DHANANJAY,
Indian USHA2006;
J. Anaesth. : ABDOMINAL
50 (6) : 455 - AORTA
458 ANEURYSM WITH RENAL INVOLVEMENT
ANAESTHETIC MANAGEMENT OF ABDOMINAL AORTA
ANEURYSM WITH RENAL INVOLVEMENT
Dr. Dhananjay Kumar Singh1 Dr. Usha Kiran2
SUMMARY
Renal failure is one of the most important causes of early death after surgery for aortic aneurysm demanding very meticulous
management. Here We report two cases of thoracoabdominal aneurysm with renal involvement where selective renal artery perfusion
with cold perfusate was done to protect renal function.
Keywords : Abdominal aortic aneurysm, Renal protection, Selective renal artery perfusion.
Introduction
Renal injury accounts for 10-18% of causes of early
mortality after aortic aneurysm surgery. Renal insufficiency
is associated in 13% of cases of aortic aneurysm. Patient
after having undergone aortic aneurysm surgery may go
into the renal failure in 8.5-33% of cases. Seeing the grave
consequences of aortic aneurysm with renal involvement it
needs very precise management of such patients. We hereby
report two such cases of abdominal aortic aneurysm with
renal artery involvement.
Case-1
A 50 years old male patient had history of dull
abdominal pain in periumblical region for the last two
years with radiation to the back and decreased urine output
for the previous fifteen days. There was no history of
vomiting and haematemesis. On examination patient was
thin built, conscious and weighed 49 kg. There were no
positive findings in respiratory and cardiovascular system.
Pulse Rate was 66/min, regular, good volume with normal
character. Blood pressure was 170/110 mmHg but seeing
the consequences of impending rupture of aneurysm case
was taken for surgery with infusion of nitroglycerine.
Abdominal examination showed pusatile mass in the
epigastric area. Chest x-ray showed gross rotation of
heart. Ultrasonography showed dilatation of entire abdominal
aorta involving the both renal arteries, mild increase in the
renal echogenocity in the both kidneys and maintained
cortical medullary demarcation. Right kidney measured
98 x 55 x 54 mm and left kidney measures 77x37x38 mm.
Haematology showed blood urea – 72 mmg/dl, serum
1. Senior Resident
2. Addl. Prof. & Head
Dept. of Cardiac Anaesthesia,
C.N. Centre, AIIMS., NEW DELHI-110029,.
Correspond to :
Dr. Usha Kiran
E-mail : drushakiran@reddifmail.com
(Accepted for publication on 20 - 08 - 2006 )
455
CASE REPORT
creatinine - 2.2 mgdl-1, Hb -11.2%, serum Na -146 mmol/
lt, and serum K - 4.6 mmol/lt. Patient was taking tab
atenolol (100 mg BD) and tab prazosin (4 mgOD). Depending
upon the history and Ultrasonography report patient was
diagnosed to be having abdominal aortic aneurysm with
renal artery involvement. Patient was premedicated with
oral diazepam 5mg each in night and two hours before
surgery, intramuscular morphine sulphate 5 mg and phenargan
12.5 mg one hour before surgery. Antihypertensives were
continued. Three wide bore canula (16G) were put in
right and left upper limb and right external jugular vein.
7Fr-gauge triple lumen catheter was put in right internal
jugular vein. Left radial artery was canulated with 20G
canula for continuous invasive arterial pressure monitoring.
Heart rate, electrocardiogram, invasive arterial pressure,
central venous pressure, oxygen saturation, end tidal carbon
dioxide, temperature and urine output were monitored. After
preoxygenation patient was induced with inj fentanyl
(150 mcg), midazolam (1 mg) and thiopentone (150 mg)
intravenously. Intubation was done with inj atracurium
(25 mg) intravenously. Anaesthesia was maintained with inj
fentanyl, midazolam, atracurium and isoflurane (1-3%).
Patient was put in right lateral position with left arm
abducted over head. After the incision in 7th intercostal
space diaphragm was reflected anteriorly. Inj heparin
(1 mgkbw-1), Inj methylprednisolone (30 mgkbw-1) and inj
aminocaproic acid (100 mgkbw-1) I.V. were given. On going
nitroglycerin infusion was increased before the application
of aortic cross clamp proximally and distally to aneurysm
to prevent blood pressure shoot up. Renal artery was
dissected and kidney was perfused with a perfusate containing
cold ringer lactate (1lt), methylprednisolone (250 mg),
mannitol (50 ml) and heparin (25 mg). Synthetic graft was
anastomosed to proximal and distal aorta and renal
vessels were also anastomosed to the synthetic graft.
Splenectomy was also done as a part of surgery. Urine
output was 120 ml before and 100 ml after the release of
aortic cross clamp. Inj frusemide and mannitol and infusion
dopamine (3 mgkbw-1min-1 ) was started. Intraoperatively
456
4 units of blood, 1 unit of fresh frozen plasma and 1 unit
of platelet and 2 units of cryoprecipitate were used to
enhance the haemostasis. Cell saver collected 1700 ml of
blood. Inj protamine was given to reverse the action of
heparin. Aortic cross clamp time was 38 min. Muscle
relaxant was not reversed and patient was shifted to intensive
care unit for overnight elective ventilation. Renal dose
dopamine was continued for two days. Urine outputs
improved gradually and blood urea decreased from
60 mgdl-1 o n 1st postoperative day to 28 mgdl-1 o n 5t h
postoperative day. Then patient was shifted to ward.
Postoperative pain was managed with inj ketoralac.
Case- 2
54 years old male with body weight 59 kg with
systemic hypertension developed abdominal pain with
radiation to back for the last 3 weeks with history of
malaena and haematochezia and no history of decreased
urine output. P.R. was 52/min, and B.P. was 150/90 mmHg.
Respiratory and CVS did not show any positive findings.
Perabdomen examination showed prominent periumblical
pulsation. Ultrasound of abdomen reveals dilatation of
entire abdominal aorta (4.8x5.4 cm) above the origin of
renal artery with specks of calcification and leak in the
aortic wall.
Echocardiography showed concentric left ventricular
hypertrophy with regional wall motion abnormality
(RWMA). Coronary angiography was not available.
As aneurysm was significantly associated with coronary
artery disease proper care like afterload reduction by
infusion nitroglycerin was taken to prevent intraoperative
myocardial ischemia. On the basis of history and
ultrasound finding fusiform aortic aneurysm involving
entire abdominal aorta with contained leak above the
aortic bifurcation was diagnosed. Haematology showed
Hb-9.3 gm%, blood urea-36 mg/dl and serum creatinine-
1. mgdl-1 Serum electrolytes were within normal limits.
Patient was premedicated with oral diazepam 5 mg each
in night and two hours before surgery, intramuscular
morphine sulphate 10mg and phenargan 12.5 mg one
hour before surgery. Rest of anaesthesia was similar to
case one except the inserting the pulmonary artery catheter
to monitor the cardiac output and pulmonary artery
pressure as patient had regional wall motion abnormality
(RWMA). Cardiac output and pulmonary artery pressures
were within normal limits. Surgery was done in right
lateral position. Before aortic clamp application, on
going infusion nitroglycerin was increased to prevent
hypertension. Inj aminocaproic acid (100 mgkbw-1 ) and
methylprednisolone (30 mgkbw -1 ) were given. Aortic
cross clamp applied and synthetic graft was anastomosed.
INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2006
Kidney was perfused through renal vessels by perfusate
containing cold ringer lactate (1lt), methylprednisolone
(250 mg), mannitol (50 ml) and heparin (25 mg) to protect
from ischemic injury. Just before the release of aortic
cross clamp, infusion nitroglycerine was decreased and
infusion dopamine (3 mgkg -1 min-1) was started. Urine
output was maintained by giving frusemide and mannitol.
Urine outputs were 300 ml before and 600 ml after release
of aortic cross clamp. Total urine output was 1300 ml.
Intraoperatively 5 units of blood were used. Cell saver
collected 900 ml of blood. Collected 350 ml of autologous
blood was transfused. For haemostasis fresh frozen
plasma, cryoprecipitate and platelet were given. Inj
protamine was given to reverse the heparin. Muscle
relaxant was not reversed. Patient was electively ventilated
in ICU overnight. Inotropic support was continued for
two days. Urine output was maintained adequately. Blood
urea and serum creatinine came within normal limits.
Patient was shifted to ward on 5th postoperative day.
Discussion
Aortic aneurysm may involve any segment of aorta
but thoracoabdominal aneurysm is the most common. Most
common pathogenesis is atherosclerosis. It may be of
fusiform (80%) or saccular (20%) type.1
Crawford proposed classification for thoracoabdominal
aortic aneurysm (TAAA) according to the extent of
involvement.2
Type-I = most or all of descending thoracic aorta,
suprarenal abdominal aorta.
Type-II= most or all of descending thoracic aorta,
most or all of abdominal aorta.
Type-III= distal descending thoracic aorta, varying
segment of abdominal aorta including the renal and visceral
arteries.
Type-IV= most or all of abdominal aorta.
Our patients were of type–III as there was
involvement of renal vessels.
Resection of thoracoabdominal type (TAAA) is very
challenging for surgeon as the well as cardiac
anaesthesiologist because of high overall mortality rate of
3% to 28% and intraoperative mortality of 4%.3,4 The
causes of death are bleeding, cardiac factors and multiple
organ failure.5
Among the causes of early mortality cardiac failure
contributes 10% to 75% 6 and renal failure contributes 10%
to 18% 7. Renal insufficiency is associated in 13% of
aneurysms. The most dreaded consequence of renal
DHANANJAY, USHA : ABDOMINAL AORTA ANEURYSM WITH RENAL INVOLVEMENT
ischemia is acute renal failure. The incidence of acute
renal failure after thoracic aneurysm surgery is 3.6%
to 27%.8
The median survival time of patient without
surgery is only 3.3 years.9 The incidence of rupture of
TAAA varies from 20% to 50%.10 Rupture occurs primarily
in patient with aneurysm larger than 5 cm.
Upto 33% of survival becomes dialysis dependent11.
Risk factors 12 that potentiate postoperative renal failure are
cardiac diseases (left ventricular dysfunction), re-operation,
aortic cross clamp time more than 30 to 45 min, renal
ischemia time more than 30 min, postoperative respiratory
insufficiency, preexisting renal dysfunction, sustained intra
and post operative hypotension, failure to use atriofemoral
bypass.
Our first case had preoperative renal dysfunction
(risk factor), as blood urea and serum creatinine were
high. Proper prophylaxis like use of frusemide, mannitol,
short aortic cross clamp time, adequate hydration and
blood conservation were taken to bring down the blood urea
and serum creatinine. Case two had regional wall
motion abnormality as a risk factor. Coronary artery
disease (CAD) is the most likely condition to affect
survival in patient undergoing TAAA repair. The risk of
sustaining a perioperative myocardial infarction ranges
from 7.3% to 13%.13 It is the major cause of death in
TAAA if a patient get intraoperative collapse or transmural
myocardial infarction. That is why pulmonary artery
catheter was put to monitor cardiac output and pulmonary
artery pressure and infusion nitroglycerin was started to
reduce afterload and aortic cross clamp was tried to be
as short as possible. To prevent homologous blood
transfusion 350 ml of autologous blood was withdrawn
before surgery and cell saver was used that conserved
around 1200 ml of blood in 1st case and 1500 ml of blood
in 2nd case. Nephrotoxic drugs were avoided. Inj atracurium
was used as it has got Hoffman elimination.
A recent series using a statistical model to
evaluate a patients risk revealed advanced age (more than
70 years) and preoperative serum creatinine level as a key
predictors of postoperative renal failure.14 Suprarenal
aortic cross clamping is associated with higher rate of
renal complication (17% to 51%).15 Aortic cross clamping
affects both renal perfusion and blood flow distribution as
ischemia-reperfusion insult to kidney play a central role in
pathogenesis of renal failure with aortic surgery. In our
case aortic cross clamp was very short (31 min).
Renal insult may result to acute tubular necrosis,16
30% decreased in cortical blood flow,17 increased renal
457
vascular resistance due to activation of renin–angiotensin
and sympathetic nervous system. 18 There are other causes
like microembolization, endothelin release, and inhibition
of nitric oxide formation by myoglobin and release of
prostaglandin contributing to intrarenal maldistribution of
blood flow. Renal haemodynamic changes persist even after
unclamping of aortic cross clamp and may result in a
prolonged decrease in glomerular filtration rate.
Adequate hydration and renal perfusion pressure
are important factor for renal protection. The changes
in renal blood flow are significantly attenuated if adequate
intravascular volume and cardiac output are maintained.19
There are so many methods 20 like minimizing aortic
cross clamp time, maintaining adequate renal perfusion
(adequate intravascular volume, ventricular function and
cardiac output), decreasing renal metabolic rate (cold
perfusion to renal artery, frusemide, systemic hypothermia),
decreasing reperfusion injury (mannitol, calcium channel
blocker, superoxide dismutase), using pharmacological
manipulation of renal blood flow (low dose dopamine,
mannitol, frusemide, fenoldopam, PGE), are there to protect
renal function.
Selective renal artery perfusion is also very important
way to protect the renal function. The orifices of exposed
renal artery are cannulated with 9Fr catheter and perfused
with cold perfusate from the centrifugal pump using
Y shaped connection. We also did selective renal artery
perfusion to both kidneys with coldperfusate21 containg
ringer lactate (1lt), methylprednisolone (250 mg), mannitol
(50ml) and heparin (25 mg) decreasing metabolic rate and
reperfusion injury and maintaining renal blood flow thus
minimizing the incidence of renal failure.
The newer technique of endovascular aortic aneurysm
repair has evolved for the treatment of TAAA. The
endovascular stent graft is composed of a stainless steel
endoskeleton of stent elements & covering of woven Dacron.
Repair is done through the surgically exposed femoral or
iliac artery or the lower abdominal aorta. The premeasured
graft is inserted through an open arteriotomy under
fluoroscopic control. 22 Generally patient undergoing
endovascular stent graft aortic repair appear to have greater
haemodynamic stability compared to traditional open
repair.2 3
There is controversy regarding the use of regional
(epidural) anaesthesia for surgery on descending thoracic
aorta. Combined general and epidural anaesthesia has been
decided for thoracic and abdominal aortic surgery. Benefits
of combined technique are decrease in postoperative pain,
adrenocortical stress response, protein catabolism,
hypercoagulable state and pulmonary and myocardial
458
morbidity. Epidural anaesthesia improve the graft patency,
blunt the increase in systemic vascular resistance and blood
pressure associated with proximal aortic cross clamping.
One major concern about the use of epidural blockade
is risk of epidural haematoma in patient receiving
anticoagulant. Epidural anaesthesia is associated with more
pronounced intraoperative hypotension especially after the
release of aortic cross clamp. Well controlled prospective
& randomized trials are needed to substantiate the risk and
benefit of combined (epidural-general) anaesthesia compared
with general anaesthesia for thoracoabdominal aortic
surgery.24
Conclusion
The preservation of renal function by perfusing the
renal artery by perfusate containing cold ringer lactate,
methylprednisolone), mannitol, and heparin, measure taken
to bring down the blood urea and serum creatinine and use
of autologous blood and cell saver to prevent homologous
blood transfusion proved safe and effective to protect renal
function while doing surgery for abdominal aortic aneurysm
involving renal artery.
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