatory aneurysm; 10% of the inflammatory aneurysms were TAA, and there was no surgical mortality in this series.4

In that case report, the tomography showed an aneurysm starting at the emergence of the superior mesenteric artery, with signs of thickening of the wall in all its circumference. However, this examination did not show the double halo of contrast, which is characteristic of inflammatory aneurysms, maybe due to the technique used (only 13-33% of these aneurysms are diagnosed in the preoperative period).11 We do not have a preoperative VHS available, neither biopsy of the aortic wall, but the intraoperative findings confirmed the inflammatory etiology of the aneurysm (Figure 4) and made extremely difficult to expose the left renal artery and the distal neck of the aneurysm. Proximally, the fibrosis did not reach the diaphragmatic crus, but the distal adherence caused a diffuse and continuous bleeding of the retroperitoneum, which was exposed after the medial visceral rotation.

We do not routinely perform ureterolysis of the inflammatory aneurysms, as suggested by Crawford, Sterpetti and Rasmussen,13 once there is regression of the fibrosis that involves the ureters in 70% of cases and rarely there is worsening of the renal function secondary to the postoperative ureteral "imprisonment".13

We chose to use the visceral perfusion with a circuit projected by our service (Figures 3 and 4),14 due to the possible prolonged clamping time in the case of multiple adherence and limited exposition. Moreover, one of the preoperative indicators of mortality in the surgery of TAA is the serum creatinine level higher than 1.5 mg/dl,10 which reinforces the need for preserving the renal perfusion during the aortic clamping in patients with abnormal renal function.

In the literature, the use of visceral perfusion for type IV TAA is still controversial. Several authors report good outcomes with this technique,15-17 whereas others present the same results with the clamp and go technique or only perfusion of cold crystalloid solution.7-9,18 We believe that each case should be assessed individually, taking into account the technical difficulties found. The association of TAA with inflammatory aneurysm seems to be a good indication of visceral perfusion during the suprarenal aortic clamping.

REFERENCES

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2. Luccas GC, Prezotti MA, Matsui IA, Menezes FH. Anomalias venosas associadas à cirurgia de aorta abdominal. Cir Vasc Angiol. 1999;15:51-4.

3. Crawford JL, Stowe CL, Safi HJ, Hallman CH, Crawford ES. Inflammatory aneurysms of the aorta. J Vasc Surg. 1985;2:113-24.

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5. Martin GH, O'Hara PJ, Hertzer NR, et al. Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome. J Vasc Surg. 2000;31:851-62.

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14. Rocha EF, Guillaumon AT, Antunes N, VieiraRW. Aneurisma toracoabdominal roto: modificação do circuito de perfusão visceral. Rev Bras Cir Cardiovasc. 2004;19:413-16.

15. Kuniyoshi Y, Koja K, Miyagi K, et al. Selective visceral perfusion during thoracoabdominal aortic aneurysm repair. Ann Thoracic Cardiovasc Surg. 2004;10:367-72.

16. Morishita K, Yokoyama H, Inoue S, Koshino T, Tamiya Y, Abe T. Selective visceral and renal perfusion in thoracoabdominal aneurysm repair. Eur J Cardiothorac Surg. 1999; 5:502-7.

17. Jacobs MJ, Eijsman L, Meylaerts SA, et al. Reduced renal failure following thoracoabdominal aortic aneurysm repair by selective perfusion. Eur J Cardiothorac Surg. 1998;14:201-5.

18. Eide TO, Romundstad P, Saether OD, Myhre HO, Aadahl P. A strategy for treatment of type III and IV thoracoabdominal aortic aneurysm. Ann Vasc Surg. 2004;18:408-13.


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