[Thoracoscopic bypass from the descending thoracic aorta to the femoral artery. Experimental study and clinical application]. / Pontage thoracoscopique entre l'aorte thoracique descendante et l'artère fémorale. Etude expérimentale et application clinique.

OBJECTIVE: Descending thoracic aorta to femoral artery bypass (DTAFB) has demonstrated usefulness in the treatment of aorto-iliac occlusive disease but related morbidity and mortality are not negligible. We wanted to determine the feasibility of thoracoscopic DTAFB and to report our clinical experience. MATERIAL AND METHODS: An experimental study was performed on 8 pigs in helicoidal position under general anesthesia with right selective ventilation ). Three trocars were inserted and the descending aorta was dissected ). After tunnelisation of a 6 mm graft, a lateral aortic anastomosis was thoracoscopically performed ) then femoral anastomoses were made. At the end of the procedure, an angiogram and then an autopsy were performed ). Subsequently, three patients were operated, two for thrombosis of a previous aortobifémoral bypass and one for infrarenal aortic hypoplasia. Dissection and graft tunnelisation were performed thoracoscopically ). Then, the aortic anastomosis ) was constructed through a left lateral minithoracotomy (10 cm). RESULTS: One pig died during surgery of acute lung oedema due to the difficulties of selective ventilation. Excluding this case, the average times of surgery and of dissection were respectively 246 (205-325) and 68 minutes (50-90). The average aortic clamping and anastomosing times were 135 (105-220) and 120 minutes (80-210) ). Three aortic tears were noted; one was repaired. Angiogram was normal 5 times; one pig had a minor stenosis and a leak, and another one had a leak. All the anastomoses were patent without stenosis at autopsy; no organ lesion was found. In humans, the procedure was performed with simple postoperative course in 2 patients and a conversion (20 cm long thoracotomy) was necessary for the third due to poorly supported selective ventilation. CONCLUSION: Totally thoracoscopic DTAFB can be performed in pigs. In clinical practice, we recommend the use of a mini thoracotomy. This way, the aortic anastomosis can be performed with aortic clamping time under 30 minutes, reducing the risk of spinal cord ischemia. These results allow to propose mini invasive thoracoscopically assisted DTAFB for the patients for whom laparoscopic access of the abdominal aorta appears to be difficult (calcified aorta, hostile belly.).

[Laparoscopic transperitoneal replacement of the abdominal aorta with left renal artery reimplantation: experimental study on pigs]. / Remplacement laparoscopique transpéritonéal de l'aorte abdominale avec réimplantation de l'artère rénale gauche.

OBJECTIVE: To study the feasibility and the tolerance of a combined laparoscopic transperitoneal aortic and renal restoration performed on animals. METHODS: Six pigs (mean weight: 79.5 kg, range 73-86) underwent laparoscopic replacement of the abdominal aorta using a 6-mm Dacron(R) graft, with direct reimplantation of the left renal artery. The study protocol was approved by the Advisory committee of Animal Ethics. The animal was placed supine on the operative table with a pillow under the lumbar region in order to raise the aortic area. A first midline, 10-mm diameter trocar was placed under direct vision, 5 cm above the pubis and allowed the insufflation of a 12-mm Hg pneumoperitoneum. One 30 degrees optic was used during the intervention. The pig was then tilted to a 30 degrees Trendelenbourg's position and two other 10-mm trocars were introduced 5 cm medially to the right and left antero-superior iliac spines ). Four other 10-mm incisions were necessary for introduction of an intestinal retractor, a suction-irrigation device and two laparoscopic aortic clamps. RESULTS: The procedure was performed in all animals in a mean operative time of 320 min (292-366), including ): - a time for aortic and renal artery dissection of 104 min (90-120), - a supra-renal aortic clamping time of 221 min (180-276), - a time for confection of proximal and distal aorto-prosthetic anastomosis of respectively 59 min (40-75) and 64 min (50-80), - a time for the left renal artery reimplantation of 72 min (40-140). Average blood loss was 525 ml (250-1050), and the mean pre and postoperative hemoglobin and pH values were 9.9 g/dl (8.9-10.7) versus 9.4 g/dl (8.5-11.3) and 7.36 (7.31-7.38) versus 7.30 (7.21-7.43) respectively. An angiogram ) performed before the sacrifice of animals showed a wide patent anastomosis in 18 (56%) cases, a<50% stenosis in 4 cases (22%), a > 50% stenosis in 1 case (5%) and a thrombosis of the first three renal artery restorations (17%) probably due to insufficient intraoperative heparinization. CONCLUSION: This experimental study shows the feasibility of laparoscopic transperitoneal abdominal aortic restoration with re-implantation of the left renal artery (fig. et ). The techniques of arterial sutures must be improved in order to decrease aortic and renal clamping times.