Open surgical techniques for the management of complex juxtarenal aortic occlusions.

The surgical management of aortic occlusive disease can be significantly complicated by the extension of disease, or occlusion, to the level of the renal arteries. The juxtarenal occlusion necessitates careful consideration of operative exposure, technique, and the method and extent of reconstruction. While endovascular techniques have revolutionized the management of occlusive disease of the distal aorta and iliacs, both the presence of bulky, eccentric or exophytic calcification and thrombus at the level of the renal arteries increase the technical difficulty and risk of perforation, stent compromise, or embolization. Disease extending to the visceral segment often necessitates the application of lessons learned in an earlier era and techniques less familiar to the modern surgeon. We will focus on direct, rather than extraanatomic surgical reconstruction.

Targeted Regional Optimization in Action: Dose-dependent End-organ Ischemic Injury with Partial Aortic Occlusion in the Setting of Ongoing Liver Hemorrhage.

INTRODUCTION: Targeted regional optimization (TRO) describes partial resuscitative endovascular balloon occlusion of the aorta strategy that allows for controlled distal perfusion to balance hemostasis and tissue perfusion. This study characterized hemodynamics at specific targeted distal flow rates in a swine model of uncontrolled hemorrhage to determine if precise TRO by volume was possible. METHODS: Anesthetized swine were subjected to liver laceration and randomized into TRO at distal flows of 300 mL/min (n = 8), 500 mL/min (n = 8), or 700 mL/min (n = 8). After 90 min, the animals received damage control packing and were monitored for 6 h. Hemodynamic parameters were measured continuously, and hematology and serologic labs obtained at predetermined intervals. RESULTS: During TRO, the average percent deviation from the targeted flow was lower than 15.9% for all cohorts. Average renal flow rates were significantly different across all cohorts during TRO phase (P < 0.0001; TRO300 = 63.1 ±â€Š1.2; TRO500 = 133.70 ±â€Š1.93; TRO700 = 109.3 ±â€Š2.0), with the TRO700 cohort having less renal flow than TRO500. The TRO500 and TRO700 average renal flow rates inverted during the intensive care unit phase (P < 0.0001; TRO300 = 86.20 ±â€Š0.40; TRO500 = 148.50 ±â€Š1.45; TRO700 = 181.1 ±â€Š0.70). There was higher blood urea nitrogen, creatinine, and potassium in the TRO300 cohort at the end of the experiment, but no difference in lactate or pH between cohorts. CONCLUSION: This study demonstrated technical feasibility of TRO as a strategy to improve outcomes after prolonged periods of aortic occlusion and resuscitation in the setting of ongoing solid organ hemorrhage. A dose-dependent ischemic end-organ injury occurs beginning with partial aortic occlusion that progresses through the critical care phase, with exaggerated effect on renal function.