A technique for adequate coverage of the proximal suture line during abdominal aortic aneurysm repair☆☆☆

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Abstract 

The proximal suture line is a vulnerable area after abdominal aortic aneurysm repairs. This area has been implicated in various postoperative complications, such as pseudoaneurysm formation, graft-enteric fistula, and suture line disruption. We present a technique that provides safe and adequate coverage of this suture line by using the aneurysm sac. This technique is derived from the z-plasty technique used for scar revision. The technique is illustrated with detailed line drawings. None of the patients in whom we used this technique have had any complications related to the proximal suture line. (J Vasc Surg 2001;34:367-8.)

The technique of endoaneurysmorrhaphy involves the placement of either a straight or bifurcated graft “inside” the aneurysm and closure of the aneurysm sac over the repair. The retroperitoneum is then closed over the repair to protect the graft. The aneurysm sac, for the most part, is saccular in architecture and, thus, when opened and reclosed, will often leave the proximal suture line exposed. We performed an extensive literature search, and we failed to note any description of a technique for the protection of the proximal suture line. We present a simple technique for adequate coverage of the proximal suture line in such repairs. The proximal suture line is an area that can contribute to postoperative complications by means of disruption and fistula formation. One way of reducing these complications is by adequately covering this suture line with the aneurysm sac, thus protecting it from the abdominal viscera. We are unaware of any published descriptions of a technique for adequate coverage of the proximal suture line with a z-plasty approach incorporating the aneurysm tissue.

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Technique 

The technique that we present is one that we frequently use at our institution with excellent results. Our technique of protecting the proximal suture line involves creating a mobile flap from the aneurysm sac and rotating it cephalad. This flap can then be used to cover the suture line adequately and safely. This technique is illustrated in line drawings (Figs 1-3).

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• Fig. 1. 

  Position of proximal anastomosis after abdominal aneurysm repair with aortobifemoral graft.

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• Fig. 2. 

  Mobile flap has been created in aneurysm sac on right side with electocautery. This is then rotated cephalad to cover proximal anastomosis (inset ). The apex of the aneurysm sac on left side is then approximated to the corner created on right side, after mobilizing the flap superiorly (solid arrow ).

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• Fig. 3. 

  Flap is closed over proximal repair, and aneurysm sac is closed over graft. This illustration shows final appearance of such closure over graft.

The appearance of an aortobifemoral graft after repair of an abdominal aortic aneurysm is shown in Fig 1. A triangular-shaped flap has been created approximately 3 cm caudad from the proximal aneurysm sac in an oblique fashion on the right side (Fig 2). In most cases, we create this flap on the right side only. When this is inadequate, we create a similar flap on the left side, with particular attention to the course of the inferior mesenteric vessels lateral to the aneurysm sac. The flap is then rotated cephalad (Fig 2) and closed on top of the proximal anastomosis with absorbable suture. The superior edge of the aneurysm sac on the left side is then sutured to the corner created on the right side after mobilizing the flap superiorly (Fig 2). The rest of the aneurysm sac can then be brought together with ease to provide good native tissue coverage over the repair. The appearance of the graft coverage at the end of the procedure is illustrated in Fig 3. Finally, the retroperitoneal tissue is closed over this layer. This simple technique allows for a quick and efficient closure of the aneurysm sac over the repair.

We believe that this technique provides secure native tissue coverage over the proximal anastomotic line. This technique works well in most cases. However, in instances in which the aneurysm sac is rigid, unmalleable, and inadequate, we have used other techniques for closure over the repair. For example, bovine pericardial tissue can be used for coverage over the repair. The pericardium is incorporated on top of the repair to ensure that it is protected from the intra-abdominal contents. All patients treated at our institution for complications related to the proximal suture line have only had a simple aneurysm sac closure with the retroperitoneal tissue closure; however, we have not noted any complications related to the proximal suture line in patients in whom we have used the z-plasty technique. We think that the z-plasty technique allows for the use of the aneurysm sac as an additional barrier between the aorto-graft suture line and bowel. This technique adds very little time to the aneurysmorrhaphy, but provides enormous benefit by protecting the proximal suture line from postoperative complications. We think that this technique needs to be an integral part of abdominal aortic aneurysmorrhaphy.