1. Severe segmental stenosis of the distal abdominal aorta.
2. A 3.5 cm juxtarenal aneurysm between the left renal artery and the aortic stenosis.
3. Right pelvic kidney.
4. Chronic obstructive pulmonary disease.
POSTOPERATIVE DIAGNOSIS: Not dictated.
OPERATION PERFORMED: Aortobifemoral bypass graft using 19 x 8 Gelsoft Vascutek bifurcated graft.
John Doe, MD
Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS FOR OPERATION: The patient presented with disabling claudication involving his lower extremities bilaterally. He was watched for close to two years. His symptoms had significantly deteriorated. The patient had absent bilateral femoral pulses. He underwent an MRA of the abdomen, which showed 90% stenosis of the distal aorta. The stenotic area was around 3 cm in length. Also, the patient had moderate left renal artery stenosis and right pelvic kidney. The right kidney has multiple branches feeding off of the stenotic aortic area. There is no main renal artery to the right kidney. He also was found to have a 3.5 cm aneurysm. The aneurysm extended from the stenotic area all the way to almost around a centimeter below the left renal artery. The patient was seen by Dr. Jeffrey Doe preoperatively for pulmonary and cardiac clearance. Extensive discussion with the patient was made on an outpatient basis. Different options were explained. He opted to proceed with aortobifemoral bypass graft with the intent to establish multiple things. One is to excise the abdominal aortic aneurysm that is located below the left renal artery. Also, the bypass will provide inflow to his lower extremities bilaterally and subsequently will relieve his ischemic lower extremity pain. At the same time, our intention was to allow the back flow through the stenotic aortic segment to perfuse the right kidney. The patient was agreeable to proceed with surgery and gave me his informed consent.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and was placed on the table in a supine comfortable position. A general endotracheal anesthesia was given to the patient without any problem. A
sump was introduced into the stomach to decompress his stomach. A Foley catheter was introduced into the bladder to monitor urine output. Knee-high Salem Kendalls were placed to pump the legs during the operation. The abdomen, groins, and thighs were prepped and draped in the usual sterile fashion. The patient had received preoperative Ancef prophylactically. The procedure was started by making a longitudinal incision along the right groin. The incision was carried down to the skin and subcutaneous tissue. The common femoral artery was isolated. A vessel loop was placed around it. The superficial and deep femoral arteries were isolated. The vessel loops were placed around them.
Attention was then directed to the left groin. A longitudinal incision was made at that location. The incision was carried down through the skin and subcutaneous tissue. The left common, superficial, and deep femoral arteries were isolated. Vessel loops were placed around them. Attention was then directed to the abdomen. A longitudinal incision was made between the xiphoid and pubis. The incision was carried down through the skin and subcutaneous tissue. The fascia was opened in the midline. The abdominal cavity was entered. A minimal amount of adhesions were identified in the pelvis. These were freed and moved laterally. The liver felt normal. The spleen felt normal. The stomach and small bowel are normal in appearance. The colon was normal in appearance. No ascites was noted. Attention was then directed to the retroperitoneum. A Bookwalter retractor was placed. Retraction of the lateral wall of the abdominal cavity was performed. The dissection was carried down on the lateral aspect. The retroperitoneum was opened longitudinally. The incision was carried up from the iliac bifurcation all the way to the renal vein. The retroperitoneum was opened completely. The dissection was carried out along the inferior mesenteric artery, which was identified. The aneurysm was identified. The left renal artery was identified. The right kidney was visualized. It was located in the pelvis. There were maybe 3 or 4 less than 2 mm vessels feeding the right kidney. The inflow originates from a stenotic long segment atretic aorta. The iliac arteries felt to be calcified, but they were patent.
The patient was given 5000 units of heparin. Heparin was allowed to circulate for 3 minutes. A clamp was placed on the aorta just above the stenotic segment. A clamp was placed on the aorta below the left renal artery. The intention was to close the stenotic aortic area, allow the flow from this aortic segment just below the renal artery via the graft into the femoral arteries bilaterally. Flow retrograde through the external iliac will feed the kidney and the hypogastric system. The aorta will be suture ligated superiorly to allow backbleeding to the right kidney. There were multiple small vessels originating from the aorta. The aortic wall was very diseased. There was not enough room to use a Carrel patch to implant to the graft.
The aorta was clamped just immediately below the left renal artery and above the right renal origin. Perfusion to the right kidney was retrograde via the femoral system. The aneurysm was opened. Hemostasis was performed by ligating bleeding lumbar vessels. An 18 x 9 bifurcated Vascutek graft was spatulated. It was sutured superiorly with 3-0 Prolene on an SH needle. The proximal anastomosis was intact. Once this was established, the aorta just above the stenotic area and above the origin of the right renal arteries was suture ligated with Prolene sutures. As I said before, the aortic wall was very atrophic. There were no healthy viable tissues to implant a Carrel patch that includes all these little branches into the graft. The vessels were very small and it was almost impossible to implant them separately.
Tunnels were created between the groins and the retroperitoneal area. The grafts were tunneled all the way down to the groin. Attention was then directed to the left femoral system. The left common femoral artery was clamped. The left superficial and deep femoral arteries were clamped. Longitudinal arteriotomy was performed. The graft was spatulated. It was sutured into the left femoral artery. All vessels were allowed to backbleed. We had good backbleeding from the iliac circulation. The flow was restored to the lower extremities via an open limb of the graft. The other limb was tunneled to the right groin. The femoral artery was patent. The superficial and deep femoral arteries were clamped. The proximal common femoral artery was clamped. Longitudinal arteriotomy was performed. The graft was spatulated and was sutured into the femoral artery with 3-0 Prolene on an SH needle. Hemostasis was performed. Flow was restored to both lower extremities. The patient was stable. Blood loss was noted from flushing the aortic graft, from ligating the limbs of the graft, from flushing femoral vessels; it was estimated to be around 1200 mL. The feet were examined. They were warm and had dorsalis pedis pulses bilaterally.
Attention was then directed to the abdominal cavity. The retroperitoneum was examined. No bleeding was noted. The retroperitoneum was closed to cover the graft and separate it from the duodenum. Hemostasis was performed well. The fascia was closed with running looped PDS. Two sutures were used, one from above and one from below. The subcutaneous tissue was closed with running 3-0 Vicryl. The skin was closed with staples. Attention was then directed to the femoral area. The subcutaneous tissues were closed in the usual fashion, 3-0 Vicryl in two layers for the subcutaneous and staples for the skin. Hemostasis was intact. The patient had good palpable femoral and dorsalis pedis pulses bilaterally. The patient tolerated the procedure well.