Laparoscopic aortoiliac surgery for treatment of limb critical ischemia: report of the first case in Brazil

Abstracts

A cirurgia videolaparoscópica vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aorto-ilíaca. O objetivo deste relato é demonstrar os resultados da primeira cirurgia videolaparoscópica realizada no Brasil para o tratamento da doença oclusiva aorto-ilíaca, associada a procedimentos híbridos distais para lesões ateroscleróticas multissegmentares em paciente com isquemia crítica. A técnica videolaparoscópica é mais uma ferramenta minimamente invasiva, viável, segura e eficaz para o tratamento da doença oclusiva aorto-ilíaca extensa. A referida técnica, que nada mais é do que a cirurgia convencional realizada sob visão laparoscópica, tem bons resultados a longo prazo, associados à elegância técnica.

Cirurgia videoassistida; aorta; doenças vasculares; aterosclerose

CASE REPORT

Laparoscopic aortoiliac surgery for treatment of limb critical ischemia: report of the first case in Brazil

Ricardo de Alvarenga Yoshida^I; Winston Bonetti Yoshida^II; Hamilton de Almeida Rollo^II; Ralf Kolvenbach^III; Regina Moura^IV; Rodrigo Gibin Jaldim^V; Paulo Roberto Kawano^VI; Hamilto Akihissa Yamamoto^VI

^ICirurgião vascular e endovascular. Doutorando. Colaborador, Disciplina de Angiologia, Cirurgia Vascular e Endovascular, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, SP

^IIProfessor adjunto. Livre-docente, Disciplina de Cirurgia Vascular e Endovascular, UNESP, Botucatu, SP

^IIIChefe. Professor titular, Serviço de Cirurgia Vascular e Endovascular, Augusta Hospital and Catholic Clinics, Duesseldorf, Alemanha

^IVDoutora. Professora, Disciplina de Cirurgia Vascular e Endovascular, UNESP, Botucatu, SP

^VResidente, Disciplina de Cirurgia Vascular e Endovascular, UNESP, Botucatu, SP

^VIDoutor. Professor, Disciplina de Urologia, Departamento de Cirurgia e Ortopedia, UNESP, Botucatu, SP

Correspondence

Abstract

Laparoscopic surgery has been increasingly used as a less invasive surgical option for the treatment of aortoiliac occlusive atherosclerotic disease. The objective of this case report is to describe the results of the first laparoscopic surgery conducted in Brazil for the treatment of the aortoiliac occlusive disease associated with distal hybrid procedures to treat multisegmental atherosclerotic lesions in a patient with critical limb ischemia. The laparoscopic technique is an additional minimally invasive tool, being feasible, safe, and effective for the treatment of extensive aortoiliac occlusive disease. This technique, which is nothing more than a conventional surgery performed under laparoscopic viewing, brings good long-term results associated with technical elegance.

Keywords: Video-assisted surgery, aorta, vascular diseases, atherosclerosis.

Introduction

Atherosclerosis is considered a disease of civilization, growing with it and afflicting increasingly younger individuals every day.^1-3 Widespread throughout the world, seemingly with great regularity, it afflicts circa 3 to 10 percent of world population, but 15 to 20 percent of people over the age of 70.^1,3 According to Framingham,⁴ mean annual incidence of symptomatic PAOD (peripheral arterial occlusive disease - atherosclerosis) is equal to 26 per 10,000 men and 12 per 10,000 women, with numbers increasing for older age ranges.

Among patients 50 years old or older, 20 to 30 percent of patients are initially asymptomatic, 30 to 40 percent experience atypical leg pain, 10 to 35 percent have typical intermittent claudication, and 1 to 3 percent have critical ischemia.⁵ After 5 years, among patients who initially did not have critical ischemia, 70 to 80 percent have stabilized claudication symptoms, 10 to 20 percent experienced worse claudication, and 5 to 10 percent developed critical ischemia.⁵ Among patients who initially had critical ischemia, 45 percent are alive and have both limbs, 30 percent have undergone amputations, and 25 percent have died.⁵

Various epidemiological studies have established what risk factors influence the natural evolution of PAOD, increasing its incidence and accelerating its progression.^2,5 The factors seem to be independent; therefore, in association, they probably add up, which in association with the systemic nature of the disease may lead to the simultaneous appearance of atherosclerotic lesions in various vascular regions.^2,5,6 The most important consequences of chronic limb ischemia (CLI) PAOD are short survival times and limited limb survival, regardless of treatment.⁵

In general, critical ischemia caused by aortoiliac occlusions are more severe when the region is fully occluded (TASC D lesions) or when associated with underlying lesions in the femoropopliteal or popliteodistal regions.⁵ The gold standard for treating TASC D lesions is conventional surgery, including: anatomic grafts (transperitoneal or retroperitoneal), extra-anatomic grafts and endarterectomies; the endovascular technique may be used, but only for select cases.⁵ More recently, there have been reports of video-assisted surgery for such cases, serving as a minimally invasive alternative for aortoiliac reconstructions.^7-10

The objective of this report is to publicize the outcome of the first videolaparoscopic surgery (VLS) in Brazil to treat occlusive aortoiliac disease, associated with hybrid distal procedures for multisegmental atherosclerotic lesions in a critical ischemia patient.

Case report

The patient was 57 years old, male, Caucasian, complaining of intermittent claudication in left lower limb for 3 years, initially at 300 m, with progressive worsening as time passed. He entered our health care facility with a history of trauma in the ungual region of the left halux progressing to wet gangrene of toe (Figure 1). The patient had the following associated comorbidities: systemic hypertension (SHT), diabetes mellitus (DM) and dyslipidemia. He was also an ex-smoker, 45 pack years, abstinent for 2 years.

Physical examination revealed no palpable pulse in the left lower limb, and diminished femoral pulse in the lower right limb, with fremitus, while other pulses were absent. Ankle-brachial index (ABI) values for the lower left limb were: anterior tibial (AT) = 0.41; posterior tibial (PT) and fibular (Fib) without Doppler flow. Right limb: AT = 0.53; PT = monophasic flow; Fib = no Doppler flow. Arteriography showed occlusion of left common and external iliac arteries, moderate stenosis of right common iliac artery, and chronic femoropopliteal and bilateral infrapatellar occlusion (Figure 2).

Preoperative examinations and standard cardiological assessment revealed an intermediate risk of cardiovascular event, according to the algorithm from the American College of Physicians.

The objective was to perform aortoiliac reconstruction surgery using a totally laparoscopic technique to place the aortofemoral graft (Figure 3A). The patient was submitted to general anesthesia, a nasogastric tube was inserted, and antibiotic prophylaxis administered using second generation cephalosporin. Next, the patient was placed on the operating table over a pad, in right lateral supine position with his left arm above the body. After antisepsis and sterilization, pneumoperitonium began after using a Veress needle to puncture the left subcostal region. It was kept at a pressure of 12 mmHg of CO₂. Next, an 11 mm trocar was placed to his left, laterally from the navel, to insert the 30° optical instrument. Two other 11 mm trocars (Endopath^®, Johnson & Johnson) were placed laterally to the middle line, below and above the navel. Four other trocars were placed around the left side, based on the costal margin, middle axillary line, dorsal musculature, and iliac crest (Figure 3B). Aortic exposure began by medial mobilization of the left distal hemicolon using graspers, laparoscopic scissors, and harmonic scalpel (Ultracision^®, Johnson & Johnson), following "Apron Technique" guidelines¹¹ (Figure 4). However, a small fusiform dilatation of the aorta (maximum diameter, circa 3.0 cm) was seen during aortic dissection. After full dissection of the distal aorta and its bifurcation (Figure 5), aortic lumbar arteries were externally clipped using Liga-clip^® (Johnson & Johnson). After endovenous heparinization (100 UI/kg), a laparoscopic aortic clamp (Storz Laparoscopic Vascular Clamp) was placed on the infrarenal distal aorta, while another clamp was placed on the aorta right above its bifurcation, via portals located below the costal margin and iliac crest, respectively (Figure 6). After longitudinal aortotomy, thrombi were found within the vascular lumen, and were removed. The Dacron 10 mm prosthesis was inserted into the cavity. Due to the friable nature of the aortic wall, total laparoscopic anastomosis was not possible. The surgeons chose to perform minilaparotomy (10 cm) at the anterior axillary line of the lower left abdomen. From then on, the surgery became an open procedure, without use of the pneumoperitonium. Proximal anastomosis was performed under direct view and with the help of an Omni-Tract^® abdominal retractor, using end-to-side conventional technique between the distal aorta and the Dacron 10 prosthesis, with two Prolene^® 3.0 threads (Ethicon^®, Johnson & Johnson), continuous suture. After releasing the flow and reviewing hemostasis, the graft was covered by the left hemicolon and peritoneum by simply placing the patient in a prone position. The distal branch of the prosthesis was externalized by left inguinotomy (performed at the beginning of the surgery) and the mini-incision and portals were closed.

Longitudinal arteriotomy of the previously exposed common femoral artery (CFA) showed lead reflux through the deep femoral artery and no reflux through the superficial femoral artery (SFA). There was also atherosclerotic plaque blocking most of the CFA lumen extending into the SFA. The surgeons chose to perform endarterectomy of the CFA and SFA with a Vollmar ring, but even so no reflux through the SFA was seen. Intraoperative arteriography showed severe stenosis in the distal SFA (adductor channels), as well as intimal flap caused by the endarterectomy. The surgeons then decided for femoral anastomosis of the graft, performed successfully using the conventional technique. The prosthesis was punctured and a stiff hydrophilic guide wire introduced, and through it a 5F sheath. The guide wire was extended distally, passing through flap and stenotic areas with ease. Angioplasty followed, successfully implanting a 5 x 60 self-expandable stent. Control arteriography detected patent arteries with good flow and runoff. However, the patient still had extensive occlusions in infrapopliteal arteries, which went untreated. At the end of the procedure, femoral and popliteal pulses were noted, as there was no distal pulse. There were no complications caused by the surgical incisions (Figure 7A).

The patient had good outcomes, with stable femoral and popliteal pulses, and left ABI: AT = 0.55; PT = 0.41; Fib = 0.5, healing of ischemic wound (Figure 7B), and good healing of incisions (Figure 7C).

Discussion

Determining the best revascularization method for treating symptomatic PAOD is based on balancing the risk of specific interventions and the level and durability of expected improvement from the intervention.⁵ Adequate flow and runoff are needed to keep revascularized segments working.⁵ In general, the results of revascularization depend on the magnitude of the underlying arterial disease, the level of systemic disease (comorbidities that might influence patient survival and procedure patency), and type of surgery performed.⁵

Due to the severity of PAOD patients, who have systemic and multisegmental disease accompanied by countless comorbidities,¹² researchers are constantly looking for less invasive surgical treatment with the same long term outcomes as conventional alternatives. From that point of view, endovascular treatment, with the advent of balloon angioplasty, endoprosthesis and stenting, thrombolyses and atherectomies, among others, has led to considerable gains for cases such as this.⁵ According to the TASC II classification,⁵ TASC A and B lesions have the best outcomes from endovascular treatment, making it the treatment of choice for those cases. TASC C and D lesions, on the other hand, may be treated using the endovascular technique, but the procedure can only be justified for patients who would be clinically unable to undergo conventional surgery.

CFA endarterectomy, associated or not with endovascular procedures, has been indicated for treating multisegmental lesions, since isolated endovascular treatment would not be recommended, considering the CFA is located in a joint.¹³ Results from a recent study¹³ suggest endarterectomy should be the treatment of choice for isolated CFA occlusive disease, since there is no statistical difference between the isolated endarterectomy group and the group receiving endarterectomy concurrently with endovascular techniques.

The most frequent forms of surgical access for aortoiliac reconstruction are the transperitoneal and the retroperitoneal.¹⁴ The literature does not provide uniform comparative results for both approaches; however, overall, surgical time, replacement of liquids and length of hospital stay are lower for the retroperitoneal route.^14,15 Either way, both are considered invasive procedures requiring intensive postoperative care and considerable morbidity, as well as causing high levels of inflammatory response and oxidative stress.^16,17

VLS has been used routinely to treat aortoiliac occlusions in some European and Canadian centers.^7,8,10,18 For aortic reconstructions, the advantages of the technique are: it is less invasive, there is less surgical trauma and less postoperative pain, the abdominal incision is smaller, oral feeding can restart earlier, and postoperative stays are shorter.^10,19,20 Laparoscopic aortic surgery have had similar or better outcomes than conventional open surgery when comparing hemodynamic, metabolic and inflammatory parameters,¹⁶ as well as for long term follow-up.^7,8 The surgical procedure can be done fully laparoscopically^7,8,19 or by minilaparotomy,^19,21 with similar long term outcomes; the only difference between the two is in how anastomoses are performed.¹⁹

Hybrid procedures involving endovascular and conventional open techniques, performed simulatenously or separately, are increasingly used for complex vascular surgery.⁶ Videolaparoscopic surgery is a viable, safe, effective minimally invasive technique for treating extensive aortoiliac occlusive disease.^7,8,10,19 The technique, no more than conventional surgery done laparoscopically, has good long term outcomes associated with the elegance of the technique.^7,8,19 However, further studies are needed to assess the long term outcomes of joint therapies.

Ackowledgments

The authors would like to thank Johnson & Johnson, Ethicon Endo-Surgery Division, German and Brazilian Karl Storz, and H. Strattner for their support and for providing the equipment and material for this surgery.

References

• 1. Yoshida R, Yoshida WB, Maffei FHA, et al. Comparative study of evolution and survival of patients with intermittent claudication, with or without limitation for exercises, followed in a specific outpatient setting. J Vasc Bras. 2008;7:112-22.
• 2. Lastória S, Maffei FHA. Aterosclerose obliterante periférica: epidemiologia, fisiopatologia, quadro clínico e diagnóstico. In: Maffei FHA, Lastória S, Yoshida WB, Rollo HA, eds. Doenças vasculares periféricas. 4Ş ed. Rio de Janeiro: Guanabara-Koogan; 2008. v. 2, p. 1141-55.
• 3. Yoshida R, Yoshida WB, Sobreira M, Silva C. Infrapopliteal angioplasty: the more arteries are treated the better? J Vasc Bras. 2008;7:176-82.
• 4. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc. 1985;33:13-8.
• 5. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1-75.
• 6. Liapis CD, Tzortzis EA. Advances in the management of iliac artery occlusive disease: a short review. Vasc Endovascular Surg. 2004;38:541-5.
• 7. Kolvenbach R. Total laparoscopic aortic aneurysm surgery. Acta Chir Belg. 2006;106:36-9.
• 8. Lin JC, Kolvenbach R, Schwierz E, Wassiljew S. Total laparoscopic aortofemoral bypass as a routine procedure for the treatment of aortoiliac occlusive disease. Vascular. 2005;13:80-3.
• 9. Kolvenbach R, Da Silva L, Deling O, Schwierz E. Video-assisted aortic surgery. J Am Coll Surg. 2000;190:451-7.
• 10. Cau J, Ricco JB, Corpataux JM. Laparoscopic aortic surgery: techniques and results. J Vasc Surg. 2008;48:37S-44S; discussion 45S.
• 11. Dion YM, Thaveau F, Fearn SJ. Current modifications to totally laparoscopic "apron technique". J Vasc Surg. 2003;38:403-6.
• 12. Yoshida WB, Bosco FA, Medeiros FATM, Rollo HA, Dalben IN. Lípides séricos como fator de risco para pacientes com doença arterial periférica. J Vasc Bras. 2003;2:5-12.
• 13. Kang JL, Patel VI, Conrad MF, Lamuraglia GM, Chung TK, Cambria RP. Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg. 2008;48:872-7.
• 14. Junior O, van Bellen B. Transperitoneal and retroperitoneal approach to the abdominal aorta: early results. J Vasc Bras. 2004;3:331-8.
• 15. Johnson JN, McLoughlin GA, Wake PN, Helsby CR. Comparison of extraperitoneal and transperitoneal methods of aorto-iliac reconstruction. Twenty years experience. J Cardiovasc Surg (Torino). 1986;27:561-4.
• 16. Kolvenbach R, Deling O, Schwierz E, Landers B. Reducing the operative trauma in aortoiliac reconstructions: a prospective study to evaluate the role of video-assisted vascular surgery. Eur J Vasc Endovasc Surg. 1998;15:483-8.
• 17. Yoshida WB. Radicais livres na síndrome de isquemia e reperfusão. Cir Vasc Angiol. 1996;12:82-95.
• 18. Dion YM, Griselli F, Douville Y, Langis P. Early and mid-term results of totally laparoscopic surgery for aortoiliac disease: lessons learned. Surg Laparosc Endosc Percutan Tech. 2004;14:328-34.
• 19. Kolvenbach R, Yoshida R. Cirurgia aórtica videolaparoscópica. In: Maffei FHA, Yoshida WB, Lastoria S, Rollo H, Gianini M, Moura R, eds. Doenças vasculares periféricas. 4Ş ed. Rio de Janeiro: Guanabra-Koogan; 2008. v. 1, p. 859-86.
• 20. Yoshida R, Yoshida W, Kolvenbach R, Rollo H, Lorena S. Laparoscopic aortic surgery learning curve: experimental study in pigs. J Vasc Bras. 2008;7:231-8.
• 21. Fearn SJ, Thaveau F, Kolvenbach R, Dion YM. Minilaparotomy for aortoiliac aneurysmal disease: experience and review of the literature. Surg Laparosc Endosc Percutan Tech. 2005;15:220-5.

Publication Dates

• Publication in this collection
  26 Mar 2010
• Date of issue
  Dec 2009

History

• Accepted
  28 July 2009
• Received
  04 May 2009