Journal of Vascular Surgery
Volume 49, Issue 5 , Pages 1135-1139, May 2009

Laparoscopic abdominal aortic aneurysm repair in octogenarians

  • Isabelle Di Centa, MD

      Affiliations

    • Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, the Faculté de Médecine Paris-Ile de France-Ouest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, Paris
    • ,
  • Marc Coggia, MD

      Affiliations

    • Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, the Faculté de Médecine Paris-Ile de France-Ouest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, Paris
    • Corresponding Author InformationReprint requests: Marc Coggia, MD, Department of Vascular Surgery, Ambroise Paré University Hospital, 9 Ave Charles de Gaulle, 92104 Boulogne Cedex, France
    • ,
  • Frédéric Cochennec, MD

      Affiliations

    • Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, the Faculté de Médecine Paris-Ile de France-Ouest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, Paris
    • ,
  • Pascal Alfonsi, MD

      Affiliations

    • Department of Anaesthesiology, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, the Faculté de Médecine Paris-Ile de France-Ouest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, Paris
    • ,
  • Isabelle Javerliat, MD

      Affiliations

    • Department of Vascular Surgery, Trousseau University Hospital, Tours, France
    • ,
  • Olivier Goëau-Brissonnière, MD, PhD

      Affiliations

    • Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, the Faculté de Médecine Paris-Ile de France-Ouest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, Paris

Received 18 July 2008; accepted 3 December 2008. published online 23 March 2009.

Article Outline

Objective

Open abdominal aortic aneurysm (AAA) repair in octogenarians is considered to have higher risks of mortality and systemic complications compared with younger patients. The purpose of our work is to present our experience with total laparoscopic repair for AAA in this subset of patients.

Methods

From February 2002 to February 2008, 29 octogenarian patients underwent total laparoscopic AAA repair. Median age was 82 years (range, 80-85 years). Median aneurysm size was 52 mm (range, 40-85 mm). Disease was classified as American Society of Anesthesiologist (ASA) class II in 12 patients and class III in 17 patients. Ten patients presented with past medical history of myocardial infarct (34.5%).

Results

We implanted 12 tube grafts and 17 bifurcated grafts. Twenty-six procedures were totally laparoscopic (89.6 %). Median operative time and aortic clamping time were 280 min (range, 160-480 min) and 75 min (range, 22-125 min), respectively. Two patients with juxtarenal AAA underwent suprarenal clamping. Median blood loss was 1100 cc (range, 600-3000 cc). Four patients (13.8%) needed adjunctive vascular procedures because of intraoperative complications. Two patients died in the postoperative course (6.9%). Four patients developed severe systemic non-lethal complications (14.8%, pneumopathies). Mild or moderate systemic complications were observed in 14 patients (51.8%) including transient renal insufficiencies without dialysis (13) and cardiac arrhythmia (1). Postoperative creatinine levels returned to baseline before discharge in all patients. Liquid diet was reintroduced after a median duration of 2 days (range, 1-10 days) and most patients were ambulatory by day four (range, 3-30 days). Median stays in intensive care unit and hospital were 72 hours (range, 12-1368 hours) and 11 days (range, 6-74 days), respectively. Sixteen patients (59.2%) were discharged directly to home with complete recovery. After a median follow-up of 24 months (range, 2-48 months), 23 patients are still alive and regained their baseline status. Four patients died after hospital discharge of non-vascular etiologies.

Conclusion

Total laparoscopic AAA repair is a worthwhile but challenging procedure in octogenarians. Laparoscopy is complementary to open surgery and EVAR in this subset. These results encourage us to offer laparoscopic AAA repair in good surgical risk octogenarians.

 

Open abdominal aortic aneurysm (AAA) repair in octogenarians is considered at higher risk of mortality and systemic complications compared with younger patients.1, 2, 3, 4, 5, 6 Limited functional reserve of octogenarians has stimulated the use of minimally invasive techniques, mainly endovascular aneurysm repair (EVAR).7, 8, 9, 10, 11, 12, 13, 14 However, direct aortic repair (DAR) with aneurysmorraphy and bypass graft interposition remains a reliable and suitable alternative in selected octogenarians.2, 15, 16, 17, 18, 19 The purpose of laparoscopy focuses on reduction of surgical stress when DAR is scheduled. In general surgery, laparoscopy in elderly patients positively affects outcomes and postoperative quality of life.20, 21, 22, 23 We present early and mid term results of laparoscopic AAA repair in octogenarians and discuss potential drawbacks and benefits of laparoscopy in this subset of patients.

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Material and methods 

Between February 2002 and February 2008, we performed 160 total laparoscopic AAA repairs. We do not include in this series patients who were operated in other centers. There were 29 patients older than 80 years, which represents 18.1% of the entire series. Demographic and clinical data were collected prospectively and reviewed retrospectively. This study was approved by our institutional review board. During the same time period, AAA repair was performed by either open or EVAR in 12 and three octogenarians, respectively.

Helical CT scans were obtained in all patients. Indications for AAA repair were (1) AAA with maximum diameter > 50 mm; (2) AAA > 40 mm with blebs or saccular morphology; and (3) AAA with severe symptomatic aorto-iliac occlusive disease (AIOD). Patients were classified in accordance with American Society of Anesthesiologist (ASA) classification. All patients underwent stress echocardiography, hepatic, and renal function tests. Respiratory function was assessed using peak flow measurements and spirometry. Renal insufficiency was defined when creatinine level was > 1.5 mg/dl. Gradation of its severity was in accordance with the Society of Vascular Surgery (SVS) criteria.24 Coronarography was performed for patients with abnormal stress echocardiography. Contraindications for laparoscopic aortic repair were (1) urgent cases; (2) inflammatory aneurysms; (3) need for concomitant complex renal/visceral reconstructions; and (4) patients considered unfit for aortic surgery.

We used the technique previously described for AAA.25 Patients were warmed using a full-body forced-air cover (Bair Hugger; Augustine Medical, Eden Prairie, Minn) positioned under the body. In summary, laparoscopic approach of the abdominal aorta was either transperitoneal retrorenal (TPRR),26 transperitoneal retrocolic (TPRC),27 or retroperitoneal.28 For all transperitoneal approaches, patient was placed in right lateral decubitus position. After creating the pneumoperitoneum and ports placement, peritoneum was incised in the left paracolic gutter. Dissection, either retrorenal or retrocolic, led to complete or partial right medial visceral rotation.

Laparoscopic AAA aneurysmorraphy used similar principles than conventionnal repair.25 In summary, proximal laparoscopic clamp (Storz-Endoscopie France, Guyancourt, France) was placed through the flank or subxyphoid port. Right and left iliac arteries were occluded with laparoscopic clamps introduced percutaneously in the left iliac fossa. After aneurysmorraphy, the target zones of anastomoses were prepared. For tube grafts, anastomoses were totally laparoscopic. For bifurcated grafts, distal anastomoses were totally laparoscopic when target zones of implantation were the common iliac arteries or the left external iliac artery. In other cases, we used elective groin or iliac incisions. Bypass graft interposition used Dacron grafts (Gelweave or Gelsoft-Plus, Vascutek-Terumo, Inchinnan, Scotland). Conversion to open repair was defined by the need of a laparotomy or a flank incision to complete the procedure.

All patients were placed in intensive care unit (ICU) immediately after the procedure and taken back to their room as soon as they normalized hemodynamic, respiratory, and biologic parameters. Mortality and morbidity were reported according to SVS criteria.24 Patients were reviewed postoperatively at one month with color-flow duplex scan and CT-angiogram and yearly thereafter with a duplex study.

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Results 

There were 27 men and two women with a median age of 82 years (range, 80-85 years). Two patients had concomitant severe AIOD with disabling claudication (1) and toe gangrene (1).

Disease was classified as ASA class II in 12 patients and class III in 17 patients. One patient presented with severe chronic obstructive pulmonary disease with forced expiratory volume (FEV1) of 0.8 liter. Ten patients presented with past medical history of myocardial infarct (34.5%). Four of these patients had residual myocardial ischemia on stress echocardiography but coronarographies did not show significant lesions. Five patients had grade 1 preoperative renal insufficiency. Other preoperative data are summarized in Table I. Median aneurysm size was 52 mm (range, 40-85 mm).

Table 1. Demographic data and risk factors in 29 elderly patients
Preoperative characteristicsN(%)
Median age(years)82(range,80-85)
Median body mass index(kg/m2)24.1(range,19.3-37)
ASA class
∘ASA II12(41.4)
∘ASA III17(58.6)
Hypertension20(68.9)
Tobacco use19(65.5)
Diabetes1(3.4)
Dyslipidemia13(44.8)
Median AAA diameter(mm)52(range,40-85)
Associated AIOD2(6.9)
Previous abdominal surgery8(27.6)

AAA, Abdominal aortic aneurysm; AIOD, aorto-iliac occlusive disease; ASA, American Society of Anesthesiologists.

We implanted 12 tube grafts and 17 bifurcated grafts, either bi-iliac, bi-iliofemoral or bi-femoral in 10, 4, and 3 cases, respectively. Two patients underwent combined infrainguinal arterial reconstructions.

Laparoscopic approach of the aorta was a TPRR and a TPRC in 20 and eight patients, respectively. Retroperitoneoscopic approach was used in one patient with hostile abdomen. Twenty-six procedures were totally laparoscopic (89.6 %). Patient 12 underwent conversion to open repair because of sudden bleeding during iliac clamping. We thought it was an iliac vein injury. At conversion, no major vessels injuries were found. Two patients had conversion for limited exposure of their AAA. Patient 19 was operated through retroperitoneoscopic approach and patient 29 had a juxtarenal AAA. The latter was operated through a TPRC because of a retro-aortic left renal vein. This approach precluded a good exposure of the juxtarenal aorta for a safe proximal clamping.

Median operative time was 280 minutes (range, 160-480 minutes). We defined aortic clamping time as the time elapsed between aortic clamping and unclamping of the first iliac or femoral artery. Total median aortic clamping time was 75 minutes (range, 22-125 minutes). Two patients with juxtarenal AAA underwent suprarenal clamping of nine and 25 minutes, respectively. Median blood loss was 1100 mL (range, 600-3000 mL). The median body temperature at the end of the operation was 36.5°C (range, 35.1-37.5 °C). Four patients (13.8%) needed additional vascular procedures because of intraoperative complications. Two common iliac artery dissections were observed in two patients. In one case, it was probably due to laparoscopic iliac clamping and was treated by endoluminal stent placement. In the second case, an aorto-biiliac bifurcated graft was implanted. Left common iliac dissection was observed with concomitant prosthetic limb occlusion. Thrombectomy was performed with combined laparoscopic bypass grafting to the proximal left external iliac artery. A third patient had a dissection of the right external iliac artery distal to an open graft limb implantation. The last patient had a tight stenosis of the left common iliac ostium after laparoscopic tube graft implantation. It was probably attributable to a technical error at the anastomotic site. Endovascular procedure failed and a crossover femoro-femoral bypass was performed with a good result.

Thirty-day postoperative mortality was 6.9% (2 of 29 patients) (Table II). The first patient had been operated for a 6 cm infrarenal AAA. He had a past history of coronaropathy with severe lesions of the right coronary artery. He was scheduled for laparoscopic repair under medical treatment with blockers. During the procedure, he presented with a hepatic shock and coagulopathy, which was related to a right ventricular myocardial infarction. He was reoperated three hours later for a postoperative hemoperitoneum without any cause of bleeding and died in the course of the reintervention. The second patient died of early postoperative colonic ischemia. He was classified ASA2 and underwent an aorto-bi-iliac bypass. Procedure was uneventful except a dissection of the distal external iliac artery cited above. Blood loss was 850 mL and aortic clamping time was 80 minutes. Colonic ischemia was probably attributable to an intraoperative hypovolemia.

Table II. Postoperative data
N(%)
Mortality2(6.9)
Systemic complications18(66.6)
• Severe4(14.8)
• Mild or moderate14(51.8)
Local/vascular complications2(7.4)
Local/non-vascular complications2(7.4)
ICU stay(hours)72(range,12-1368)
Hospitalization stay(days)11(range,6-74)

ICU, Intensive care unit.

Four patients developed severe systemic non-lethal complications (14.8%), which were pneumopathies needing prolonged physiotherapy and antibiotics (Table II). One of these patients needed a tracheotomy weaned on postoperative day 40 and presented with a transient renal insufficiency without dialysis. Mild or moderate systemic complications were observed in 14 patients (51.8%) including transient renal insufficiencies without dialysis (13) and cardiac arrhythmia (1). Postoperative creatinine levels returned to baseline before discharge in all patients. Two patients presented with local vascular complications (7.4%). First patient had an asymptomatic dissection of the left renal artery discovered on the postoperative CT scan. She had a juxtarenal aneurysm and was considered unfit for suprarenal clamping. Laparoscopic AAA repair was performed through a TPRR with proximal clamp introduced in the subxyphoid port. We think the dissection was attributable to the traction on the left renal pedicle during clamp positioning. The second patient was described above. He had an attempt of endovascular procedure for tight stenosis of the left common iliac artery after tube graft implantation. He was reoperated on the same day for retroperitoneal active bleeding. No anomalies were observed on the tube graft. Bleeding was attributable to an accidental perforation of the distal external iliac artery during the endovascular procedure. Two patients presented local non-vascular complications (7.4%). One patient developed rectorragia due to pre-existing rectal cancer. The other patient was reoperated for an intestinal obstruction at day 13, which was attributable to incarceration of a bowel loop into a port's hole.

Postoperative course was uneventful in other patients. Mechanical ventilation and nasogastric tube were removed at the end of the procedure. Liquid diet was reintroduced after a median duration of two days (range, 1-10 days) and most patients were ambulatory by day four (range, 3-30 days) with minimal complaint of pain.

Median stays in intensive care unit and hospital were 72 hours (range, 12-1368 hours) and 11 days (range, 6-74 days), respectively (Table II). Sixteen patients (59.2%) were discharged directly at home with complete recovery. Others went less than four weeks in institutions for rehabilitation. Patients with severe complications recovered from procedures after a median hospital stay of 34 days (range, 25-74 days). All were discharged to institutions for rehabilitation. Patients with mild to moderate complications recovered after a median hospital stay of 12 days (range, 7-37 days). Out of these 14 patients, five were discharged to institutions for rehabilitation (35.7%). Patients without any complications were discharged after a median hospital stay of 7.5 days (6-12 days). Two of these patients (22.2%) were discharged to institutions before returning home.

Median follow-up is 24 months (range, 2-48 months). Twenty-three patients are still alive and have regained their baseline status. Four patients died after hospital discharge. Causes of death were acute heart failure at 13 months, septicemia after a total hip replacement at 15 months, severe bronchial infection at 29 months, and pulmonary carcinoma at 3 years. No hemodynamic or morphologic anomalies were observed on follow-up duplex and CT-angiogram studies.

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Discussion 

Incidence of AAA reaches a maximum in the eighties.29 Therefore, more elderly patients with AAAs are being considered for surgical treatment. EVAR reduces operative risk and is an alternative to open repair in this subset.7, 8, 9, 10, 11, 12, 13, 14 However, continued surveillance and risk for further procedures may be associated with poor compliance in the elderly population.

Laparoscopy is a new alternative for AAA repair in octogenarians. It focuses on performing a reliable aneurysm repair while avoiding the trauma of open surgical approaches.

Feasibility of laparoscopic aneurysmorraphy and graft interposition has been already reported25, 30 and seems valid in octogenarians. However, our data demonstrate a high technical challenge in this subset. This could be explained by extensive arterial calcifications and aortic wall weakness after the eighties. The lack of tactile feedback increases the risk of plaque rupture and dissection, especially during clamping and anastomoses. A preoperative CT scan is mandatory to precise the extent of aortic and iliac calcifications. Clamping with intraluminal occlusive balloons is an interesting trick commonly used in open surgery. We used it for severely calcified aorta during laparoscopic AIOD repairs but not yet for AAA repair. Balloon catheters could hamper the operative field near the anastomotic sites. Percutaneous balloon occlusion of iliac arteries via the groins is probably more appropriate.

Operative risks in patients aged over the eighties are not attributable to age per se but rather to unavoidable risk factors including impaired renal function, chronic respiratory failure, and cardiac disease.5, 6 A recent review of elective AAA repair in octogenarians established a pooled mortality of 7.5% (0%-33%).2 In our series, mortality (6.9%) compares with figures of open surgery. The first death was caused by MI and related to a mistake in patient selection at the beginning of our experience.25 The second death was attributable to colonic ischemia. Whether or not reimplantation of the inferior mesenteric artery (IMA) could have prevented colonic ischemia in this patient remains unknown. Senekowitsch and colleagues suggest that IMA reimplantation must be considered in octogenarians because of higher risk of colonic ischemia in this subset.31 In our entire series of total laparoscopic AAA repair, we did IMA reimplantation in less than 2% of cases but did not experience an increased risk of colonic ischemia (unpublished data). Becquemin and associates reported that operative time > 4 hours was also a significant risk factor of colonic ischemia after open AAA repair.32 They stated that prolonged operative time is often associated with intraoperative difficulties and hemodynamic disturbances, which could explain the risk of colonic ischemia. During laparoscopic AAA repair, prolonged operative time is not systematically associated with intraoperative difficulties.33, 34 It is attributable to technical features of laparoscopy, especially the lack of normal human range of motion.

Other severe systemic complications in our series were pneumopathies. We and others observed that laparoscopy decreases incidence of pulmonary complications after aortic surgery.30, 34 This benefit of laparoscopy does not seem to be valid for the subset of octogenarians. This underlines that advanced age is often associated with chronic respiratory failure.35 The incidence of cardiac complications was low compared with open series despite longer aortic clamping times.1, 2, 3, 5 This is correlated with the low hemodynamic consequences of infrarenal clamping36 and related to our aggressive screening and management of coronary disease before laparoscopic aortic procedures.

We observed a high rate of postoperative renal insufficiencies (44.8%; Table II). Advanced age is a well known risk factor of renal impairment.37 The majority were in fact transient peak creatinine levels with an uneventful course and returned to baseline before discharge. We did not investigate factors that could have played a role on renal function such as aortic clamping time and effect of pneumoperitoneum. Prognosis of these transient renal insufficencies remains controversial. Welten and coworkers, in a series of 1324 open AAA repairs, reported that transient postoperative renal impairments were associated with worsening of short and long term outcomes.38 We lack data to draw firm conclusions on this topic but we must remember that mean life expectancy of octogenarians is probably too short to observe such late events.

Other postoperative data suggest that technical challenge of laparoscopic AAA repair in octogenarians is not associated with worsening of the postoperative course. This is a well-known feature of laparoscopy.20, 21, 22, 23 In a study of 233 patients, outcomes of both laparoscopic and open cholecystectomies were compared with respect to age and ASA classification.23 Advanced age was correlated with an increase in postoperative morbidity. However, patients who underwent laparoscopy had significantly fewer complications than those who had open cholecystectomy.

As observed in our series, length of hospital stay remains long in elderly patients because social issues are often responsible for prolonged hospital stay. Despite the lack of laparotomy, we observed that 40% of patients went to an institution for a few weeks prior to returning home. This underlines that aortic surgery induces a substantial trauma in octogenarians. However, as shown by others,19 the majority of patients older than 80 years benefit from elective AAA repair, with full recovery of their preoperative status.

In conclusion, results obtained in our series will encourage us to offer total laparoscopic AAA repair in good surgical risk octogenarians. Laparoscopy is complementary to open surgery and EVAR in this subset and could be driven by patients demanding a reliable procedure to treat their AAA. Despite these encouraging results, growing experience and further studies are needed to identify octogenarians where either a laparoscopic, open, or endovascular procedure will be the most appropriate.

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Author affiliations 


Conception and design: MC

Analysis and interpretation: MC, PA, IDC

Data collection: IDC, IJ, FC

Writing the article: MC, IDC

Critical revision of the article: MC, OGB

Final approval of the article: MC

Statistical analysis: N/A

Obtained funding: N/A

Overall responsibility: MC

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References 

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 Competition of interest: none.

PII: S0741-5214(08)02126-5

doi:10.1016/j.jvs.2008.12.002

Journal of Vascular Surgery
Volume 49, Issue 5 , Pages 1135-1139, May 2009

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