Ascending Aorta to Intestinal Artery Bypass: Technical Aspects

EJVES Extra 9, 13–15 (2005) doi:10.1016/j.ejvsextra.2005.01.003, available online at http://www.sciencedirect.com on

SHORT REPORT

L. Chiche* and E. Kieffer

Department of Vascular Surgery, Pitie´-Salpeˆtrie`re University Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris, France

We describe the ascending aorta as an inﬂow in patients who need a mesenteric bypass and in whom the ascending aorta is the only remaining non-diseased segment. This operation was performed in ﬁve patients. .

Introduction interspace, is the preferred approach. Partial sternotomy can be extended by dividing the third costal A number of techniques can be used to treat chronic cartilage or by adding oblique sternotomy. Total intestinal ischemia.1,2 We use the ascending aorta as an sternotomy is necessary if access to the aortic arch or inflow in patients in whom the supraceliac, descend- supra-aortic trunks is required. ing thoracic aorta, the abdominal aorta or iliac arteries Median or subcostal laparotomy provides good are unsuitable due to the presence of extensive lesions access to intestinal artery lesions.1 The celiac trunk or previous surgery. The technique described here was (CT) can be exposed by the interhepatogastric route. performed in five patients (2.4%) out of 211 in whom Its origin is exposed after incision of the right crus of 309 intestinal artery revascularization procedures the diaphragm and division of the arcuate ligament. were carried out between 1990 and 2004. It is similar The superior mesenteric artery (SMA) can be to the classical technique of ascending aorta-abdomi- approached by the pre- or sub-duodenal intramesen- nal aorta bypass used in the management of thoraco- teric route or by a route between duodenum and 3 abdominal aortic lesions. pancreas. The right side of the proximal ascending aorta is clamped under controlled hypotension (90 mmHg). A biopsy specimen, triangular with the peak pointing Surgical Technique downward, circular or oval with the long oblique axis at the top and to the left, is taken. The proximal The patient should be supine with shoulders elevated extremity of the bypass is anastomosed end-to-side to using a transverse roll. A second transverse roll can be the aorta. Heparin is administered after the proximal placed under the xyphoid process. Pulmonary exclu- anastomosis is checked for haemostasis. The bypass is sion is unnecessary. tunneled through the right pleura. Tunneling through Limited exposure of the ascending aorta, either by the pericardium is possible for patients with pleural partial median vertical sternotomy or by a short right symphysis. anterior or anterolateral thoracotomy in the third The bypass is brought into the diaphragm through a wide orifice made in the central tendon. In most cases * Corresponding author. L. Chiche MD, Service de Chirurgie we route it behind the left lobe of the liver then in the Vasculaire, CHU Pitie´-Salpeˆtrie`re, 47-83, bd de l’Hoˆpital, 75013 Paris, France. cavity of the omentum behind the stomach (Fig. 1). E-mail address: [email protected] The bypass can be passed to the SMA below the

Fig. 1. Drawing of an ascending aorta to superior mesenteric artery bypass using the prepancreatic (continuous line) or the retropancratic route (dotted line). mesocolonic level using the prepancreatic route, through the transverse mesocolon or the retropancrea- tic route. The CT can be directly reimplanted using an Fig. 2. Postoperative angiography (oblique view) showing end-to-side button on the right aspect of the bypass. the antegrade bypass (reversed great saphenous vein) from The distal anastomosis with the SMA is made end-to- the ascending aorta to the distal superior mesenteric artery. side or end-to-end. Closure is straightforward after checking that the bypass has been positioned properly. Protection of prosthetic grafts from adjacent digestive structures is

EJVES Extra Vol 9, February 2005 Ascending Aorta to Intestinal Artery Bypass 15 achieved by omental wrapping. If the intrapericardial position of the mesentery to avoid kinking of the route was used, the pericardium should be left open to bypass after closure. avoid compression of the bypass. Despite, the long-term risk of dilatation, the reversed great saphenous vein is the most suitable conduit for revascularization of the distal branches Discussion of intestinal arteries (Fig. 2). Its advantages are to facilitate anastomosis with thin and friable arteries Antegrade bypass presents advantages for revascular- and to minimize the risk of intestinal erosion. ization of intestinal arteries. The direction of flow is Prosthetic grafts may be used in patients without physiological. The risk of kinking is low. The supra- suitable veins or electively for proximal intestinal celiac or descending thoracic aorta is usually normal artery revascularization. and can be expected to remain so even in patients with The distal bypass implantation technique varies advanced atherosclerotic lesions of the infrarenal aorta according to the location of lesions and extent of and iliac arteries. However, there are a few cases, involvement of the CT and its branches or of the SMA. especially involving extensive inflammatory or aneu- If complete revascularization is not possible, we rysmal disease, in which the ascending aorta is the consider the SMA as the most suitable recipient artery. only remaining non-diseased segment and thus the only available segment for bypass inflow. A prosthesis replacing the ascending aorta or the innominate artery in case of previous coronary bypass can also be References used. Combined coronary artery revascularization is possible. 1 Kieffer E, Chirurgie des arte`res digestives In encycl me´dchir, Before clamp placement, the proximal ascending techniques chirurgicales—chirurgie vasculaire 2003 [see also p. 17, aorta should be carefully palpated to rule out the 43–105]. 2 Mateo RB, O’Hara PJ, Hertzer NR, Masha EJ, Beven EG, presence of atheromatous plaque. Aortotomy must be Krajewski LP. Elective surgical treatment of symptomatic chronic placed on its right lateral surface so that the occlusive disease: early results and late outcome. J Vasc Surg 1999; anastomosis is sufficiently oblique to prevent kinking 29:821–832. 3 Kieffer E, Petitjean C, Ruotolo C, Ammar F, Natali J. Pontage of the bypass against the sternum after closure. In this aorte ascendante-aorte abdominale. In: Kieffer E, ed. Chirurgie de way, the bypass already takes a lateral posterior course l’aorte thoracique descendante et thoraco-abdominale. Paris: Expansion that facilitates tunnelling through the right pleura. Scientifique Française, 1986:115–130. 4 Cormier JM, Fichelle JM, Vennin J, Laurian C, Gigou F. Absence of compression at the point of passage Atherosclerotic occlusive disease of the superior mesenteric through the diaphragm must be checked. The retro- artery: late results of reconstructive surgery. Ann Vasc Surg 1991; hepatic, retrogastric route is usually the smoothest. 5:510–518. Leschi Coggia Goeäu-Brissonnie`re The mean length of bypass is 25 cm. This is compar- 5 JP, M, O. Retrograde aortomesenteric bypass with tunneling behind the left renal able to that of some long C-shaped retrograde pedicle. Ann Vasc Surg 2001;15:503–506. bypasses originating from the iliac artery.4,5 In the antegrade route it is not necessary to check the Accepted 18 January 2005

EJVES Extra Vol 9, February 2005